“Knee replacement, or knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability.” –Wikipedia
After 87 years, the cartilage separating my left leg bones had eroded, and the leg went off in unexpected directions (I could be mistaken for an old man). I considered knee replacement, but like any normal person I put it off and off.
“Use my doctor” was the repeated refrain from the ever-increasing number I encountered that had already had it done—by 2030 it is projected that 3.4 million in the US will have had this increasingly popular operation.
I took advantage of my position as WestView publisher and called the PR office of the Hospital for Special Surgery (I mean this is THE hospital for this kind of thing) and got the name of Doctor Geoffrey Westrich, the First Vice President of the Eastern Orthopedic Association. (He obtained a degree in engineering at Tufts before switching to pre-med, so he knows the knee both mechanically and surgically. He is listed in New York Magazine’s Best Doctors and is a very good surgeon—probably the best.)
My operating room was the very last in the long corridor that wrapped around the building. They wheeled me past forty other operating rooms (this is truly an OPERATING hospital) and bang they put me to sleep. I awoke in a private room with nice nurse after nicer nurse for three days. Then at-home Visiting Nurses came to instruct me in physical therapy, but I was too tired and too weak to do it—I just wanted to rest.
And suddenly it was four months since the operation and I got a call to remind me that I had a check-up with Dr. Westrich on a rainy Monday. I subway-ed and cabbed my way to 532 70th Street, where the hospital hangs over the grey rushing waters of the East River.
I was greeted by the golden glow of smiling young John Powers, assistant to Dr. Westrich. John, a white-coated medical student planning to become a surgeon, dropped his ubiquitous smile to say he had decided to go to Rome for six or seven years to become a priest.
John is so naturally nice I found myself thinking about writing an article about “niceness.” He had been on his way to correct physical ills with a scalpel and now would correct spiritual ills with niceness—equally sharp.
“How much do you think my knee operation cost? “ I asked nice John, and he looked inward and searched for a number like $10,000 -$20,000 dollars.
Then I asked the very nice practice manager, Denise Palacios (the favorite aunt of a growing Italian American family) and she too turned inward and guessed incorrectly—
$30,000-$40,000
Then I asked Dr. Westrich, and while he guessed higher, he did not know what the operation cost.
Hmm. If even the surgeon and the First Vice President of the Eastern Orthopedic Association does not know what an operation he performers at least twelve times a week costs the patient, we have a problem—and that problem is that medical costs are locked into what Medicare, Medicaid and the insurance companies have agreed to pay. The hospital accounting department writes a bill and that’s it—they don’t even bother to send the patient a copy.
Now the Hospital for Special Surgery is an old hospital with smallish rooms and mine was no exception, but it cost me $4450 a night until they moved me to a semi-private room at $5450. The total for three days was $15,350.
“How much was your fee?” I asked Westrich. He quickly responded that it was tied to what Medicare would pay, though I recall he also threw out a number like $10,000 to $12,000. Still not bad if you do twelve operations a week
My first knee doctor had to give up surgery because the insurance was in excess of $100,000 and he did not perform enough operations to pay for it.
So some weeks after the operation I got a bill that said I owed the hospital $1260.30—I paid it but I was curious to know the whole bill. You don’t get a bill if you don’t ask for it. So I called the doctor’s business manager and the accounting department, twice, and finally got it—$66,731.00.
The Sunday night before I saw Westrich, I was watching 60 Minutes when a commercial came on for the Hospital of Special Surgery. I wonder how many millions they spend on TV ads. And they are not alone—all the big and even the not- so-big hospitals trot out “ex-patients” relating how everybody gave me up for dead, but here am I alive thanks to [insert name here] hospital.
So what is the moral of this experience?
If even your surgeon does not know the final cost of an operation he performs, we have lost a realistic relationship between what it actually costs to deliver medical services and what we are paying in taxes and insurance to get it. We pay more for medical services than most advanced countries, and it is not always the best.
Here in the West Village after 161 years we lost our hospital—it ran out of money and could not pay salaries. So they locked the doors, nailed plywood over them, and sold the buildings for peanuts to a 3rd generation developer to build luxury condos.
But wait.
On Sunday March 22nd I felt nauseous and vomited then vomited again and again and again. I called my primary physician, and he said call a 911 ambulance and go to Healthplex. I did and they sent my North Shore LIJ ambulance to Lennox Hill Hospital where they shoved a tube down my nose to my stomach to evacuate its contents (an ISIS torture) and then they operated to remove an obstruction. One week in the hospital with the worst food I have ever encountered—I had to have the nurses go out and buy something I might eat.
OK can you guess the bill?
$72,475.49
And hey, the daily room cost was $7025 not the $5450 that the fancy Hospital for Special Surgery charges. Lennox Hill was going broke, and they got bought out by North Shore LIJ, so I guess they upped the charges to get profitable again.
In just a little more than 3 months, I generated $140.470.49 in fees for two of the wealthiest hospitals in New York.
We pay $8,233 per year for our health care—two and a half times more than most of the nations of the world like France, Sweden and the UK.
Here in the West Village we can’t get one of the rich hospitals to offer a trauma-one emergency room to treat heart attacks and stroke—if you have a heart attack you are expendable according to good “hospital” financial management.
Home Depot billionaire Kenneth Langone donated $200 million and NYU renamed its hospital after him.
The West Village has a few billionaires who—instead of giving $130 million to build a funny looking concrete island—could build a hospital.
We would name it after him.
Stop the Presses!
No sooner did I finish the above article than I got a call from Lydia Dalley, the patient advocate at the Hospital for Special Surgery, saying somebody from accounting would respond to my e-mailed questions. Bang, minutes later I got the call—when I expressed dismay at a $66,731.00 bill for a sixty minute operation and a three day hospital stay the staffer who asked “don’t use my name” responded that they only received $15,949.81.
Similarly, Lenox Hill Hospital, where they removed the obstruction in my intestines, revealed they received $27,607.63 out of the whole bill of $72,475.49.
Wow, it seems that they bill these crazy amounts, but Medicare pays only a fraction. “We even know what Medicare is going to pay, but we send the same big invoice.”
It seems that different payers have a different tolerance for a bill—some insurance companies pay more and a Saudi Oil Prince pays the whole bill. She actually believes they do on occasion collect the whole crazy amount.
Medicare accounts for about eighteen percent of their customers. When a patient has no insurance, they work out a deal—“we are very generous”—reducing the cost of the operation and offering time payments.
“Yes,” she agreed it is “crazy billing.” She said “I have been doing it for thirty-five years and maybe that’s why we are trying to get a better system.” I guess “better system” is a reference to Obama Care.
My daughter Athena complains that Obama Care is too expensive, and I have heard that complaint before—but if for thirty-five years the Hospital for Special Surgery has been sending the federal government invoices on which they know they will only collect one tenth the amount, we have a bit of craziness built into the bureaucracy.
Now, logic would unravel this, but what has logic to do with political solutions?
Oh, oh, and I had one item:
BLANKET, WARMING UPPER BODY $34.00
Gee, they never sent me home with this blanket—oh wait I know—the $34 was for putting it on.
Hi George—
Your article is good, it gives a feel for what billing means to us, docs and civilians alike. Doctors really don’t know all the details of billing, it’s just too complicated. That’s why we have entire billing departments or billing companies that do this.
Of course, the insurance companies, Medicare, and Medicaid have their people looking over the bills to see that the inflated charges don’t go through. It’s a real cat and mouse game for very big bucks.
I looked at the bill you sent in the previous email and to be honest, I couldn’t understand all the charges either, since they use technical billing language rather than straight medical language. By the way, some of these bills aren’t just a little bit higher then what is allowed, sometimes they are several times as high.
Also, what is billed and what they get are two different things. Often the companies and Medicare/Caid will actually pay a fraction of what the hospital is asking for. The actual amount received is more interesting then what is billed, which is often in Fantasy Land, but it’s hard to get this info.
If you remember, when the Healthplex was opening up I tried to find out what the fees would be and the billing people didn’t give me a straight answer. Either they didn’t know, because all of the fudge factors and negotiated rates hadn’t been calculated yet, or they just didn’t want to give proprietary info out to the press. If you remember some of my first articles in WestView about a single payer health system, this is one of the reasons. It greatly simplifies billing and institutions, or doctors, can’t do funny things with billing when it all goes into one computer with one set of rules.
Alec Pruchnicki, MD
