Christy called the ambulance on Christmas Eve because her husband passed out and was unresponsive. He was rushed to the hospital and remained there for three months before passing away. While Christy sat by his silent bedside—he was in a coma the entire time—she watched person after person come into the room to read the chart, order a new test, and attempt to have some interaction with her husband.
Christy is a real person; I met her in my role as a former hospital administrator, and thought my experience might help her navigate the system. And I know her story is not uncommon.
Her husband had a good job and excellent insurance. He was taken to a hospital that was in-network with his plan, so Christy felt sure they were in good hands. She believed she would only be responsible for their portion of the benefits—such as the deductible and coinsurance payment.
Yet within days of his passing, Christy began getting bills with frightening numbers on them. She didn’t even have time enough to mourn before the paperwork started piling up: EOBs (Explanation of Benefits) from the insurance company, along with bills from the hospital, the ambulance, the 30 or so doctors who consulted on his case—and anyone else who might have walked in the room or been within eye-shot.
The total amount she believed she owed was more than $4 million. Mourning turned into depression for this mother of four small children who had just lost their dad. Her church stepped in and started sponsoring spaghetti dinners to help make a dent in this monumental dollar amount.
That’s when I learned about her case. I reviewed the documents—which amounted to three reams of paper—and it turned out that she didn’t owe over $4 million. Still, in addition to the $3,500 that represented her deductible and coinsurance (she knew about and expected that), there was an additional $15,000 from out-of-network providers.
Surprise!
Certainly, $18,500 is better than $4 million. But the additional charges, from providers she didn’t know, never met and whose roles were never explained to her, seemed crazy. Does health insurance—even excellent health insurance—really work this way? And do ordinary Americans, with lives to live and families to care for, really stand a chance with a byzantine, bullying system?
Surprise billing is undermining what little confidence Americans have left in the U.S. health care system. What Christy and all consumers deserve is transparency.
The lack of transparency in Christy’s case came from the providers who rendered services while being out-of-network. The patient’s family expected that everyone was on the same team—providing a unified effort in a healing environment, all under the sheltering umbrella of the family’s health insurance plan.
The reality was different, as Christy learned—just as many Americans learn, when they go to their emergency room or their hospital many of the providers working there don’t accept their coverage.
One issue is the existence of networks. Why do we have them? Networks are essentially an artificial market designed and managed by the health insurance companies. They include who they want to include and they exclude who they want to exclude. They contract with hospitals and physicians for lower rates in exchange for volume.
But why the exclusivity? Couldn’t the companies negotiate with all providers in a given market? It’s not a safety issue; hospitals and physicians are all licensed by the state agencies and undergo the same rigorous annual/bi-annual reviews.
It’s a financial issue—and one that can be managed. We could increase transparency by eliminating networks altogether—removing one more layer of bureaucracy between patients and their providers.
Of course, a better plan is to remove all barriers. Direct Primary Care and Direct Care facilities operate under a different model—consumers receive affordable, high-quality services at bundled pricing, without the surprise bills that so many of us see. They see price tags, not just bills. They’re involved in the decisions, not merely bystanders.
Real health care reform moves providers and patients closer together, not further away.