Consider the Costs of Care

By Fine, Bryan R. | Medical Economics, December 25, 2012 | Go to article overview
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Consider the Costs of Care

Fine, Bryan R., Medical Economics


One physician's experiences bring medical expenses into focus

My right leg was shattered. The tibia was in pieces and the fibula was completely displaced. The x-ray would confirm as much an hour later, but the situation was immediately apparent as I lay on my back, the engine of the overturned snowmobile still humming a couple of yards away. I looked down and saw my foot laying unnaturally flat on the packed snow. I tried to wiggle a toe, but I couldn't

My sister ran toward me in her snowsuit and rested my head in her lap. Then came a brutal, seemingly interminable sled ride down the mountain, with every imperfection in the snowy trails stabbing into my leg and shooting shocks up my spine. After I was transported via ambulance to a nearby clinic, x-rayed, drugged, and splinted, a second ambulance drove me 100 miles or so from Whistler, British Columbia, to a Vancouver general hospital, where I spent the night awaiting surgery.

Instead of celebrating at my brother's wedding rehearsal dinner, I lay comfortably doped up in a four-bed hospital room. My mother sat in a chair near my mangled leg. She was draped in blankets and trying to sleep in this unnatural position. Across the way, separated from me by a half-closed curtain, a man snored in a deep, sonorous tone.

That night, I started along a path that has made me a better doctor. Not because I had an epiphany after interacting with an aloof physician or because I was a victim of a medical error, but rather because it helped me understand that, as a patient, money really matters.


"How long do you think you'll be in the hospital?" asked a woman from registration.

My eyes grew wide as I sat in the wheelchair. I shrugged.

"Did the doctor give you an estimate?" she asked.

I told her 3 or 4 days. I was a bit distracted, because in 2 hours I was scheduled for the operating room, where a metal rod would be hammered into my tibia.

"We'll go with 3," she said.

Upon receiving a printout some moments later, I discovered that this particular surgery, plus a 3-day hospital stay, cost nearly $15,000 in Canadian money. I put it on my credit card. Later, I wondered what would have happened if I couldn't have afforded the fees, or if my credit limit hadn't been high enough,


Before this injury, I'd had very little exposure to the nickels and dimes that drive medical care. During my residency, the few times the topic came up, it was drowned out by some variation of, "Money doesn't matter; we do what's best for the patient"

Then I took a job working as a hospitalist in an academic center, where faculty members are often far removed from the realities of healthcare costs; the focus, instead, is on protected time and resident work-hours. I never asked how much patients were charged.

As a junior faculty member, I simply put check marks next to Current Procedural Terminology (CPT) codes based on how much time I'd spent and how many "systems" I'd reviewed. Twice a week, I placed those hard-copy billing sheets in a file cabinet, and by the next day they had mysteriously disappeared. In the meantime, I continued to see patients and put check marks next to more CPT codes.

Occasionally, the division director would ask for ideas on how to increase the census. But once, when George W Bush was president and actively championing high-deductible healthcare plans, and before my leg was split into pieces, I received an enlightening phone call from the mother of a patient, asking me to waive some of the fees I'd charged for a lengdiy hospital stay.

"Please consider it," she pleaded on my office answering machine. "We're having some trouble paying."

To my lasting embarrassment, my efforts to problem-solve ended with a conversation with an office staff member, who had no idea where to forward the request She'd never heard such a thing, she said, and then she told me that she would call the family with a general number for accounts receivable.

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