Politics, Best of California Bull

Hidden Costs, Hidden Payments -- THE BLOOD CHURN

This is the third blog post that examines the cost of health care in California -- and how money is being spent and maybe wasted.

This week, I need your feedback.

I’m afraid that someone is churning my blood.

Let me explain:

There’s an excellent rheumatologist with a medical office in the Cedar Sinai Office Tower.  I will call her Dr. Stephanie, although that’s not her name. When you call Dr. Stephanie’s office to book an appointment, the office requires you to have a blood test, before you can see Dr. Stephanie. You may only need to talk. You may want her to look at a report done by another doctor. You may have had a blood test done earlier in the week, for another doctor in the same office tower. It doesn’t matter. You must have a blood test.

Dr. Stephanie’s office then charges my insurance $900.

My insurance pays 90%, so I end up paying $90, until I reach my deductible limit.

When I book an appointment to see my regular internist, they also want a blood test. Sometimes I may be going back for a follow-up appointment, or to get a referral to another specialist. Again, they draw blood. He charges $400, which my insurance company pays 90%, and I pay $40.00.

I am familiar with blood tests, and I’ve had them many times, for everything from prepping for surgery to a medical exam for a life insurance policy.

A blood draw is a hassle, especially if you’re getting a lot of them.

For proper results, I’m not supposed to eat 12 hours prior to a blood test. So what if I have an appointment with Dr. Stephanie at 3:00 in the afternoon?  Do I wake up at 3 in the morning to have breakfast? Usually it means I must go hungry all day, and I’m starving by the time I get to the doctor’s office. Or, I can go first thing in the morning, get the blood draw, then eat normally, and then return at 3:00 for the appointment. That’s two trips in the car and more time off work, but at least I can function and I won’t be chewing on my knuckles all day.

Yet, it’s often me who must clarify what I need to do before a blood test. This is a typical conversation I have with most medical offices:

THEM: You’ll need your blood drawn before you see the doctor.

ME: Okay. Can I come in the morning for that, and then come back?

THEM: You want to come here twice? Why would you want to do that?

ME: Because I don’t want to go all day without eating. Don’t you want me to fast?

THEM: Oh, right. I guess you should fast before a blood draw. Please hold.

ME (TO MYSELF ON HOLD): Is this a joke? Is this test even real?

THEM: Yes, it’s okay if you come in the morning and then come back, but make sure you explain why you’re here.

It makes me suspect that the “required” blood test is just the doctor’s office churning my account, to get easy money from the insurance company to help pay for their expensive overhead.

I get doubly suspicious when I don’t get the results of the required blood test. I ask them to call me or e-mail me with the results. I don’t need much. Just tell me that everything’s fine, or e-mail a photocopy of the results with some scribbles in the side, I can then save it for my records, and compare it to the results of my next blood test. I am also paying between $40 and $90 out of pocket for the test, and my insurance is paying even more. I expect that communicating the results is part of the cost.

Or maybe it’s all a sham.

What do you think? Are they churning my blood? I spend too much time writing stories in my head, and naturally I made one up for the excellent Dr. Stephanie:

She is in private practice by herself, so she doesn’t split the cost of the office with another doctor, which is a lot of overheard to pay each month.  She also deals with a variety of insurance companies, which don’t pay in a timely manner. She may perform a procedure in January, but not get paid by the insurance company for 60 to 90 days. They may also dispute her bill for a variety of reasons, from a new medicine she prescribed, to using an unapproved device in a surgery.

Dr. Stephanie still has tens of thousands of dollars in student loans she’s paying off, even though she’s in her late 30s. After all, when she finished her final fellowship at age 33, she was $250,000 in debt before her career even started.

So how can Dr. Stephanie keep her business moving with a good cash flow? How can she afford to hire an extra person to man the front desks, or ask the insurance company for more timely payment, or afford the newest diagnostic machine?

Simple: she charges $900 for a blood test. It’s a fast and easy way to get money coming in.

The longer I wait, the more suspicious I become. It also makes me question the larger cost we are ALL paying for health care. Are all the doctors “churning” the blood tests? Is it all one big blood churn? If every visit requires a new blood draw, how much extra cost is it adding to our health care system?

I then write a different story in my head, where the blood test is justified. Some specialties rely on a lot of blood tests. A pregnant woman gets her blood drawn on every visit to the doctor. A pregnant woman’s blood reveals a lot about an unborn baby, whom the doctor cannot examine firsthand. Dr. Stephanie is a rheumatologist, so she deals with the diseases of inflammation and pain, like arthritis, lupus, auto-immune disorders, and fibromyalgia. The blood is where she may glimpse your problem. She’s not setting broken bones or dealing with rashes, where the problem is obvious. The blood test may be the best tool she has.

Then I think that maybe the blood test protects the doctor. Let’s say I’m seeing two doctors in one week. Is my blood on Monday going to be that different than your blood on Wednesday? Can’t the second doctor just get the same blood results from the first doctor? Sometimes they’re using the same lab! But if that first test misses something, that second doctor may end up answering for it later. I can imagine the lawyer asking the questions:

You mean this medical problem could have been identified with a simple blood test, yet you didn’t order one? Instead, you relied on the blood test done by another doctor’s office, earlier that same week? Why so negligent, Dr. Stephanie?

Maybe doctors are afraid of being sued, so to cover themselves they get a blood test every time to reduce their risk. However, I have another question as I sit in the doctor’s office, twiddling my thumbs: Why don’t they call me with the results? Am I an oddball?

I guess most people assume that no news is good news, and if there was something wrong with the blood test they’d call...or worse, ask you to come in to talk to the doctor face to face. Maybe I should go with the flow (or blood flow).

I look around and count six people waiting. Let’s say the doctor sees twenty to forty people a day. Maybe they don’t call because it’s too much of a hassle for them. If a doctor or nurse practitioner called every patient who got a blood test, that’s a lot of time on the phone, mostly to reassure people that everything is normal.

But I’m still hungry and waiting, and the longer I wait, the more I suspect a churn after all.

My father was a doctor -- an ob/gyn, and he drew a lot of blood out of women over the years. He got together with four other doctors in the same medical office building, and they invested in a blood lab. That meant that his personal practice got paid a certain amount for drawing the blood and ordering the test, and then the lab made money actually running the tests on the blood. It was a good financial hedge bet. While the insurance company sometimes delayed payment because it objected to how a surgery was done on a particular patient, the payments for the blood tests, and from the lab were pretty steady.

As I sit, desperate for caffeine and an Egg McMuffin, my mind turns dark and I wonder if Dr. Stephanie and my internist both own a piece of the lab downstairs.

No, I’m being too resentful. I should give them the benefit of the doubt. They’re being squeezed by the new economy, just like the rest of us.

I have one more flip flop in me, however.

I come home and my wife shows me a letter from her doctor announcing he will be charging $500 a year to all regular patients, for maintaining their medical records. The $500 will cover the cost of photo-copying and sending her any records she requests (including blood test result), and also calling her and talking to about her medical condition (including the results of your blood tests). She can opt “out” of the $500 charge, but she’ll need to book a separate appointment to come in and discuss her case. No more free follow-up calls.

And before she can see the doctor, she’ll need to have another blood test.

What do you think? Is it all one big blood churn?

How much extra cost is it adding to our health care system? It seems inefficient and wasteful, but it may be the fat that greases the system so the doctors can keep moving.

But I’m tired of losing blood and being hungry.

I am one patient, one consumer -- am I wrong? Is there something I’m missing? 

I’d love to hear from you!