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Adventures in the Skin Trade

by Emily Friedman

First published in Hospitals & Health Networks OnLine, February 5, 2008

A foray into the labyrinth of the health care system-medical and dental-provides a glimpse into the world of the functionally uninsured and underinsured. (With apologies to Dylan Thomas, who began a novel with the same title as this piece, but died before he completed it.)

It all started when my dentist retired this summer. I had been his patient for many years, and we had become friends. But then his wife was badly injured in an accident, so he gave up his practice to care for her. At the time of his retirement, he was partway through working on an old root canal site of mine that needed some tending.

I have medical insurance; I pay $8,000 a year for quite skimpy coverage. I do not have dental insurance. My dentist was always nice about that.

The Dental Labyrinth

The dentist who inherited his practice-whom I knew and liked from casual previous experience when she covered for him-checked me out and gave me advice on the tooth in question that was 180 degrees opposite to what my previous dentist had recommended. She referred me to an oral surgeon whom she described as gentle and caring and "the best." She said that this practice "would treat me like family." The Addams Family, I presume.

It was all kinds of fun. When I called, the oral surgeon's staff spent the first 10 minutes interrogating me about my insurance status and financial situation (at no time was I asked, "Does it hurt? Are you bleeding?"). I was stiffly informed that they collect all money, at billed-charge rates, up front, and if any insurance money comes in later ("sometimes we can pass it off as a medical procedure that your insurance might cover"), they will send me a refund. Right. I was also informed that they don't take Medicaid or indigent patients.

Well, heck. I went to their office. The financial requirements that they had outlined on the phone were posted prominently on the wall. I filled out the form. I agreed to the outrageous consultation fee. I waited. And waited. And waited. Forty-five minutes after my appointment time, they escorted me into an examination room. I asked how long it might be before I actually saw the oral surgeon. The young woman responded, "Oh, I'm just a trainee; I'll get someone who knows." I overheard the conversation in the hallway: "Oh, the doctor's running late today. It will be quite some time."

I informed the staff member who eventually came to give me the news that my time was valuable, too, and I walked out.

Second Opinions and Then Some

Time for a second opinion. I found a dentist (on the Internet) who practices close to my home. I chose her because she appeared to be a member of a group practice (although it turns out to be a two-person group), so there was coverage if one dentist was out of commission. Good thought; the dentist I had chosen was pregnant. She was also polite, helpful, professional, sensitive to my uninsured state-and reinforced what my other new dentist had said: The tooth was in trouble and would probably have to be removed.

She referred me to a different oral surgeon. With great reluctance, I went to visit his office and prepared for another round of financial-status interrogation. I was treated with respect and sympathy, but the news was bad: The tooth had to go. I related my experiences to him about the first oral surgeon. He escorted me into a private room and asked who the other oral surgeon was, as he did not appreciate his colleagues treating patients like that. I gave him the name. He smiled, and said, "Actually, I know [George-not his real name], and he's a nice guy. But, well, uh, I don't run a high-volume practice. My staff do have to talk about money with patients, but we try not to do it in an offensive or insensitive way."

A high-volume practice. I guess that's what they're calling patient mills these days.

So we agreed that I would come in and lose the tooth, and that was all arranged. I appreciated his honesty. But I was also a little ticked off that to get to this point, I had already spent several hundred dollars. As I was leaving and paying for the consultation, a staff member asked, "Do you have dental insurance?" I said no. She sighed sympathetically and said, "It has become a rare thing." Which is probably why every dentist, endodontist and oral surgeon I have encountered during this ordeal takes credit cards.

Groundhog Day

Around then I developed a minor joint problem-nothing serious, mostly a nuisance, but enough that I wanted to see an orthopedist.

I do not have coverage for outpatient physician visits.

There's a physician who practices near my home who is well-known for his expertise in the subspecialty area that applies to my condition (let's call him Dr. Jones). I call his office; he's out of the country, but he has a colleague (let's call him Dr. Smith) who would be glad to see me in his downtown office.

I go to the downtown office. Here we go again.

The waiting room is jammed. A harried front desk clerk is trying to manage the traffic. An equally harried physician's assistant is running in and out, grabbing charts. I fill out a 10-page form. I am told that "the doctor's on time today." The lady asks if I have insurance. I say, not for the physician visit itself. "Oh, in that case," she says airily, "the consultation fee is $250." I stare at her. I don't know why I stared; we're all aware of the charges that are laid on uninsured patients by many providers. I gulp. I agree.

I sit down. And wait. And wait. And wait. It was like a medical version of Groundhog Day, given that I had just dealt with the wonderful world of waiting in dentistry. The better part of an hour after my appointment time, I am called by my first name (something I find irritating in a professional situation) and told that an exam room had opened up. And how long before I can see the doctor? "Oh, that I couldn't tell you. He's running late today." This is the same woman who an hour ago had told me he was running on time.

I look around at what appears to be an orthopedics mill-oh, excuse me, a "high-volume practice"-very few patients were in with "the doctor" for very long-and I decide to leave. I tell the lady that I'll be going. She says, "You should come here in the morning; it's always like this in the afternoon." I glare at her. She asks, "Do you want to reschedule?" I say no, I think I'll try to see Dr. Jones, the one with expertise in my problem, closer to home. "Jones?" she blurts out. "He's even slower than Smith! And with you being a new patient."

Apparently, "new patient" is code for "underinsured."

I asked her, loudly enough for the entire waiting room to hear me, "Are you going to charge me for waiting?" "No." "Fine." I left.

I'm still trying to get in to see Dr. Jones, who will, no doubt, charge the same $250 consultation fee and make me wait until the cows come home.

Smoke and Mirrors

I spoke about this with a physician friend, whose response-a tragic commentary on our health care system-was: "I have learned over time, as a patient dealing with this system, to put up with any kind of abuse in order to get what I want, but that doesn't mean I am doing it gladly." He is a renowned physician at a renowned teaching hospital.

About then, the insurance statement for my annual mammogram came in. Fortunately, the state of Illinois requires insurers to cover mammograms; not all states do. The hospital's billed charges were around $250; that's what uninsured and underinsured patients pay. The insurer paid the hospital about $110.

I've been talking with my friends about these adventures and have learned about their adventures. One friend was stuck with thousands of dollars in charges for treatment of a potentially fatal cancer because the insurer wouldn't approve the care, despite the fact that it has been documented that this is the right approach for treating this cancer.

Another friend had two root canals on the same tooth, costing thousands, only to find out that they had not worked and that the tooth would have to be removed and replaced with an implant; total cost, more than $10,000. Someone else I know, a temporarily unemployed financial management consultant, is doing her dentist's books to pay for the care she needs. Yet another friend who was having some dental problems went for a consult; total cost of what they proposed was $26,000. She is 91 years old. Most of my friends who do have dental insurance report that the annual cap is $1,500 or $2,000, which in most cases would pay for bridges on one-and-a-half teeth.

Patients are starting to complain publicly about this. In a harrowing piece in the Nov. 16, 2007, Wall Street Journal, John Carreyou told the story of a woman with a rare genetic disease who had good insurance (supposedly) and had roadblocks thrown in her way at every turn when she was simply trying to find out what was wrong with her. In M.P. Dunleavey's piece in The New York Times on Dec. 29, 2007, she relates her efforts to find out what she owed for an emergency appendectomy, given that she had a $3,000 deductible and 80 percent coverage thereafter. The hospital tried to bill her; the insurer said not to pay; the hospital sent a bill collector after her and her husband. They paid. It took seven months to get a final bill.

A Glimpse of the Future

Three months ago, I asked a major figure in the quality improvement movement what his organization was doing about monitoring quality in dental care. He replied, looking pained, "It isn't even on the radar." Of course not; few people have dental coverage, and few employers offer it, and if the people who pay for the care are only individuals and not employers or health plans, who cares what happens to them? As a friend of mine recently wrote to me about his experiences and mine, "I do wonder about the 'professionals' who do root canals and other procedures and just how skilled or experienced they are."

It seems to me that all of us-well insured, underinsured or uninsured-might deserve something better than potluck when it comes to our care.

A couple of years ago, a very wise (and fully insured) hospital trustee said, regarding his recent experience with the health care system, "It was like my time in the Army during World War II: hours and hours of waiting and boredom, and then a few moments of sheer terror."

I think we need to be honest here. I'm white, English is my first language, I'm pretty savvy about the health care system (at least, that's how I earn my living), I am terminally middle-class, I dress decently, and I have adequate insurance (or so I thought). And all this happened to me. What is this system doing to people with high deductibles, low incomes, poor English-language skills, insufficient health literacy or cultural challenges?

As high-deductible health plans, underinsurance and lack of insurance spread through the middle class, a great many more people who thought they were safe are going to experience the same thing.

By the way, Dylan Thomas died, in all probability, as the result of medical error.

And people wonder why I refuse to use the term "consumer-directed health care."

First published in Hospitals & Health Networks OnLine, February 5, 2008

Emily Friedman 2008

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