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I had a persistent small growth on the back of my scalp. After a year, I decided to have it removed, concerned that it could be cancerous. It was less than one-half inch in size. Waterproof Stickers
I scheduled an appointment with a surgeon at my local health care organization. I expected that the growth could be easily removed in the clinic during that visit. However, the surgeon expressed concern that the scalp tends to bleed a lot, and wanted to schedule the procedure in the ambulatory surgery center. I respected his judgment, but I was concerned that this would turn into "a big to-do about nothing." What an underestimation that was.
For my little scalp excision procedure, I was given the same high level of care that would be provided for a major outpatient surgical procedure. I was placed on a gurney and had a full preoperative clearance evaluation by a nurse. The procedure was done in a fully-equipped operating room, designed for major outpatient surgical procedures. There were at least three nurses attending to me in the operating room along with the surgeon. I had only a local anesthetic, no sedation, no IV.
I want to be clear that I have no concerns whatsoever about the care or the caring … both were superb.
The procedure took about 20 minutes and was free of complications. I then had outpatient observation for about 30 minutes and drove home.
I received my explanation of benefits statement from the insurance company. For the 10-minute clinic surgical consultation, the total charge was $400 (I paid $40). For the surgical procedure, the charge was $10,440. Insurance paid $10,000. I paid $400.
This was well above even my most cynical of estimates — $10,840 for a one half-inch skin excision!
If I were not a physician myself, suddenly coming to the realization of why the cost of health care and health insurance is so exorbitant today, I would consider this to be outright fraud. However, in a huge conglomerate health care corporation, I'm sure that the physician who scheduled me for ambulatory surgery, in all good conscience, had no clue of what kind of cost he was initiating. The left hand just doesn't know what the right hand is doing in these huge corporations. Unless a physician has been in a small private practice himself, he/she would not be aware of the high cost that a relatively simple decision can incur.
And the insurance billing department of that corporation has no idea that this charge, for that procedure, is obscene.
The total cost for this procedure should have been $440, not $10,840. However, the goal of all insurance companies has long been to maximize their profits and minimize payments to physicians, clinics and hospitals. My primary reason for leaving solo private practice was because of insurance company nightmares. A system has evolved in which physicians, clinics and hospitals overinflate their charges in order to compensate for underpayments by insurance.
In my case, the insurance company paid almost the full amount charged without question. That's partly due to the fact that insurance has always paid well for surgical procedures, but grossly underpays for cognitive encounters such as disease management and preventive medicine. I know from my professional experience that clinics and hospitals overcharge for surgical encounters to make up for measly payment on clinic medical visits.
What the health care organization should be providing is an intermediate level of outpatient surgical care where a full-blown surgical suite isn't required … but where emergency backup support is readily available in the rare case that it may be needed. No pre-op evaluation, no post-op observation, no fully-equipped operating room with three nurses.
What the insurance companies should be doing is paying fair amounts for services, provided in clinics and hospitals, without hassle and bureaucracy, so that physicians and clinics are not tempted to over-provide and overcharge.
This is just one minor example of the continual games played between health care providers and insurance companies. If all participants do not contribute toward a reasonable solution, then health care costs will continue to skyrocket beyond viability.
Wayne Kaniewski, of Minneapolis, is a retired physician and small-business owner.
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