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For Lack Of Transparent Prices

I am approaching an important anniversary of my heart attack. Until then, I had missed but a single day of work due to illness since starting medical school in 1975. Even in the middle of the heart attack, I played an entire ice hockey game, slept a few hours, had a business meeting with a fellow doctor at Starbucks, and went back to the office to see patients.  In retrospect, my actions could be labeled as folly, bravado, machismo, denial, and lucky. I accept all labels as true. Without a trace of shame I have shared this archetypal story with friends, and patients hoping that by laughing hard enough at me, I might prevent at least one person from dropping dead from stupidity.

In my defense there is an untold story that contributed to my irresponsibility. It’s called the lack of transparent pricing.  I’m sure that you too have your own story. Here’s mine …

It started a year ago last April, when a friend called asking if I could play tennis that evening as a sub. To make the 8 pm court time, I rushed from work, and having skipped lunch, I was famished ate the only thing in my car: potato chips. After 45 minutes of playing, I suddenly was struck with the classic chest pain that people describe when they are having a heart attack — dead center in the chest which worsened when I ran for shots and eased up when I stalled.

The stalling between points caught my opponents’ attention. To my disbelief, they refused to keep playing and offered to call me an ambulance. “You guys are crazy,” I retorted, “It’s those stupid potato chips I ate on the way over; it’s just reflux.”  They returned fire by saying, “Only a doctor is dumb enough to not follow his own advice.”

We drank a beer and the chest pain gradually went away during the next 30 minutes. Unfortunately the pain came back during the next week every time I exercised.

My wife was out of town and knew nothing about this. I wasn’t about to tell her since it would open a Pandora’s Box of my denial. Too, we were about to celebrate our 30th wedding anniversary in a few days and we’d spent a year coordinating schedules, plane reservations and  work arrangements so that we could both get away for a week to St Lucia’s.

I figured it would be inconsiderate to have a heart attack or drop dead during our anniversary so “just to be safe” I called a local cardiology group to schedule a Thallium stress test, a good test to help determine whether or not I was having heart trouble. Here’s how my conversation went with their front desk person:

“I have high deductible insurance” I asked, ”How much will I have to pay when I leave?”

“The Thallium study costs $2200,” was the reply.

“Out of curiosity, if someone doesn’t have insurance what’s it cost?” I probed, expecting them to say a lot more.

“We have a special price for those situations, we charge $1300 if you pay cash,” was the answer.

”Then, I’ll pay cash and give you $1300.”

“We can’t do that, you’ve already told us that you have insurance so we have to charge you $2200.”

After several prolonged conversations, I finally spoke to the office manager who agreed to $1300 price. An hour later the manager called back, apologizing:” We legally must charge you $2200 for the test.”
I thanked her and then canceled the test.  I planned to call another cardiology group, vowing to start by saying I had no insurance.

To shake off my annoyance, I went for a run.  The chest pain struck me again with exercise. “Stupid reflux!”  I cursed and dialed a family practice doctor friend who conducts stress echo-cardiograms (another good test).

He worked me into his schedule the following day, offering me a transparent price. This time, I had no chest pain and passed. We took our anniversary trip, which was a dream, and my wife heard the details of my story without worrying that I might have a heart problem.

For the next six months I had no significant chest pain. Then, last December, I found myself in a hospital bed listening to the discharge instructions from the cardiologist after my heart attack. “Alan, schedule a stress Thallium in six weeks.”

This time I wasn’t going to fight it. After dutifully completing the test, I walked to the out window my checkbook in hand. I dreaded forking over the $2200.

“Dr. Dappen, you don’t owe us anything yet,” the billing specialist explained, “we bill your insurance company and they’ll send you the bill with the negotiated rate, which is usually about one half of the amount of our standard charge of $2200.”

In reality, my cost was about $1000 when the bill finally came – a far cry from the $2200 I had been quoted a few short months prior.

Because of the lack of transparent prices, I made a decision that might have killed me. There are millions of medical decisions that are based, just like mine, on non-transparent pricing and misinformation; not even a doctor’s office has the right information.  Yet, I know that I was one of the lucky ones and, unfortunately, there will be others who suffer the cruel hand of fate.

Without a trace of shame I share this archetypal story to all in the healthcare system that but for lack of transparent and reasonable pricing the kingdom will be lost. It starts one case at a time until it becomes my story then your story too.  If it’s not your story, don’t worry, your time is coming. I wish you best of luck.

Really.

Until next week I remain yours in primary care,

Alan Dappen MD


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