Here's the response by someone, who works at staying in excellent health and reserves assets for emergencies - rather than pay insurance premiums - to an outrageous health care charge and its much wider implications.

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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.

Perhaps the fees charged to me are not outrageous with respect to those currently being charged for hospital employee physicians, but that is a separate issue that I am not addressing here since all information available to me representing Dr Cenizal's status (until the end of the first office visit when I asked her how we were to pay and she stated that she was a CGRMC employee and had no idea what fees were charged for her services) indicated to me that she was in private practice and would charge fees according to that standard in the Casa Grande area, rather than some different standard of fees charged by CGRMC for its employee physicians. In fact, if I had any reason at all to suspect that she was an employee of CGRMC rather than in private practice, then I would certainly have required her fee structure before beginning the first visit.

We had taken the time to research online what the medical profession's main representative group has published regarding physician's fees and Paul provided a quote in his response to Karen Francis, from the AMA's policy regarding "excessive fees":

"A fee is excessive when after a review of the facts a person knowledgeable as to current charges made by physicians would be left with a definite and firm conviction that the fee is in excess of a reasonable fee. Factors to be considered as guides in determining the reasonableness of a fee include the following: (1) The difficulty and/or uniqueness of the services performed and the time, skill, and experience required (2) The fee customarily charged in the locality for similar physician services (3) The amount of the charges involved (4) The quality of performance (5) The experience, reputation, and ability of the physician in performing the kind of services involved (II) Issued prior to April 1977; Updated June 1994."

The fact that Dr Mary Joseline Cenizal was a hospital employee and not a physician in private practice had been a great surprise to us at the end of that first visit. There was absolutely no indication of this in her office and this fact along with several others was clearly pointed out in Paul's reply:

 

1) A Yellow Pages listing under physicians with the business name "Casa Grande Infectious Diseases" and no reference to CGRMC.
2) A business card on the receptionist window ledge with the same business name and no reference to CGRMC.
3) Letterhead and envelope return addresses indicating the same business name and no reference to CGRMC.
4) An office external door stating the same business name with no reference to CGRMC.
There is nothing stated inside Dr Cenizal's office nor on any forms that I was given to indicate that she is anything but a private practice physician sharing an office with a neurologist, Dr Harry S Morehead, in a building close to CGRMC (similar to how Dr Fieldstone's office is located).
5) A statement from Resolutions Billing asking for payment to Dr. Mary Joseline Cenizal with no reference to CGRMC. The fact that CGRMC uses a billing service separate from their own adequate in-house service, again suggests intent to misrepresent the status of Dr Cenizal (and likely many other CGRMC employee physicians) as being in private practice.
6) Just yesterday evening, a phone call about that statement from a "Kimberley" at Resolutions Billing, who first stated she was phoning from Dr Cenizal's office, later admitted that she was with Resolutions Billing, but was still adamant that Dr Cenizal was in private practice and only related to CGRMC by having staff privileges there. I am not accusing Kimberley of lying; I think that she did not realize the true status of Dr Cenizal as an employee of CGRMC rather than a private practice physician as many others of Resolutions Billing's clients may be. Kimberley may also have been instructed to state to patient/customers that she was "from Dr Cenizal's office", but I do fault both her for accepting such a dishonest task and Resolutions Billing for giving such an instruction to an employee.

Paul acknowledged to Karen Francis that he did not know the legal status of a hospital's requirement to be part of the Medicare/Medicaid systems. However, and as he wrote her, if participation in the Medicare/Medicaid systems is voluntary (as it is for physicians), then Casa Grande Regional Medical Center has *chosen* to be part of them and by charging higher fees to everyone else to offset such lower payments is effectively forcing all non-Medicare/Medicaid patients to make charity payments. Even if CGRMC is legally compelled to accept Medicare/Medicaid patients (and by what law - perhaps to qualify for some government funding of some kind?), what Karen Francis failed to state and may not even think about, is that the very same government, that she, in essence, maligned, also enforces the special status regulations under which hospitals and physicians operate. He specifically pointed this out and added:

Without such licensing and myriad other regulations (greatly restricting entry into and availability of a variety of offerings of such services), hospitals and all health care workers would need to compete in a truly free market in health care services. This would both greatly lower the prices of services and bring many new choices into the marketplace. Worst of all, in the current monopolized bureaucratic health care system, is that there is virtually no industry regulating feedback on procedures and prices by the individual patient/customer. The trend toward universal health insurance coverage is greatly exacerbating this lack of any feedback to reign in the use of medical procedures that are mostly advised without any regard to cost relative to benefit. As a self-pay health care client, I am trying to do my part to give this necessary feedback to this runaway system.

Correction was in order for Karen Francis' conclusion that Paul's decline to apply for government assistance and hospital charity write-off, if the former were denied, was because "it was not a matterof financial hardship." Paul made a very clear statement that our financial status had no relevance to his original and continuing complaint:

Nothing that I said indicated anything of the sort. Whether or not there is any "financial hardship" is both totally irrelevant to my dispute here and *only my judgment to make*. It has nothing to do with any of the points I have raised.

As stated above, Karen Francis had claimed in her message that "we have very few complaints from other patients regarding the charges from our physicians". The obvious answer to this is, first, that the vast majority of people are fully insured and pay no attention whatever to any actual underlying costs of medical procedures that they have done, and second, that most of the rest are indigent and unquestioning because they are happy to get whatever they can. Paul added to these points:

How many patients do you have who have *intentionally elected* to be self-pay after analyzing the cost/benefit parameters related to the decision and who therefore care about the cost/benefit ratio of the procedures that are suggested to them, rather than simply being insured through employment or otherwise because they could afford it?

Karen Francis' decline to offer anything more than the 20% off the current bill (200% of the Medicare accepted fee) was met with Paul's reply:

And I serve notice that I am declining to pay Dr Cenizal's bill (actually CGRMC's bill) for services until I get satisfactory answers to all my questions and some changes in the policy of CGRMC with respect to its misrepresentation of the practice status of Dr Cenizal (and likely other employee physicians.

This message of Paul's then included the additional points that he raised in his previous correspondence to which he required a response. He closed with the request that Ms. Francis "please pass [this matter] on to CGRMC higher management" if she "can not or will not deal with this." The receipt of the email from Karen Francis the next day, February 14 2008, was not a surprise, given the tone of the initial message from her.

Karen Francis failed to address any of the particulars of Paul's message and instead took a stubborn stand that simply because she did not "continuously have patient complaints", then the charges were not excessive. This individual apparently cannot fathom Paul's simple explanation for why she has no complaints from patients. Either that or she wrote what she did simply because she thought that was the way to bully a patient. It is also quite possible that hospital lawyers advised her not to address any of Paul's complaints, but simply to ignore them and demand payment, again claiming the fees to be not excessive.

I and Paul discussed how to proceed, and the following is the text of what we sent along with a check made out, as directed on the bill, to Dr Mary Joseline Cenizal.

As detailed on the enclosed email correspondence with Karen Francis, Chief Financial Officer of Casa Grande Regional Medical Center (CGRMC) all indications were that Dr Cenizal was a private practice physician, rather than an employee of CGRMC.

Therefore, the enclosed payment of $31.20 itemized as follows is based on fees obtained for private practice physicians located immediately next to CGRMC and having staff privileges there. The level numbers reflect length and complexity of the visit. The number that I have assigned is based on a comparative visit to a private practice physician.

[Itemization omitted]

I thank you for useful suggestions concerning my ongoing efforts to obtain a diagnosis of my strange intermittent/acute infection and I ask that you accept this as full payment of your current bill for services rendered.

Although the personal check for $31.20 was cashed on March 14 2008, another bill from Dr Cenizal's office was received in mid-April for $188.20 and designated as 90 days past due. The accepted check was clearly marked "Acct#1131 Paul Wakfer IN FULL". We consider the services obtained from Mary Joseline Cenizal to be paid for in full and the entire transcription of written exchanges also serves as public notice of the same.

One of the main problems of the delivery and receipt of health care in the US and virtually all of the industrialized world is that the one-to-one patient-physician relationship has disappeared, having been replaced by intermediary health insurance companies and government, this last either directly or indirectly by way of literally hundreds of rules and regulations. The fact that prices for all types of services are ever increasing while the satisfaction of those receiving them very often is decreasing, is very much because the patient is not directly making payment for those services and therefore not interested in determining the cost vs benefit analysis such as s/he would do for the purchase of a new car in comparison to the repair of an older one, or the same prior analysis relative to buying a house or any other major purchase. Simply because a person's body is essential for one's continuation does not make this need for personal involvement in the analysis less important, but actually more - much more.

The lack of personal responsibility for one's own bodily health and the costs involved is undoubtedly a part of the reason behind the enormous growth in the percentage of the population who are obese and their ensuing health degeneration. It has caused the ballooning health care costs that are passed down to individuals via direct premium increases or reduced take home pay from employers who pay the premiums. It has resulted in enormous government budgets - and increased national debt - to cover health care costs of those individuals who governments have decided should be taken care of via tax money (often extracted from the individuals themselves and always from others). And finally, it has now apparently caused many hospitals (and perhaps some physicians?) to inflate their prices so that those who can pay are again, in addition to their payments through taxes, forced to support those who supposedly cannot pay, but are getting the services anyway, at least partly because governments compel the hospitals to provide them.

The purpose of our presentation here about our own difficulty with the local hospital, that has a deceitful practice of representing employee physicians as being in private practice, is not only to make clear to others that this is happening, but to encourage others to be responsible consumers of what health care they do decide to obtain. When individuals are taking measures to be responsible for maintaining their own vigorous health, they will have less need to depend on the paternalism of health care providers, whether in private practice or as employees of a hospital. Such individuals will seek consultations only as they determine necessary and will be responsible for the mutually agreed upon fees.

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As a resource for further information on re-establishing the one-to-one patient-physician relationship, I recommend The American Association of Physicians and Surgeons. http://www.aapsonline.org

Authors Website: http://selfsip.org

Authors Bio:
I am a professional life-extensionist and liberty promoter who practices what I and husband, Paul Wakfer, encourage. More detail about both of us - philosophically and physically - at http://morelife.org/personal/

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