(Illustration: Alex Nabaum…)
The story of 11-year-old Ella Moser's $5,000 tummy ache begins in October, when her Studio City parents called their pediatrician one night and were advised to go to an emergency room, just to be safe.
Ella's father, John Moser, was mindful of the fact that emergency room costs can be sky high. He's the son of a doctor who teaches medicine at Yale and has written several articles about excessive medical testing and overcharging. But Ella was in a lot of pain and as the pediatrician had advised, it might be smart to rule out appendicitis and other serious ailments.
So they went to Providence Tarzana Medical Center's emergency room, where Moser handed over his insurance information. He had lost his job in TV production, and later bought his own medical insurance. To keep the monthly premiums manageable, he went for a plan with a $5,000 deductible.
"I kept asking, 'Is this really necessary?' " said Moser, who first questioned the emergency room staff about the need for an IV drip to administer a saline solution.
The staff agreed not to do the saline solution. After some blood work, the doctor recommended an ultrasound, which Moser questioned. He relented, though, when the doctor said it wasn't absolutely necessary but would rule out anything serious. And it did, so Ella went home with what was diagnosed as nothing more than an upset stomach, from which she quickly recovered.
But when the bill arrived, John Moser felt a sharp pain in his own gut.
The cost for just walking in the door of the emergency room? That came to $1,288. The ultrasound nicked him an additional $1,135. A comprehensive metabolic panel (blood analysis) was billed at $1,212.
Moser was also charged $158, accidentally, for the saline solution he had turned down. The total came to $4,852.55, not counting separate bills that would arrive later and total nearly $1,000, including $540 for pathology and $309 for the doctor.
"I was shocked," said Moser.
The first bill, $4,852.55, was confusing, as medical bills often are. It said "your health plan has recently made a payment on your account." It said the balance, $2,571.85, "is now your financial responsibility."
When Moser mentioned the bill to his father, Marvin Moser flipped.
"Yes, the fees in ERs are off the wall all over the country," the professor of medicine told me, but he found Tarzana's to be extraordinary. "The one thing that stands out, beyond belief, is $1,212 for a metabolic panel."
That's a test, Dr. Moser said, in which a technician draws blood for chemical analysis, and it takes just minutes. Moser questioned not only the charge, but the usefulness of the test in his granddaughter's case.
Out of curiosity, I went online to see what a lab might charge for a comprehensive metabolic panel.
Some labs advertise prices as low as $39.
Glenn Melnick, who teaches hospital economics at USC, was not surprised.
"By and large, these prices are fictitious numbers," said Melnick, who argued that Tarzana and most other hospitals routinely charge astronomical fees, especially for emergency room services.
Of course, and it's all part of a years-long game in which the charge for service, the true cost of the service, and the acceptable payment are in three different orbits. And that doesn't even take into account how the charges are adjusted up or down depending on who's paying them and whether they have worked out a deal. How can patients hope to make sense of such an indefensibly convoluted system?
Starting Monday, President Obama's healthcare reform act will get a hearing before the U.S. Supreme Court. But how can you have an honest conversation about soaring healthcare costs and health insurance, Dr. Moser asked, without addressing the maddening fictions built into the system? Patients seldom know in advance what they are being charged, he said, and many later find themselves in "medical bill bankruptcy."
Melnick said hospitals argue that they lose money providing service to the uninsured, and by not getting reimbursed enough for Medicare or Medicaid patients. There's some truth to that, Melnick said, but prices are set artificially high to help balance the books on the backs of paying customers. In the case of a $1,200 charge for entering an emergency room, Melnick said, the Medicare reimbursement is likely to be $300 or less, and far closer to the hospital's true cost.
"Hospitals have figured out they can rapidly increase charges in the ER," Melnick said, "and that will lead them to get higher amounts even from insurance companies they negotiate with."
This is a very big deal, Melnick said, because half of all patients admitted to a hospital in California go in through the emergency room. Melnick said there's also been a huge increase in the number of patients who lost group coverage and purchased individual plans with high deductibles, making them more vulnerable to exorbitant charges.
"More and more, people are seeing their deductibles eaten up on one visit."