Shock treatment
Nathan Welton
The Tribune
May 8, 2005

May Belle Maynard was walking across her front yard last May when she tripped over the edge of her carport, stumbled to the ground and splintered her right wrist.

"It simply was an accident caused by 88 years of walking," she'd later write on an insurance form. "The odds were against me."

Maynard quickly recovered from her complicated surgery and two-day stay at Sierra Vista Regional Medical Center in San Luis Obispo, but she has a new ailment now: sticker shock.

The bill to fix her broken arm topped $31,000.

"The hospital room alone was $5,300," she said recently, shaking her head at the pages of a cryptic statement. "I could have bought it for that much money."

She eventually figured out that "05210519 2350002 SEMIRETRO 02482" simply meant "room." But she still doesn't know what "05240520 3703026 MAC EA ADDL MIN" is, even though she was billed $1,092 for 42 of them.

Her bill is not unusual, and Sierra Vista isn't the only place with such prices. This is just how it works.

The average inpatient hospital bill is more than the price of a new BMW.

At the four local facilities, it ranges from about $30,000 to $65,000.

Patients have seen increasingly higher hospital bills in recent years, and many are perplexed -- often frightened -- when they open the envelope for the first time.

Maynard has Medicare and her late-husband's veterans insurance, so she was covered.

Although the hospital recovered only a small part of what it charged, that's beside the point for this frugal grandmother.

Maynard is just outraged about her statement -- and she wants answers.

Hospitals offer a litany of them: escalating pharmaceutical costs, lower insurance reimbursements, the costs of underwriting care for the uninsured, new technology.

"I don't think there's a single hospital in the state with a profit margin of more than 5 percent," said Sue Andersen, chief financial officer for French Hospital Medical Center and Arroyo Grande Community Hospital. She added that French has steadily lost money since 1997.

But tell that to May Belle Maynard and you won't get far.

Or tell it to the 2 million people nationwide who experienced bankruptcy because of medical bills in 2001.

MAY BELLE'S BILL

Like many seniors living on fixed incomes, Maynard is always scouting for deals.

She carries in her purse a plastic wallet filled with coupons: one for a scented oil warmer, another for $1 off eye drops.

Settling into the sofa recently in her See Canyon home, Maynard leaned over her coffee table, reached for her bill and brought it close to her face. She peered through her glasses at the jargon-filled lines of prices and dates and codes and acronyms all scattered unintelligibly across the page.

They included:

• $1,082 for two bags of intravenous electrolytes, each available online for $5.

• $1,269 for nine doses of the pain medication Demerol, a markup of 14 times above retail.

• $253 for a $3 bag of saline solution

• $996 for exactly 12 minutes of extra surgery time, on top of the base rate of $3,072 billed for the first half hour.

The prices, which include labor, all add up to $31,392.

And that's perfectly normal for a hospital bill.

One patient with a similar injury emerged from two days at a local facility with charges of $55,998.

According to a Tribune analysis of 2003 state data, the average inpatient hospital bills were $28,031 at Arroyo Grande hospital; $30,457 at French; $49,701 at Twin Cities Community Hospital; and $64,492 at Sierra Vista.

Those figures were compiled before Catholic Healthcare West bought Arroyo Grande and French last summer. Also, Sierra Vista's higher figures likely reflect its patients' more serious health problems; the facility has the county's most critical care wards.

That doesn't matter much to Maynard, who became aggravated and threw down the statement.

"They print this so small you can hardly read it," she said, still squinting at the bill. "Supplies and others: $1,900. Radiology: $1,400. Pharmacy-injections: $2,700. Sterile supplies: $2,840."

She lifted her head sharply, gazed out the window and let out a frustrated chuckle.

NOT THE ONLY ONE

If Maynard is annoyed, said health expert Tim Curley, "I don't blame her."

As the vice president of a nonprofit industry group called the Hospital Council of Northern and Central California, he's steeped in the business of medicine.

"Even as an insured patient looking at my bill, it wouldn't be easy to understand," he said. "It's a crazy system."

First, running a hospital isn't cheap.

"How much does it cost for a needle? Tubing? How much does it cost for the tech to open it? The stand? How much does it cost for the nurse to bring it up?" asked Kaye Mickelson, executive director of the County Medical Society. "Every single step along the way, there's a cost factor that's built in."

As a result, charges have little to do with the cost of providing care -- or even with how much a hospital actually receives.

One facility might charge $5,000 for an appendectomy, for example, while one across town could charge $10,000 -- even though it might cost just $2,000 to perform the procedure.

Because federal law requires each hospital to bill all of its patients the same amount for every item, regardless of insurance, only the uninsured face the sticker price.

They often have to negotiate charges with finance staff, and sometimes get sent to collection -- although hospitals say they willingly work with the uninsured and offer reduced rates.

According to a February study in the journal Health Affairs, medical bills -- from pharmacies, doctors and hospitals -- are the leading cause of bankruptcy in the nation, and those who've gone bankrupt in such a way have out-of-pocket costs averaging $11,854.

Medical economics were different a few decades ago, when facilities billed for what they did and were paid accordingly.

"It used to be that it didn't take a rocket scientist to run a hospital," said Sierra Vista business development director Ron Yukelson.

But pricey new technologies came online, the financial burden of the uninsured grew, and hospitals began dealing with government mandates such as minimum nurse-to-patient ratios.

According to Andersen, caring for a patient costs French Hospital an average $2,001 a day in the most recent figures.

So in an effort to recoup costs, hospitals hiked their prices.

MEDICARE FIGHTS BACK

This started to cost Medicare more than expected, so it changed its ways.

In 1983, the government introduced the diagnosis-related group code (DRG), a way to denote the primary ailment or injury a patient is diagnosed with when admitted.

Hundreds exist: a 495 is a lung transplant, while a 294 is diabetes.

With the DRG codes came the decision to pay only a set amount for each one, so hospitals essentially lost control of the billing process.

"When they introduced the DRG," said Yukelson, "the world shifted on its axis."

If someone arrives with a torn tendon and has an aneurysm walking down the hall, the government only pays for the orthopedic ailment.

The severity of the problem also doesn't matter. A significant arm injury could be a shattered bone, a major muscle injury or a tendon tear.

The government still pays the same rate, according to Sierra Vista's chief financial officer Houshang Abd. Medicare figures the average cost of a DRG -- along with the average hospital stay -- and reimburses accordingly.

It might pay a little more if a patient's care was extraordinarily costly or if a facility cares for an unusually high number of low-income or uninsured patients.

"You can send the bill for a million dollars, but you're only going to get paid a certain amount," said Mickelson, of the local Medical Society. "The rest of it? It basically gets written off as a contractual adjustment."

So when Maynard was diagnosed with a 223 -- a complicated arm injury -- finance officers knew they weren't going to get all $31,000 they billed.

Sierra Vista received instead about $5,300 -- what Medicare pays locally for that diagnosis.

But the difference could have been greater.

The average bill in the county in 2003 for a 223 was more than $47,000.

REPERCUSSIONS

Throughout the 1980s, private insurers mirrored the government's refusal to pay more money for health care. Health Maintenance Organization providers started bargaining with hospitals, too.

Over time, hospital charges and reimbursement rates grew to be wholly unrelated.

Private insurers now pay a set amount for each day a patient is in the hospital, no matter what the ailments are. Heart attack, brain surgery, even an infected toenail -- it's all the same.

Hospitals get a bit more if the patient goes to a critical care ward.

Now, although many health experts say charges are almost arbitrary, hospitals aren't going to lower them.

Because of that pesky law mandating equal charges for all patients, hospitals have to bill the same to patients who are admitted and to those treated in the emergency room.

So if they reduced their rates for inpatients, they'd have to reduce their rates for outpatients.

And insurers still pay for outpatient procedures the old-fashioned way, where charges are tied to services provided.

So the hospitals would lose lots of money.

PAYING FOR IT

Back in her See Canyon home, Maynard showed off her repaired arm, running her fingers through her wispy white hair and then petting her fluffy calico named Tinker.

Everything still works, but her wrist bothers her occasionally because of arthritis.

Always scouting for deals and discounts, the grandmother says she just wants to make sure nobody's cheating her Medicare.

"I praise the Lord that I have this kind of insurance," she said. "I do not want to ever take advantage of it."

Pointing to two small scars on her arm, Maynard explained how doctors bolted to her bone an external brace.

"I should have asked for that back," she said sardonically.

She joked of hanging it on the wall, perhaps in a frame.

"I paid for it."