By Robert Gray, MD
Where I’m from, you can have someone killed for $5000. I will do it for $1,110. I’m a hand surgeon.
I practice (or practiced, by the time you read this) in an area that is what we often refer to as “underserved.” Rather, the area isn’t, but the people I treat are. I work in a large urban referral center it’s nothing like the clinic you would go to if you want to see a surgeon at the hand surgeons nyc clinic, this referral center that has a very high proportion of Medicaid as well as unfunded patients. No one else in town will touch them. I am not blaming them–they are in private practice and they can’t cover their expenses if they are paid nothing or close to nothing for their time and supplies. While there may be an element of greed, it is not all greed. I know my colleagues in private practice and almost without exception, I respect them all as physicians and people.
In my referral center, the hospital has favorable contracts with Medicaid that yield good revenue for the center from Medicaid patients. But, as a consequence, all of my procedures are “hospital-based” as opposed to “clinic-based.” It is a semantic billing distinction that I do not completely understand myself (another part of the problem) and it allows the hospital to generate enough revenue to cover costs for an unquestionably needy population. For the patients with Medicaid, it allows us to care for them with little, if any out-of-pocket cost to them and keep the lights on.
However, for patients with private insurance that is anything less than a top-of-the-line plan, procedures done in outpatient “hospital-based” clinics are not covered and are billed at very high rates that come out-of-pocket. A steroid injection for tendonitis can yield a bill in excess of $1,000. Doing a simple wound “clean-up” or debridement can be north of $1,100. I am on salary and don’t make an extra nickel either way.
Which is why when Mr. Jones, an overweight diabetic with private insurance presented with a small local infection that I probably could have addressed in the office, I took him to the OR. His insurance company would only cover the costs if it were done upstairs, but would pay nothing if I did it in my clinic.
Once in the OR, the regional block he received did not work well (which happens) and his sedation was increased. The increased sedation made it difficult for him to breathe and he had to be ventilated emergently. He lost his airway. His oxygen saturation dipped below 60% of normal, briefly, and the anesthesiologists were able to right the ship and wake him up.
Ultimately, things went well. The patient’s hand was healed and he didn’t face a medical bill that would have decimated his financial health. However, I nearly killed him to save him $1,110.
Robert Gray, MD is a 2013 Costs of Care Essay Contest Winner.