It’s time again for me to use my bad back as a case study in why American health care has such crazy incentives. 

About a month ago at the HLTH conference in Vegas, over the course of a few hours I developed debilitating leg pain. To quote from my earlier twitter  thread on my time in Vegas,  “After 3 days of excruciating pain, my wife insisted I went to the ER. The public policy person in me was horrified but we had already spent our deductible, so the cost was actually lower than paying cash for an MRI”

What actually happened was that after 3 days of dreadful pain & inability to walk (including getting myself home from Vegas using multiple wheelchairs, and being that guy who crawls off the plane onto a wheelchair), I got in to see my chiropractor. He said, you need an MRI to figure out what’s wrong with you. The alternatives were 

1) Get insurance to pre approve the MRI. His guess was that that would take a few days or more. I actually called One Medical‘s urgent care video line and the PA I spoke to told me that usually insurance would only approve an MRI after I had done 6 weeks of physical therapy.

2) Pay $500 cash for a free standing MRI that could probably get me in during the next few days 

3) Go to the ER

Now the “incentives” part of this starts to really matter.

It’s November and due to some unrelated medical conditions my family has already spent the $4k deductible connected to our insurance, which comes from a big regional Blues plan via my wife’s employer. (For you health policy wonks, the employer happens to NOT be self insured, so apologies to those of you in the Boston area but the TL+DR is I am helping your rates go up next year!). Of course 6 weeks from Nov 15 is a new year and my deductible resets on January 1st.

So after we leave the chiropractor’s office, I talk to One Medical on the video line which is where I get the news about 6 weeks of PT required before an MRI (and get prescribed some oral steroids which didn’t seem to do too much). At that point my wife takes over and insists I look up the cost of ER care.

It’s a $150 fee once deductible has been met.

She says, “you are in dreadful pain and need care now. And we aren’t waiting 6 weeks for an MRI, and it costs less to go to the ER than paying cash”. 

This discussion was held at a mall where we stopped for lunch on our way home. She had dropped me off about a 20 ft walk from a table. I tried to walk with my stick but I was yelping in pain so much and going so slowly that three little kids came to help me and get me onto a chair! I could tell that she wasn’t very interested in me doing “watchful waiting” at home.

The local hospital was literally 1/2 a mile from the mall, so after lunch my wife drove the car as close to the table as possible, I basically crawled into it, and she took me to the ER. The ER had a wheelchair which made life easier.

They admitted me and asked lots of questions for the Epic EMR. No I wasn’t thinking about suicide, at least not yet! Yes I drink alcohol. No, I wasn’t there just to get opiates. On the other hand, if they happened to have some….

One thing that they never asked at triage or in my intake interview me was to see my insurance card. And they didn’t have me sign anything, yet…

Al Lewis will get very upset with me and them

Here’s a quick detour as to what Al Lewis & Quizzify tell you to do about ER costs. If you are going to an ER and have NOT spent your deductible, they have a great idea for you. They tell you that when the ER gives you its terms and conditions, you physically write in that you will only pay 200% of the Medicare rate. Medicare pays about 1/10th of what many ERs charge, but once you change the contract and sign it, the hospital can’t get out of it because of the EMTALA regulations they have to treat you. I know this because last year my kid fell off my shoulders in a pool, cut his chin (on my head incidentally!) and we had to take him to the same ER. But because it was during Covid they only let one parent in, and I forgot to tell my wife about that trick. It cost us our $4,000 deductible (about $1.5k a stitch!)

Now remember that this time, I already knew our deductible was spent so my cost for me to go to the ER was going to be just $150. I waited for the payment form to see how or if I could change it as Quizzify suggests but they never gave me one! In fact, I didn’t sign anything until I was already on a gurney. While I was waiting, a clerk came in and had me sign on an iPad. He told me it was my HIPAA authorization, then he had me sign one other thing (not a payment form). Then later he asked for my insurance card, I don’t recall signing any payment authorization, but I didn’t care.

I didn’t care because I knew my max cost was $150. In fact as I was going there to get an MRI, I didn’t want them to think they would only get the Medicare x 200% rate. I wanted them to be incented to give me the MRI, and I specifically asked for it. The doctor told me I might not get it, but then an hour later a spot in the MRI schedule had miraculously opened up! A cynic might suggest that seeing a fully insured patient show up demanding an MRI was too good for Marin Health to turn down.

As it happened, they had pumped me full of opiates which not only got me some relief from the pain for the first time in 4 days but as it turned out was necessary for me to get into the MRI.Had I gone to a freestanding MRI, not an ER, it’s likely that I wouldn’t have been able to actually get into the machine because you have to be able to straighten your leg (somewhat) to fit it in. In fact getting into the MRI was so painful on my leg that they gave me more opiates. But that is of course my post-facto justification for going to the ER.

So now you all want to know the answer. The charges finally appeared on my insurance website. They were 

$17,249.06 hospital

$399 ER medical group (CEP) 

$242 other doctor (I don’t know what that was but it came from a Foundation connected to the hospital)

Of course charges don’t mean anything if you have insurance. BCBS actually paid — $10,263, $235 & $132 respectively (I included my $150 copay in the $10,263)

Total cost = $10,630

Had I done this early in the year, I would either have used the Quizzify technique, in which case the ER (had it been paying attention) would have likely tried to boot me out without an MRI, or I would have suffered through the process of getting the MRI approved, or I’d have paid cash.

So the conclusion is, the incentives to me the patient to not care about cost because I had already spent my deductible–in other words based purely on the date–made a swing of over $10,000 in costs (and revenue) for the system.

And it gets worse, or better. I’m now receiving regular in home physical therapy via Luna (my plan covers that but not Hinge Health,  Sword Health  or Kaia Health which are remote PT care and would be much cheaper). I am getting better–probably about 50% of normal now. But I am likely to go for a steroid shot in my back at the 6 week mark.

Why? I will not go into what needs to be another post on how totally appalling the data surrounding back pain is, and how impossibly bad it is to try to make a decision based on 15 year-old papers that are inconclusive. But if you have a herniated disc or pinched nerve the best option is to try to work it out using physical therapy. The next progression is a steroid shot, and finally a microdiscectomy.

In order to discover what my options were I spoke to my PCP, my chiro and one surgeon. The consensus was to do PT and have a steroid shot if things weren’t better by about 5-6 weeks post-injury. I  tried to get hold of various pain doctors. Not easy. There’s yet another blog post to be written about how far behind the customer service from doctors’ offices is. Literally the internet state of play for most of them is for you to download a PDF, fill it in by hand and fax it in. And then hope they call you back in 72 hours.

Eventually I got hold of two different pain specialists and had very successful video calls with both of them (one via Doximity, one via Zoom connected to Epic). They were both able to diagnose me as I limped around in my office. Both recommended a steroid shot if I wasn’t better in 3 weeks. But one of them was busy for at least 8 weeks!  The other one thought he could get me in before and had his office call me.

I was offered Jan 3. 

Guess what I said. “Can you fit me in before Dec 31?”  Why yes, they could squeeze me in on Dec 27. Of course my deductible resets on Jan 1. So of course I want to have the procedure this year, not next!

I’ll let you know how that goes next year….but my apologies to Boston area insurees.

Matthew Holt is publisher of The Health Care Blog and hopes to be back on skis this winter