Hospital price tags hide more than they reveal
A uniform hospital tariff is nearly unworkable in a vast country like the US, which has non- profit and for- profit hospitals that depend mostly on medical insurance
US President Trump might have reiterated that the United States will never be a socialist country in his State of the Union address just the other day but at least the American healthcare system has quite a few socialist features.
For instance, all non- profit hospitals in the US are bound to treat all patients coming to the emergency room under Emergency Medical Treatment and Labour Act. EMTALA stipulates top quality treatment, as available to the President of the US, regardless of whether one is a guest, visitor or tourist and whether insured or not. Whether this system is working fine and commercially viable is a moot point.
And to assume that healthcare in the world’s richest country is simple, straightforward and well- organised would be overstating the case. A deeper look at the system would reveal a maze of structures; healthcare is structured more like a privilege than a basic right. One has to be medically insured to avail oneself of healthcare. The indigent depend on non- profit hospitals.
But major drawback to the healthcare system, till recently, has been a lack of transparency about prices of procedures and services at hospitals. It was like going to a store and trying to buy products with no price tags on them.
A small step in this direction was made on January 1, when all hospitals in the US were required to post their charge prices.
“However, the list of over 15,000 procedures is notoriously incomprehensible, even for medical professionals. What exactly is a “HC PTC CLOS PAT DUCT ART,” a procedure listed by one Tennessee hospital? Perhaps more importantly, patients’ out- ofpocket costs often depend on the specifics of their insurance plan and the prices that are negotiated by their insurer, meaning the listed prices do not reflect what they actually pay,” says Dr Zach Y. Brown, Assistant Professor of Economics, University of Michigan.
Many hospitals resist voluntary disclosures of charges by keeping displays incomprehensible for the average patient. But 42 out of the 50 states have switched over to the new regime of charge displays.
Again, what decides the cost of treatment depends a lot on the patient.
An uncomplicated laparoscopic gall bladder surgery has the patient leaving hospital on the third day. One day’s hospital stay costs $ 2,006. But if the patient had undergone a previous surgery, there could adhesions, making the surgery complicated. In which case, the stay extends to five days and the cost goes up to $ 10,000$ 11,000.
Someone has to explain the difference between the quoted $ 6,000 and the actual charge of $ 10,000 at the time of discharge.
Unanticipated expenses have to be factored in; extra charge for anticoagulants in case of blood clot in legs and a CT scan if the patient develops breathlessness. These variables can jack up the per diem $ 2,006 average cost, rendering a uniform price tag on all procedures impractical. Uniform tariffs are stymied by variables in the cost of implants and variables in complexities of cases. Some may need more time, accompanied by variables in ancillary services such as ambulance. Some may be uninsured. Hence, uniform tariff display may not be pragmatic in the US system.
Some of the reasons are genuine because you cannot have same price for same service uniformly enforced in the entire country, especially if hospital is not for profit and they are obligated to take care of patients without insurance, which means they have an extra burden.
Hospitals cannot turn back a patient, be he a visitor, uninsured and with no kin to pay for medical services. In many cases, the patient would say he is broke.
The host is not liable to foot the bill on behalf of the visitor. This leaves the hospital with no option but write off the bill, in what is known as uncompensated care. It is universal in the US.
President Trump has displayed zero tolerance to such drain on public funds. Illegal immigrants are clever and exploit the sophisticated altruistic healthcare. Hospitals can deny treatment at their own peril. Litigation will leave them poorer and the patient richer by a few million dollars in damages for deficient service. The patient’s lawyer takes away half the compensation.
President Obama had brought in the much vaunted and much criticized Obamacare under Affordable Care Act, making insurance mandatory. Co- pays and deductibles are features of health insurance plans. Copay is a fixed amount paid for receiving a particular health care service, with the balance covered by the insurance company. A deductible is a fixed amount a patient must pay during a given time, usually a year, before the health insurance benefits begin to cover the costs.
There are also Medicaid for the indigent and Medicare for senior citizens. Medicaid is a joint federal and state programme that helps with medical costs for some people with limited income and resources. It provides free health insurance to 74 million low- income and disabled people ( 23 per cent of Americans) as of 2017.
Medicare is a national health insurance programme for Americans aged 65 and older. It also provides health insurance to younger people with some disability status as determined by the Social Security Adminis- tration, as well as people with end stage renal disease and amyotrophic lateral sclerosis.
But many doctors shy away once they realise the patient belongs to the subsidised category as bills often remain unrealised.
Above all there is the difference in the approach to life. The JudeoChristian philosophy is about living life to the full on this planet, whereas Indian Karmic theory is fatalistic. An 84- year- old American, who recently underwent prostate cancer surgery, insisted on having a penile implant to correct his erectile dysfunction. This is the fundamental difference in the philosophy of longevity. Of course, the American has the insurance to back it.
No perfect mechanism is easy because of stratification. America thrives on competition. Recall Reagan’s old principle deregulating airlines. Americans need a better health care system, but there is the vulgarity of capitalism. Healthcare is luxury; if one wants it, buy; if not affordable, don’t buy.
( The author specialised in internal medicine, haematology and medical oncology. He is a Clinical Professor of Oncology at Sidney Kimmel Medical College of Thomas Jefferson University)