Health Care Confidential: Self-Pay In America

The health-care reform debate has become so poison- and rhetoric-filled that it's really easy to lose sight of the primary issue: How are individuals affected by our current health-care system? Before we can support change, or dismiss the need, it's important to grasp what truths our neighbors and friends are living with daily, the realities they must accept. In these essays, four local adults describe their lives as shaped by their work and families, and their corresponding health-care coverage. From a doctor's lament to a firsthand reckoning of end-of-life counseling to an eyes-wide-open account of an uninsured heart attack waiting to happen, our essayists offer a very personal view of why changes are needed in our current health-care system.

Dean Novelli, 53, is the author of On A Corner Of Gay Street: A History of the Lamar House-Bijou Theater. Currently training to become a paramedic, he is writing a memoir about his mother, Princess Ruthie, Queen of My Heart.

The phone rang less than an hour after I got home. That wasn't a good sign. When I left the hospital, I was told test results would be available to my family physician in 24 to 48 hours unless... unless it was bad news. And now less than an hour later my doctor's office was calling, "We need you to come in right away."

No, this is not a good sign.

While I pay close attention to my health, I am paying little attention to the current national debate on health care. It appears to have nothing to do with me. Nobody seems to care about the 45 million Americans like me. You see, I'm uninsured or "self-pay" as the health-care providers label me.

Pundits have other labels, and as usual, they're mostly myth. I'm not an illegal alien or a healthy 20-something too cheap to buy insurance. Nor am I a deadbeat who never goes to the doctor till they end up in the emergency room very sick, expecting someone else to pay.

I am a 50-something native-born Tennessean with a family physician I see routinely. I had group coverage till I got laid off. I kept up the Cobra payments as long as I could but with less income and then the responsibility of being a 24/7 caregiver for my stroke disabled mother—an unpaid job I occupied for seven years—health insurance simply became unaffordable. Consequently, I have been a self-pay health consumer for over 10 years.

According to the journalist T. R. Reid in his new book, The Healing of America, being self-pay in America is the equivalent of living in a third-world country. You get all the health care you can afford.

Another way of looking at it is, just as I take personal responsibility for my health, I am personally accountable for paying for my health care.

Being self-pay requires a different strategy than being insured. Economics forces me to approach consuming health care as I would any merchant wanting my business. It's about educating yourself and knowing value. It's about buying all the care you need but not procedures that don't add value. And it's about watching out for shady business practices.

But most of all, it's about being proactive. I follow the adage, "An ounce of prevention is worth a pound of cure." That's why, even though I had no symptoms, when a chance event led to the discovery of an abnormal electrocardiogram —the paramedic asked, "Hey buddy, you ever have a heart attack? No? Well you're goin' to!"—I followed up with a visit to my family physician.

"You need a stress test," my doctor said, "I'll have my office set up an appointment at the hospital."

It sounds simple enough and if you're insured you probably don't even think about all the people and material involved when a doctor orders a procedure for you, let alone cost unless you have a co-pay.

Do you get your car repaired, buy a washing machine, or have your house painted without knowing what it will cost? Of course not. Why buy your health care that way? Because you're insured? It's an invitation to be exploited.

How much does a stress test cost? For what is a routine procedure, it's not an easy answer to get. There is the hospital bill where the procedure takes place, the cardiology bill (they supply a tech to monitor the test and a doctor to read the EKG results) and the radiology bill (they read the imaging results). Three separate businesses to contact and get a quote from.

Before I ever took the test, I had three prices and three different discounts. Yes, discounts. Another myth about the uninsured is we pay more for health care. Straight-up cost comparisons (between self-pay and insured) are difficult, but every provider I deal with offers me a "cash discount" for paying my bill in full at the time of service. If they don't offer, I ask, and so far I always get a discount.

It's a cash-flow issue any business owner understands. Collections cost time and time is money. And collecting from the insurance industry takes lots of time, hence insured costs are higher. They'd rather have one dollar in hand from me now than try to collect two dollars from an insurance company sometime in the future.

Discounts on my stress test ranged from 10 percent from the cardiologist, 40 percent at the hospital, to 50 percent from the radiologist.

My family physician offers a straight 20 percent off everything thing done at his office, but unfortunately he makes everyone pay the basic office visit fee in advance. Why? Because so many of his insured patients walk out without making their co-pay.

Knowing the price in advance doesn't prevent a poorly run business from attempting to overcharge you. Three weeks after I paid the hospital in full (or so I thought), they sent me a bill for an additional $1,500, more than doubling the cost.

"Bullshit," was my reply. Their response: the first price was only an estimate. I was having none of it. Nobody said anything about estimates. This was a simple test hardly more complicated than rotating the tires on your car. I negotiated a price in good faith and that was the price I was asked to pay on delivery of services.

Still the hospital persisted. Obviously something came up and a doctor had to order additional services, was their reply. I asked for and was given a "detailed" invoice of charges. One look told me what was going on. Five bundled fees with obscure names and lots of codes. You could hide half the national debt on an invoice like this and I told them so.

"If you expect me pay this bill," I informed them, "then show me a change order with the doctor's signature and mine next to it OK'ing the additional charge." Isn't that what other businesses do when an estimate changes? Why should business practices be any different in health care?

"Bad accounting practices on your part doesn't give you the right to overcharge me weeks later," I told them. "If a car repair shop tried to pull this kind stunt they'd be run out of business and you should too." Three days later, the hospital dropped the bill.

But a well-negotiated price doesn't prevent a negative test result. I trust my family physician and if he says get in here now, I drop everything and go.

"You have a blocked left coronary artery," he announced matter-of-factly. "It's serious and you need to see a cardiologist."

Yes, this is bad news.

It's called a "widow maker" and for good reason. The left coronary artery feeds blood to the workhorse of the heart, the left ventricle. If it goes, you have a massive heart attack, usually dropping dead on the spot. It is the hallmark of the "silent killer" that is heart disease.

The good news? It's a common condition with proven, effective treatments: a catheter to determine the extent of blockage for starters, followed by an angioplasty and a stent, if necessary to relieve symptoms, or in a worst-case scenario, heart-lung bypass surgery.

The bad news? Treatment is expensive. After spending nearly $1,400 on the stress test, I can hardly afford the cardiologist's $200 consultation fee to tell me what I already know, let alone the tens of thousands of dollars the simplest stent procedure will cost. And bypass surgery, if necessary, is simply beyond my means.

What to do? Not wait for health care/insurance reform. If it comes at all, I don't see it addressing the needs of people like me: affordable fees and insurance where a pre-existing condition won't disqualify you from coverage. Right now I live in a different America from the insured. I'm on my own and my uncertain future includes a heart attack, waiting to happen.