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发帖数: 931 | 1 Time杂志最近一期专辑。
1. Routine Care, Unforgettable Bills
When Sean Recchi, a 42-year-old from Lancaster, Ohio, was told last March
that he had non-Hodgkin’s lymphoma, his wife Stephanie knew she had to get
him to MD Anderson Cancer Center in Houston. Stephanie’s father had been
treated there 10 years earlier, and she and her family credited the doctors
and nurses at MD Anderson with extending his life by at least eight years.
Because Stephanie and her husband had recently started their own small
technology business, they were unable to buy comprehensive health insurance.
For $469 a month, or about 20% of their income, they had been able to get
only a policy that covered just $2,000 per day of any hospital costs. “We
don’t take that kind of discount insurance,” said the woman at MD Anderson
when Stephanie called to make an appointment for Sean.
Stephanie was then told by a billing clerk that the estimated cost of Sean’
s visit — just to be examined for six days so a treatment plan could be
devised — would be $48,900, due in advance. Stephanie got her mother to
write her a check. “You do anything you can in a situation like that,” she
says. The Recchis flew to Houston, leaving Stephanie’s mother to care for
their two teenage children.
About a week later, Stephanie had to ask her mother for $35,000 more so Sean
could begin the treatment the doctors had decided was urgent. His condition
had worsened rapidly since he had arrived in Houston. He was “sweating and
shaking with chills and pains,” Stephanie recalls. “He had a large mass
in his chest that was … growing. He was panicked.”
Nonetheless, Sean was held for about 90 minutes in a reception area, she
says, because the hospital could not confirm that the check had cleared.
Sean was allowed to see the doctor only after he advanced MD Anderson $7,500
from his credit card. The hospital says there was nothing unusual about how
Sean was kept waiting. According to MD Anderson communications manager
Julie Penne, “Asking for advance payment for services is a common, if
unfortunate, situation that confronts hospitals all over the United States.”
The total cost, in advance, for Sean to get his treatment plan and initial
doses of chemotherapy was $83,900.
Why?
The first of the 344 lines printed out across eight pages of his hospital
bill — filled with indecipherable numerical codes and acronyms — seemed
innocuous. But it set the tone for all that followed. It read, “1
ACETAMINOPHE TABS 325 MG.” The charge was only $1.50, but it was for a
generic version of a Tylenol pill. You can buy 100 of them on Amazon for $1.
49 even without a hospital’s purchasing power.
(VIDEO: The Exorbitant Prices of Health Care)
Dozens of midpriced items were embedded with similarly aggressive markups,
like $283.00 for a “CHEST, PA AND LAT 71020.” That’s a simple chest X-ray
, for which MD Anderson is routinely paid $20.44 when it treats a patient on
Medicare, the government health care program for the elderly.
Every time a nurse drew blood, a “ROUTINE VENIPUNCTURE” charge of $36.00
appeared, accompanied by charges of $23 to $78 for each of a dozen or more
lab analyses performed on the blood sample. In all, the charges for blood
and other lab tests done on Recchi amounted to more than $15,000. Had Recchi
been old enough for Medicare, MD Anderson would have been paid a few
hundred dollars for all those tests. By law, Medicare’s payments
approximate a hospital’s cost of providing a service, including overhead,
equipment and salaries.
On the second page of the bill, the markups got bolder. Recchi was charged $
13,702 for “1 RITUXIMAB INJ 660 MG.” That’s an injection of 660 mg of a
cancer wonder drug called Rituxan. The average price paid by all hospitals
for this dose is about $4,000, but MD Anderson probably gets a volume
discount that would make its cost $3,000 to $3,500. That means the nonprofit
cancer center’s paid-in-advance markup on Recchi’s lifesaving shot would
be about 400%.
When I asked MD Anderson to comment on the charges on Recchi’s bill, the
cancer center released a written statement that said in part, “The issues
related to health care finance are complex for patients, health care
providers, payers and government entities alike … MD Anderson’s clinical
billing and collection practices are similar to those of other major
hospitals and academic medical centers.”
The hospital’s hard-nosed approach pays off. Although it is officially a
nonprofit unit of the University of Texas, MD Anderson has revenue that
exceeds the cost of the world-class care it provides by so much that its
operating profit for the fiscal year 2010, the most recent annual report it
filed with the U.S. Department of Health and Human Services, was $531
million. That’s a profit margin of 26% on revenue of $2.05 billion, an
astounding result for such a service-intensive enterprise.1
The president of MD Anderson is paid like someone running a prosperous
business. Ronald DePinho’s total compensation last year was $1,845,000.
That does not count outside earnings derived from a much publicized waiver
he received from the university that, according to the Houston Chronicle,
allows him to maintain unspecified “financial ties with his three principal
pharmaceutical companies.”
DePinho’s salary is nearly triple the $674,350 paid to William Powers Jr.,
the president of the entire University of Texas system, of which MD Anderson
is a part. This pay structure is emblematic of American medical economics
and is reflected on campuses across the U.S., where the president of a
hospital or hospital system associated with a university — whether it’s
Texas, Stanford, Duke or Yale — is invariably paid much more than the
person in charge of the university.
I got the idea for this article when I was visiting Rice University last
year. As I was leaving the campus, which is just outside the central
business district of Houston, I noticed a group of glass skyscrapers about a
mile away lighting up the evening sky. The scene looked like Dubai. I was
looking at the Texas Medical Center, a nearly 1,300-acre, 280-building
complex of hospitals and related medical facilities, of which MD Anderson is
the lead brand name. Medicine had obviously become a huge business. In fact
, of Houston’s top 10 employers, five are hospitals, including MD Anderson
with 19,000 employees; three, led by ExxonMobil with 14,000 employees, are
energy companies. How did that happen, I wondered. Where’s all that money
coming from? And where is it going? I have spent the past seven months
trying to find out by analyzing a variety of bills from hospitals like MD
Anderson, doctors, drug companies and every other player in the American
health care ecosystem.
When you look behind the bills that Sean Recchi and other patients receive,
you see nothing rational — no rhyme or reason — about the costs they faced
in a marketplace they enter through no choice of their own. The only
constant is the sticker shock for the patients who are asked to pay.
Yet those who work in the health care industry and those who argue over
health care policy seem inured to the shock. When we debate health care
policy, we seem to jump right to the issue of who should pay the bills,
blowing past what should be the first question: Why exactly are the bills so
high?
What are the reasons, good or bad, that cancer means a half-million- or
million-dollar tab? Why should a trip to the emergency room for chest pains
that turn out to be indigestion bring a bill that can exceed the cost of a
semester of college? What makes a single dose of even the most wonderful
wonder drug cost thousands of dollars? Why does simple lab work done during
a few days in a hospital cost more than a car? And what is so different
about the medical ecosystem that causes technology advances to drive bills
up instead of down?
Recchi’s bill and six others examined line by line for this article offer a
closeup window into what happens when powerless buyers — whether they are
people like Recchi or big health-insurance companies — meet sellers in what
is the ultimate seller’s market.
The result is a uniquely American gold rush for those who provide everything
from wonder drugs to canes to high-tech implants to CT scans to hospital
bill-coding and collection services. In hundreds of small and midsize cities
across the country — from Stamford, Conn., to Marlton, N.J., to Oklahoma
City — the American health care market has transformed tax-exempt “
nonprofit” hospitals into the towns’ most profitable businesses and
largest employers, often presided over by the regions’ most richly
compensated executives. And in our largest cities, the system offers lavish
paychecks even to midlevel hospital managers, like the 14 administrators at
New York City’s Memorial Sloan-Kettering Cancer Center who are paid over $
500,000 a year, including six who make over $1 million.
Taken as a whole, these powerful institutions and the bills they churn out
dominate the nation’s economy and put demands on taxpayers to a degree
unequaled anywhere else on earth. In the U.S., people spend almost 20% of
the gross domestic product on health care, compared with about half that in
most developed countries. Yet in every measurable way, the results our
health care system produces are no better and often worse than the outcomes
in those countries.
According to one of a series of exhaustive studies done by the McKinsey & Co
. consulting firm, we spend more on health care than the next 10 biggest
spenders combined: Japan, Germany, France, China, the U.K., Italy, Canada,
Brazil, Spain and Australia. We may be shocked at the $60 billion price tag
for cleaning up after Hurricane Sandy. We spent almost that much last week
on health care. We spend more every year on artificial knees and hips than
what Hollywood collects at the box office. We spend two or three times that
much on durable medical devices like canes and wheelchairs, in part because
a heavily lobbied Congress forces Medicare to pay 25% to 75% more for this
equipment than it would cost at Walmart.
The Bureau of Labor Statistics projects that 10 of the 20 occupations that
will grow the fastest in the U.S. by 2020 are related to health care.
America’s largest city may be commonly thought of as the world’s financial
-services capital, but of New York’s 18 largest private employers, eight
are hospitals and four are banks. Employing all those people in the cause of
curing the sick is, of course, not anything to be ashamed of. But the drag
on our overall economy that comes with taxpayers, employers and consumers
spending so much more than is spent in any other country for the same
product is unsustainable. Health care is eating away at our economy and our
treasury.
The health care industry seems to have the will and the means to keep it
that way. According to the Center for Responsive Politics, the
pharmaceutical and health-care-product industries, combined with
organizations representing doctors, hospitals, nursing homes, health
services and HMOs, have spent $5.36 billion since 1998 on lobbying in
Washington. That dwarfs the $1.53 billion spent by the defense and aerospace
industries and the $1.3 billion spent by oil and gas interests over the
same period. That’s right: the health-care-industrial complex spends more
than three times what the military-industrial complex spends in Washington.
When you crunch data compiled by McKinsey and other researchers, the big
picture looks like this: We’re likely to spend $2.8 trillion this year on
health care. That $2.8 trillion is likely to be $750 billion, or 27%, more
than we would spend if we spent the same per capita as other developed
countries, even after adjusting for the relatively high per capita income in
the U.S. vs. those other countries. Of the total $2.8 trillion that will be
spent on health care, about $800 billion will be paid by the federal
government through the Medicare insurance program for the disabled and those
65 and older and the Medicaid program, which provides care for the poor.
That $800 billion, which keeps rising far faster than inflation and the
gross domestic product, is what’s driving the federal deficit. The other $2
trillion will be paid mostly by private health-insurance companies and
individuals who have no insurance or who will pay some portion of the bills
covered by their insurance. This is what’s increasingly burdening
businesses that pay for their employees’ health insurance and forcing
individuals to pay so much in out-of-pocket expenses.
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http://healthland.time.com/2013/02/20/bitter-pill-why-medical-b |
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