By Rita Kuwahara
Every nurse knew his name. Every provider was intimately familiar with his medical problems and why he spent 124 days in the past year in the hospital. The day I met Mr. X was the day before his discharge. He was excited to go home and motivated to never come into the hospital again. I was the medical student eager to hear his story and tasked with helping him achieve his goal of optimal health.
Mr. X undoubtedly represented the 1% of patients whose medical expenses represent 20% of our nation’s annual healthcare costs. I was curious—how much did 124 hospital days cost, and why was Mr. X always in the hospital? Answering the latter question was easy—he had had recurrent blood infections. The first question was more challenging. Only after hours on the phone and four trips to the off-campus billing facility, was my question partially answered.
With two separate hospital billing systems, no electronic calculation of total costs, and no record of hospital-administered medication costs, I went through 283 pages of hospital charges and hand-calculated an estimate of Mr. X’s total charges. My best guess was $349,845.57, which still did not include the thousands of dollars of medications Mr. X received as an inpatient.
Aware of my gross underestimate of Mr. X’s true hospital charges, but wanting to focus on actions to keep Mr. X healthy and out of the hospital, I shifted my attention to his source of infections. Apparently, his teeth were badly decayed, causing several life-threatening blood infections. Prior to discharge, the hospital dental team extracted half his teeth and scheduled the remainder to be extracted as an outpatient.
Thinking that removing all his teeth would be the magic bullet to prevent future hospitalizations, I accompanied Mr. X to his follow-up hospital dental clinic appointment. Upon arrival, I was shocked to learn that unless Mr. X paid his in-hospital dental extraction charges in full, the clinic would not remove any more teeth. Only after much persuasion, highlighting the medical necessity of Mr. X’s extractions, did the clinic agree to extract his teeth without payment of outstanding charges.
As soon as Mr. X’s last tooth was extracted, I surprised him by offering to use our interprofessional team’s $700 grant to buy his dentures from a low-cost denture clinic. Unfortunately, I spoke too soon. The surgeon who completed the extractions pointed out Mr. X needed complex oral surgery before receiving dentures. However, since Mr. X’s extraction expenses had now doubled, the clinic could not extend further credit, so, despite my efforts, they would not perform the $3600 surgery unless he paid in full. While frustrated, I was also concerned about the health implications of Mr. X remaining toothless.
Six months later, when I finally persuaded the hospital dental clinic to reconsider their decision, Mr. X was re-hospitalized. He was very disappointed, but it was not unexpected. Six months of drinking sugar-filled milkshakes and eating soft, salt-laden canned foods would cause anyone’s blood sugar to skyrocket and long-standing hypertension to turn into heart failure. The particularly cruel irony was just as we convinced the dental clinic to reconsider performing the surgery so Mr. X could receive dentures and eat low sugar, heart-healthy foods, the oral surgeon refused to perform the surgery due to his poor surgical risk from uncontrolled diabetes and heart failure.
Through no fault of his own, except paucity of money, Mr. X was trapped. He could not afford the original $3600 for oral surgery, which would have kept his chronic diseases in-check. Instead, his health deteriorated because he was too poor to afford teeth and the hospital dental clinic was too focused on saving money, resulting in a hospitalization costing thousands of additional dollars. Further, since he was no longer a good surgical candidate, and still had no teeth to eat healthier foods, he was poised to have his health spiral out of control and spend as many days in the hospital in the coming year as he did in the past. While I remain optimistic that everything will eventually turn out well, I cannot help but think: how different would things be if, six months ago, we had had $3600?
Rita Kuwahara was a contestant in the 2015 Costs of Care Essay Contest.