By Arjun Gupta
I winced in pain and stepped off the dance floor, the latest Bollywood number still ringing in my head. A cousin helped me to the nearest chair and I gingerly straightened my leg out. A few moments earlier, I had felt a sudden pop in my left knee while doing an elaborate dance routine at my sister’s wedding in New Delhi. The pop was followed by pain and swelling, and I knew the diagnosis before the magnetic resonance imaging (MRI) results came back the next day, showing a complex meniscal tear with significant joint effusion. I had had a small meniscal tear for years, but without the recommended physical therapy, the knee was prone to further injury. In my defense, residency has been busy, and 30 minutes of completing notes in the evening seemed more important than slight tolerable pain, which could give me trouble years later. As they say, doctors make the worst patients. I had also considered arthroscopic knee surgery for years, but had just not gotten around to it. Fortunately, I had mom by my side this time, which makes everything better. This dance fiasco happened right in the middle of my vacation to India, where all of my family lives. I still had a week to go before I had to fly back to the U.S.
A couple of days later, I entered Dr. V’s office accompanied by mom. Dr. V was a family friend, and an accomplished orthopedic surgeon. He had been advising me to participate in physical therapy for years- at clinic visits and when we would run into each other at dinner parties- before I left to do my residency in the states. Dr. V had made a special appointment for us and greeted us warmly. He took a detailed history, examined my knee and looked over the MRI films. We discussed the options and agreed that it was finally time to bite the bullet and get arthroscopic knee surgery. I could not squat or kneel, and simple activities like getting out of the car were incredibly painful. I asked Dr. V if he would operate on me. He leaned back in his chair, smiled, and said, ‘’Yes, but you live in the U.S. and work at a hospital. Get it done there. It’s a really common procedure- one of the most common surgeries- and you’ll get excellent outcomes there.’’
I did have great insurance and I was able to schedule an appointment with an orthopedic surgeon within a week of returning to the states. I loved everything about the visit – the scheduling was easy, the directions to the clinic were clear, and the front desk staff was courteous and uploaded my MRI scans into the electronic medical record in a flash. The surgeon was an excellent clinician with fantastic bedside manner. After discussing what my goals were, she agreed that arthroscopic knee surgery would be the best option. I had brought a list of 15 questions to ask- ranging from what anesthesia would be used, to recovery time, to wound care, and to when I could drive. She patiently answered them all, with ease and confidence, clearly experienced in the subject matter and in dealing with patients. Finally, I asked, “so, do you know how much this will cost?’’ As a physician in the U.S., I had been asked the same question about other procedures or medications, and could never give a good answer to my patients. I was hoping it would be different this time. ‘’Not really’’, she replied, sounding sheepish. ‘’I can tell you how many RVUs this procedure is worth, but I don’t think that’s important to you. I saw that you have good insurance, so hopefully not much. I’ll ask the nurse to put you in touch with the financial counselor.’’ We decided that I would confirm plans for surgery with the nurse over the next few days. The nurse soon entered the room with the after visit summary and contact details of the financial counselor.
I called the financial counselor the next day. After verifying the insurance information, he informed me about the deductible, the co-pay, and the percent of ‘equipment or specialized agents’ that I would be charged. He could not provide more details and said that a final charge would only be given once I confirmed surgery. I was taken aback. I think I understood their reason- that I would use their quote to bargain at another hospital, much like buying a car at a dealership – but I did not agree with it. With my insurance, I think the cost would have been manageable. But there was no way to be sure, and I was ticked off at this lack of transparency. I made several other phone calls but got no answers. My self-assurance at being a physician and thus being able to get answers quickly faded away. Obviously, the surgeon, nurse, and financial counselor did everything they could- they were competent, pleasant, and helpful- but I just lost faith in the system.
I made a long-distance call to Dr. V the next day and asked him if he would operate on me. Sensing something was off, he replied with an urgent but loving yes. I’ve decided to get the procedure in India during my next visit. I’m ready to buy a ticket and fly ten thousand miles. The delicious irony is that a flight ticket might possibly cost me more than the out of pocket costs of care in the U.S. – I guess we’ll never know!
Arjun is the Chief Resident for Quality, Patient Safety, and High Value Care in the Department of Internal Medicine at UT Southwestern Medical Center, and the inaugural Learning Network Fellow for Costs of Care. He will be starting a Fellowship in Hematology Oncology at Johns Hopkins in July, 2018.