The way health care takes place in the current society of the US is not something I would ordinarily write about in an article of my own, except to as an illustrated example of how one's choices are severely limited by the government interference that takes place. I generally make comments along these lines at sites where authors and/or commenters use the argument that "free enterprise (or the free market) has failed to be responsive to the public" and therefore government must regulate the providers. (See "Universal Health Care is a Fraud" for my entered comments as an example.)
However, it can be beneficial to others to understand that health insurance is not a necessity in order to maintain excellent health, even when beyond age 60. Also, I and husband Paul Wakfer think it benefits us to make it known publicly when we have had an especially good experience with a health care provider (see the January 2003 entry at Kitty Reflects at MoreLife regarding an emergency ureteral stone) and also when we have had a very poor one. This article is about just such a situation - one that we now think is fairly common at Casa Grande Regional Medical Center in Casa Grande Arizona, which has employee physicians who it misrepresents as private practice physicians. This may seem to many as something inconsequential, but it definitely is not. And this practice adds expenses contributing to the upward spiraling health care costs that are fueled by the lack of direct patient oversight of expenditures as exists with customers/clients of other products and services. Imagine the eventual cost of food or car repairs if the customer paid some 3rd party on a monthly basis - or had the same amount as everyone else removed from his/her (hir) paycheck - to cover expenses for those items. Under such a system, how much incentive would there be to optimize one's use of food and to carefully use and maintain one's car or to seek the most cost effective food sources and car maintenance services?
I am not going to attempt to present all the arguments against the current arrangements - or the even more interventionist government methods that some politicians, groups and individuals are promoting. What I am doing here is providing information on a recent experience of our own. Email exchanges are a part of this report so that the reader can see the exact wording used by all parties, and therefore is enabled to reach hir own conclusions about the reasonableness of each - the full text of each is available via the provided link. This is what social preferencing is all about.
Paul has experienced for the past 8 years (since the beginning of March 2000), periodic episodes of a mysterious infection. Physicians in Toronto who saw it at the beginning were unable to diagnose it and even though over the past 5 years it has become little more than a nuisance every 3 to 6 months for a few days, it is something that he would like to eliminate entirely. (Currently, it may even provide some positive hormetic effects by keeping Paul's immune system "on its toes", however 20+ years from now if still persisting it may have resulted in a degenerated immune system.) I wrote about this mysterious malady in a Kitty Reflects entry and it has been discussed at MoreLife Yahoo (example - #497 - 4/7/2004 and #1461 - 2/26/2007 ).
The website of the Casa Grande Regional Medical (CGRMC) has a feedback form - "Ask the CEO" - for the Chief Executive Officer (CEO), J. Marty Dernier. Paul entered a message there on January 28 2008. It consisted entirely of the email he had sent to the billing company from which he had received a bill for $338.12 - the charge for an initial office visit to Dr Mary Joseline Cenizal, who we did not know was actually a hospital employee until the end of the visit when she responded to our inquiry regarding the charges. The purpose of the message was to register Paul's displeasure over the extremely large fee in comparison to that of a very senior physician in the immediate area (Paul Fieldstone, MD - urologist) and ask two specific questions and make it clear what he was willing to pay:
Some questions are in order here. 1) Just who has determined the billing rates for Dr Cenizal (certainly a more junior physician than Dr Fieldstone)? 2) Are these rates taking into account the generally lower fees charged by physicians, dentists, etc in Casa Grande than in the Phoenix area where Resolutions Billing is located?
Although CGRMC gave us a 35% discount of total hospital fees for my wife's urgent requirement for removal of a ureteral calculus in January 2003, I am willing to pay 80% of reasonable office fees similar to those of Dr Fieldstone), which is what I anticipated when I made the original appointment.
Although Paul had stated on the feedback form to the CEO that he wanted a response by email, approximately a week later he received a phone call from a Crystal Weber, who identified herself as Physician Practices Manager for CGRMC. She explained that she wanted to address his questions/concerns and some small conversation on them took place. At the end, Paul told her that her solution was not sufficient and gave the reasons why and asked her to speak to her supervisor. Paul also repeated this desire for email from her and she agreed to send additional remarks by that method. He received an email message from her on February 7, 2008.
Crystal Weber repeated from her phone conversation that she was "only able to offer you the 20% prompt pay discount that we offer to all of our cash pay patients". The bulk of the remainder of the brief message was regarding what could be done in the instance of financial hardship and closed with, "If you have any further questions or would like any information regarding our fees, please do not hesitate to call me."
Paul sent a response to Crystal Weber on February 11, 2008, copied also to Kathy Young, owner of Resolutions Billing, the company name provided on the bill sent supposedly from Dr Cenizal's office and to which questions about it were to be directed. As Paul noted in his first message to Casa Grande Regional Medical Center via the CEO's feedback, what he was sending was also being sent to that billing company. Kathy Young had replied to Paul promptly that the charges were set by the hospital and not by Resolutions Billing. He appended the full text of his original compliant to the CGRMC CEO and also emphasized the need for written record. He brought out some additional points regarding errors of procedure by Dr Cenizal during that visit, her failure to order blood cultures to be drawn during the acute phase of Paul's mystery episodes and in the number and time frame recommended by the testing lab, LabCorp, as referenced to the peer reviewed medical literature. Then there was the fact of the initial distortion by CGRMC, that while Dr Cenizal is a hospital employee the bill was sent in her name only and to be paid to her - something quite bizarre. Paul was quite clear about his displeasure:
I furthermore wish to inform you that as a result of this experience with what I consider to be outrageously high fees even or excellent service (which it was not), I will most certainly never again use the services of any CGRMC physician unless in dire emergency with no other alternative, and I will recommend that any others not do so also.
While Crystal Weber had not repeated her statement from their phone conversation that the setting of setting of fees is 200% of what Medicare will pay, Paul repeated that in his message. "[I]t is clear that self-paying patients are being used to offset the lower fees paid by the government and by insurance companies." In regard to her comments about possible financial hardship, he wrote that this was irrelevant and added:
My concern about the size of your bill and my payment of it is no different than if I were paying for servicing of my car, which would not relate to hardship/poverty, but rather to contractual rights and responsibilities.
Paul included the fact that he would make known this experience of his "in future public writings concerning the status of and problems with the US medical establishment" and closed with the request that his complaint and provided information be forwarded to someone with the authority and responsibility to lower his bill.
Just as Paul had written in his message to Crystal Weber, letting others know of this practice by CGRMC of passing off employee physicians as being in private practice is a major purpose of this article. Hopefully many others will realize that some (?many ?all) of the doctors located at 1780 E Florence Blvd in Casa Grande (immediately adjacent on the west side of the hospital) are not private practice physicians, but actually employees of the hospital itself. The further question arises of how prevalent is this practice throughout the United States, particularly after the IRS ruling that services of private practice physicians at hospitals must be separately billed and declared as part of physician income.
But the saga is not finished and continues with a message from Karen Francis, the Chief Financial Officer of the hospital, received the next day, February 12 2008, copied to Crystal Weber (but not Kathy Young), who confirmed that "our fees are based on 200% of the Medicare fee schedule." She followed that with:
I do not consider this to be an outrageous amount to charge for our services. ..... The only place hospitals and physicians have to make up these shortfalls, when they are not even receiving enough to cover their costs from Medicare and Medicaid and be able to afford to stay in business is to shift part of those under funded costs to
everyone else.
Karen Francis justified this practice, "or else all Hospitals and Physicians would be out of business." She immediately went on to reiterate the hospital's policy regarding self-pay patients, expendingresources "to get people signed up and qualified for Medicaid....However you did declined [sic] that offer and indicated it was not a matter of financial hardship." She closed her message with:
However I do not feel the charges are out of line, we have very few complaints from other patients regarding the charges from our physicians and therefore I am declining to offer more than the 20% discount to you.
Paul replied to Ms. Francis the following day, inline as he almost always does in order to make it clear to the receiver to what he is responding. This (inline replies) is a practice we think is necessary for forthright communication but is often neglected by others, especially when they are purposely avoiding addressing specific issues -and he requested that she do so in the future with him. Those who were privy to the previous exchanges, Crystal Weber from CGRMC and Kathy Young of Resolution Billing were included with copies. The email from Ms Francis was inadequate, as Paul pointed out, because it contained little new information to him and it did not address several important points that had been made previously to Crystal Weber. He went on to present additional evidence that the charge for the initial (and subsequent also) office visit to Dr Cenizal was indeed outrageous.
I maintain that the fees charged for Dr Cenizal's office services are outrageous because they are far higher than the fees charged by highly qualified physicians in private practice in Casa Grande,namely Dr Fieldstone. Furthermore, Dr Cenizal did no special procedures during either office visit (requiring expensive equipment or supplies), even less so than Dr Fieldstone in his area of expertise, but merely did standard medical examinations, took information, gave opinions and advice, wrote out orders for tests and reviewed our documentation of the progress of the episode of my intermittent/acute infection of unknown type and origin which had just occurred prior to the second visit.
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