Money
Included here are the first two bills I have received for my treatment. The bill for $1646.31 was the first one I received. You may wish to rotate it; I couldn’t figure out how to do that on this device.) Before I paid it I got another one for 5542.20. It thus includes the 1646.31. (Don’t worry, I paid the second one, so I’m up to date.) There were still by my estimation 25-30% of the radiation sessions to go, so there is perhaps roughly several thousand yet to be billed. (We will see.) I still have at least one physician consultation later this month.
The item dated 10/7/21 is labeled “TX DEV DESIGN&CONSTJ CPLX.” TX is medical code for treatment. (You are probably familiar with the Rx shorthand for prescription.) Like every item on the bill, there is an entry here for “insurance adjustment.” My insurer (i.e., the one Wright State contracts with to provide health insurance for its employees) is Anthem. They immediately applied an “insurance adjustment,” which I understand to mean the amount of the doctor’s charge for design, $385.31 (cheap, it seems to me) they will not pay. The 385.31, analogues to which appear throughout the statement, is like the sticker price a dealer announces for a car, or a list price for a home. Subtracting that 111.49 leaves 273.82 for me to pay. Depending on market conditions, the actual price paid can be in the case of a house greater, while ordinarily for a car it will be no greater. And so far, for the physicians’ announced price, the actual price paid by insurance company (0 here) and me 273.82. I suspect this allows the party that negotiated on behalf of WSU with Anthem to get the contract to insure its employees to boast in future negotiations with all potential business partners about the discounts they “achieve” for their customers.
The next block of charges is charged on10/29/2021. The first line apparently (it took some work to find some hints online) is Intensity Modulated Radiation Therapy Plan, the drawing up of which includes calculation of Dose and Volume, and HISTOS, which as best I can tell is not “Histories” but “Histologies,” the analysis by the planners of tissue, probably taken during my biopsy. (As best I can recall I had no tests done, other than a PSA test to see whether the cancer might be growing (apparently not) between diagnosis and the first day of treatment. Blood as far as I know is not considered tissue.)
Once the plan has been drawn up, then the plan for me had to e designed (second line on 10/29) for the machine I was treated with (MLC, Multi-Leaf Collimator). You might say these are just different descriptions of the same task, but the second task is a bill for essentially programming a computer. (When I was going in there for treatment one day the technicians described this process briefly.) Dosimetry (line 3 on 10/29), I have discovered, is the calculation of the actual dosage that will come out of the machine. (I am not clear what is distinct about this.)
So the sticker price for all of this was $8135 and change. (I confess puzzlement about the charges after the decimal points, the cents.) The insurance company at least looks like it bargained the price down for each of the above three items, leading to a (perceived, anyway) “savings” of $4013.92 + 1049.63 + 488.20, and then according to the terms of its contract with WSU split the $3518.89 the doctors originally wanted to charge between it ($2146.40) and me ($1372.49).
Each radiation treatment (page 2) had a sticker price of $756 and the part the insurance company paid was $205.46 (the amount it refused to pay varied by a few cents sometimes, for whatever reason), leaving me with about $50 a day.
The final item on p. 2 is not-quite-weekly consultations with one nurse and with physicians, usually the one directing my treatment, but sometimes others in the same radiation-oncology practice. During these consultations, each physician seems to have billed $2786 for “Dlvr,” and guidance for placing the CT (as in CT scan — computerized tomography it appears). What I remember of each of these consultations was that the physicians said they could say where the radiation was being targeted, with which they were satisfied. But (not because of any fault of theirs, just technological and anatomical constraints) they couldn’t see at any point during treatment whether the cancerous tissue was shrinking. Every doctor’s appointment after the first (pretty much orientation) I was asked if I was having side effects. Only once did I, for difficulty urinating. A medicine was immediately prescribed, and things got quickly better but the problem still crops up if I fail to take it one day. (After my last treatment I was told by the nurse, with whom I consulted separately on the same days I consulted a physician, that radiation would continue to do its thing before — and as someone who loves the English language I loved the way she put it — “after a couple of weeks it will half-life off.”)
The entire billing system is based on billing codes, five-digit numbers created In the 1960s and modified periodically since by the American Medical Association. These are number that insurance companies (and Medicare) use to reimburse medical firms. (Recall that these are increasingly large firms that employ many doctors, nurses, administrative personnel and others.) They are not defined around medical condition but by the nature of the medical task.
Radiation-oncology-service treatment (i.e., therapeutic) codes are found in the 70000s, along with X-ray, CT, MRI and ultrasound (often diagnostic). Planning and implementation of radiation treatment in particular is found in the 77000s. (The AMA protects the whole list as intellectual property.)
Alas, given the complete reliance of insurers, Medicare and Medicaid on the AMA code, no doctor can get reimbursed (through any means other than direct compensation by the patient) unless his treatment method is codable. Some recent research, alas, indicates that innovation in medical procedures (which, unlike drugs or medical devices, receives no intellectual-property protection) is hampered by this extra bureaucracy, and that approved procedure innovation is disproportionately found in specialties rather than in general practice. Of course, procedure innovation is not destroyed by this. Doctors, after all, generally want their patients to get better, and may want the gratification that comes from having their new procedure be researched and published in a medical journal. But perhaps procedure innovation is not what it could be.
Speaking of not what it could be, I estimate that when all is said and done my out-of-pocket expenses for radiation treatment and the associated doctor visits will cost between $8000 and $9000. As I was diagnosed in January but my treatment didn’t begin until November (although I had a couple of other doctor visits before), I had plenty of warning. Thus, I started saving well in advance. There will be a significant cost in terms of whatever else I could have spent the money on (including saving it), but it will not be a problematic financial burden. And with respect to saving, it is often said (by my Japanese wife, notably but now inaccurately apparently because of years of economic difficulties in Japan) that Americans don’t have the discipline to save for the emergencies that, over the course of a lifetime, are inevitable.
And yet, how could a reasonable person deny that cancer treatment for even an insured person who is poor, let alone one who is not insured, can be a financial catastrophe? Having said that, charity care is common throughout the medical system, and there is the Medicaid program (which some doctors admittedly do not participate in) for the poor. But still, it is well-known that health-care expenses consume a far higher percentage of GDP in the US than in all other advanced countries, maybe all other countries. The reliance on third-party payment(which gives neither doctor nor patient any reason to economize), exacerbated to some extent by special-interest demands that these third parties cover treatments of dubious value, along with the fact that so much medical compensation is determined by political processes, makes this I suppose inevitable.
Of course, the big issue is not just what we pay, but what we get. And this is complex. The literature on how cancer is treated in different countries seems to look at five-year survival rates. According to these data, this metric (a better one would look at average length of life given detection of cancer at a given age, along with measures of the quality of life after diagnosis, but such data do not exist) the US system, with its very high costs but ease of using the most advanced treatment regimens, does very well with respect to breast, lung and (yes!) prostate cancer, not quite so well in stomach cancer. Once we standardize for differences in rates of confirmation through diagnosis among people who actually have cancers (which I would guess is high in the US because of all the testing done here, partly in fear of malpractice litigation) it might be that the U.S. does even better compared to, say, South Africa, which along with Tunisia reports 100% survival rates for prostate cancer.
It is all speculation at this point, but I feel the quality of care I have received is high, and delivered very professionally. With one exception (when my oncologist decided to cancel the Space Oar procedure referred to previously, but somehow his office was convinced that it was I who had canceled it), I have been treated with great respect. As far as I know (and therein of course lies the rub) I am getting more or less state-of-the-art treatment, because of the requirements of licensed physicians to keep up with the literature. Still, even for someone like me who seeks the relevant information, the lack of transparency in our health-care system is a big problem. One cannot compare physicians and the companies that employ them unless one has information to use in the comparison. For sure, getting cancer treatment is not like buying a suit, and so perhaps the ability of the patient to educate himself is inevitably limited. Still I feel we could do better.
Finally, is $8000-$9000 too much to pay out of pocket? Of course not. I am getting treatment that my oncologist and urologist think will extend my life for years. (We will have a better idea, though not be certain, after Jan. 18.) Would I have that kind of money lying around if I were poor? Probably not. Might I get it anyway, and be stuck with major medical debts? That is my understanding, although often the reporting of this phenomenon is anecdotal. What is the best way to arrange for health-care provision? Beyond making health insurance not tax-deductible, as salary is not, and therefore restraining gold-plated insurance, a problem since the 1940s, I can only say that it is a difficult question, that requires careful moral reasoning, which is in very short supply in the US in 2022. The world is full of tradeoffs. It is also full of people who acknowledge that they exist, and those that don’t.
Finally, I note that today, as I was writing this post, I got a notice from Anthem that they have approved covering my treatment, 2 1/2 weeks after it was completed. 🤔