Claire was admitted to Penrose Hospital's emergency department after a lengthy wait. She received morphine along with an anti-nausea medication via an IV. A CT scan of her abdomen was performed and she also had a number of tests.
Staff at the hospital ruled out appendicitis. They suspected Claire had a ruptured Ovarian Cyst. This can be an innocuous part of menstrual cycles, but can also cause discomfort and pain. The pain disappeared after a few days and a chemistry test using gritted teeth.
The bill was then sent.
Patient:Claire Lang-Ree is a 21-year old Stanford University student. She was studying remotely while living in Colorado for a few weeks. Through her mother's work in Northern California as a pediatric nurse practitioner, she is insured by Anthem.
Total bill:$18,735.93 including two $722.50 charges for a nurse who "pushes" drugs into the patient's IV. This takes only seconds and costs $18,735.93. Anthem negotiated $6,999 for the entire treatment. Anthem paid $5578.30 and Lang-Rees owed $1270.45 to hospital. Additional bills for radiologists, other care, and other costs were also incurred. (Claire also paid a $150 copay to the ER.
Service ProviderPenrose Hospital, Colorado Springs is part of Centura Health's regional network for health care.
What gives?Hospitals are now able to charge for services that were previously included in an ER visit or a hospitalization, but have also added new fees to boost billing. This is known as "unbundling" in the health industry. This is analogous to airlines charging extra for checked bags or exit row seats. In the medical industry, separate fees have been introduced for ever-smaller parts of care. One of these fees is a charge for medicine to be inserted into an IV line. It's also known as a "push-fee".
Claire paid $9,885.73 for a CT scan. However, Claire and her mother found push fees the most frustrating. Note to readers: Scans can often be more costly in an ER than elsewhere.
Claire says, "That was so absurd," and adds that she has taken the anti-nausea medication they gave her before. It's available as a tablet for about the same price as a cup of coffee. No IV is required. It works great. "Why wasn't this an option?"
The average cost of Claire's first IV Push in Colorado has almost tripled since 2014. In addition, hospitals have received more money for the procedure than they used to. The cost of IV pushes in Colorado Springs rose more than anywhere else.
The average Colorado Springs nurse earns $35 per hour. Penrose charges $35 an hour for a push of the plunger. This would be nearly 21 hours.
Claire shared a room with her roommates and the hospital charged Claire for one "IV Push" which was more than Claire's monthly rent. Anthem didn't pay the push fees as part of its negotiated payment. However, claims data indicates that Penrose received an average of $1,000 for their first IV push in 2020. Patients who did not have insurance to cover such charges would remain with Penrose. According to the claims database, Colorado hospitals received an average of $723 per code.
"It's crazy the variation in prices that we see, and there's not rhyme or reason," Cari Frank, of the Center for Improving Value in Health Care in Colorado, says. The Colorado nonprofit runs a statewide claims database. It's simply that they were able to negotiate the prices with the insurance company, and the insurance company decided to pay it.
According to data published by Colorado Division of Insurance, Penrose charged Claire more than the average Colorado hospital for Claire's care.
Frank said that even with the negotiated rate it was still $1,000 less than the average payment for having children.
Centura stated in an email that it had "conducted a thorough analysis and determined that all charges were correct". It also explained that the Emergency Room (ER), must be prepared for "any and all that comes through its doors." This requires highly-trained staff and equipment. All of this can lead to high operating costs, and patient responsibility.
Researchers have shown that hospitals are charging skyrocketing particularly in an emergency room where patients have few options. According to U.S. Bureau of Labor Statistics data, hospital markups more than doubled in 1999 according to a report by National Nurses United. Anthem referred to the rising hospital prices as "alarming" in an email.
Ge Bai, an associate professor in accounting and health policy at Johns Hopkins University says that when patients receive large bills, it's not just the hospital's fault. A lot also depends on the insurance company. The negotiating power and price of the payer (in this instance Anthem) are key factors in determining the negotiated price.
Bai stated that most insurance companies do not have the same bargaining or negotiating power as hospitals. Prices in Michigan, where Bai stated that the UAW union covers a large proportion of Michigan patients will be very different from those in Colorado.
Patients might mistakenly believe that insurers are wallet defenders.
She says that insurance companies aren't as aggressive in negotiating cases as they could because they make a profit on a percentage of claims. They can extract more money the more expensive the actual payment.
Although Anthem waived the push fees, the hospital paid 30% more than the Colorado Level IV emergency room visit. It also paid four times what Medicare would allow for the CT scan.
Resolution:Claire and her mother decided to fight the bill by writing letters to the hospital, and looking for information about the cost of the procedures. They were furious at the high cost of the CT scan and IV pushes. The hospital demanded more information.More than twice the amountFor a CT, you will pay less than top-rated hospitals in 2019
However, the threat of collection wore them out, and they eventually paid $1,420.45 for their share of the bill. This was mainly coinsurance.
Claire says that Claire was unable to graduate college with good credit because it became too much.
Bai and Frank believe that Maryland could be a good benchmark for medical bills because it determines the prices that hospitals may charge for each procedure. The Maryland Health Care Commission data shows that Claire and Anthem paid nearly 10 times the amount they would have paid to have their CT scan done there and seven times the price she would likely have paid for an emergency department Level IV visit. In Maryland, intravenous pushing costs about $200 per unit in 2019. A visit like Claire's in Maryland would have cost $1,350 to a typical Maryland hospital, while the Lang-Rees would have gotten $270.