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Sizing Up Two Patients And Two Healthcare Systems: Part 2

BACKGROUND

For those who are landing on this page for the first time, be sure to read the background FIRST to these case presentations. The intent here is to compare and contrast two patients, one insured and the other uninsured, from the United States and England as care is delivered today. The U.S. cases are described in detail in this blog and the corresponding cases, British-style, are described on Sarah Clarke, MD’s blog from England.

CASE #1: The U.S. Case of Mr. Thurgood Powell

The ER radio sounds: (*bleeeeee, deeeeeeeeeppppp*) “Rampart, we have a 57 year old white male en route with a 45 minute history of substernal chest pain and diaphoresis. Initial single-lead EKG discloses ST segment elevation. One ASA given, nitro given, BP 96/47, pulse 110, respirations 22, pt diaphoretic…”

ER doctor: “Code cor activated. Cath lab ready. Proceed as soon as possible.”

Pt arrives. Looks poorly. A 12-lead EKG is obtained in the ER and confirms an evolving acute anterior myocardial infarction. There is no contraindication to proceeding directly to cath lab. Given loading dose of Plavix, integrelin. Shuttled to lab. Angio performed. 95% LAD stenosis and significant 3-vessel disease is noted. Ventriculogram not performed due the patient’s condition. His BP drops, intraaortic balloon pump placed. Due to his age and lack of comorbidities, it is decided to place a drug-eluting stent in LAD artery. Aside from some VT during case and one episode of ventricular fibrillation during his procedure requiring countershock, but patient tolerates remarkably well. Patient is transfered to ICU.

After the dust settles, hospital administration comes to take patient’s valuables and to register Mr. Powell. They inquire about his insurance: he produces a platinum policy card from Blue Cross Blue Shield of Illinois which Mr. Powell chose amongst several insurance policies offered by his employer. He could cover his entire family for approximately $400 per month ($200 per paycheck): total annual outlay $4800. Employer also picks up a more significant portion of the cost (approximately $14,000 per year) but can deduct this amount from their profit for tax purposes. Mr. Powell cannot deduct the price of his insurance from his income amount and has a $5000 annual family deductible. Also, Mr. Thurgood’s income falls into the 33% federal tax bracket ($67,643 per year). Still, all is good – he’s covered.

Mr. Powell is started on Toprol XL 25 mg daily, Altace, aspirin, Plavix, and Crestor – all at the doctor’s discretion (He is young, after all). Patient has development of congestive heart failure on day two, requires ongoing balloon pump support. Some atrial fibrillation occurs, requiring titration of medications to control. Echocardiogram performed to assess LV function. Balloon pump but eventually is weaned on Day #3. He leaves the ICU on Day 4. His room outside the ICU is private (due to infection control efforts, they say) and equipped with a flat screen TV from which he orders his food (it is, after all, a brand new heart hospital that has been tastefully appointed.) He spends two more days on the ward and then is discharged to follow-up in Clinic in one month.

Pt returns home and later receives a bill for his hospital stay. On his Explanation of Benefits, he notices a total bill for $180,000. Insurance has agreed to pay about $150,000 due to a pre-negotiated arrangement of the insurer with the hospital. The insurer has likewise negotiated with the employer to offer a price point with a comfortable profit “spread.” Mr. Powell is not responsible for understanding the difference – he just has to pay his annual deductable of $5000.

Despite his care, Mr. Powell continues to have ongoing angina. Because of his recurrent pain, he is admitted and another angiogram performed which was unchanged. It is decided that because of his young age and pain refractory to medical therapy, he is referred to bypass. He is seen by the surgeon the same day, and elective surgery scheduled for the following day.

His post operative stay is uncomplicated and he returns home in 4 days. Cost for surgery and hospital stay: About $100,000.

Approximately 6 weeks later, Mr. Powell notes palpitations and lightheadedness. He returns to ER where his is found to be in sustained monomorphic ventricular tachycardia. Another angiogram performed. All bypass vessels are open and his native disease unchanged. A dual chamber ICD is scheduled for next day of manufacturer of the electrophysiologist’s choice* (patient had atrial fibrillation in the past, after all) and implanted uneventfully. Mr. Powell later returns home.

Again a bill is sent to his home: cost of hospitalization with ICD implant $160,000. Insurance has prenegotiated a lower price with hospital – $110,000 – but has agreed to pay the full negotiated amount with the remainder “forgiven” as far as Mr. Powell is concerned. Mr. Powell is amazed by the state-of-the art technology installed in his chest.

Mr. Powell follows up in two weeks after his surgery with his electrophysiologist, two weeks after that with his cardiologist, and about a month later, his internist. He is followed for his ICD every three months thereafter. Home monitoring of his ICD is instituted on his first follow-up visit. The device company sends the monitor to his home, free of charge.

* In reality, hospital has asked doctor which company’s devices he’s willing to work with and hospital negotiates bare bones pricing on ICD and up charges device approximately two to three times cost to provide margin for hospital operations.

CASE #2: The U.S. Case of Mortimer T. Schnerd

The ER radio sounds: (*bleeeeee, deeeeeeeeeppppp*) “Rampart, we have a 43 year old white male en route with a 45 minute history of substernal chest pain and diaphoresis. Initial single-lead EKG discloses ST segment elevation. One ASA given, nitro given, BP 96/47, pulse 110, respirations 22, pt diaphoretic…”

ER doctor: “Code cor activated. Cath lab ready. Proceed as soon as possible.”

Pt arrives. He looks poorly. A 12-lead EKG is obtained in the ER and confirms an evolving acute anterior myocardial infarction. There is no contraindication to proceeding direct to cath lab. Given loading dose of Plavix, integrelin. Shuttled to lab. Angio performed. 95% LAD stenosis and severe underlying 3-vessel disease is noted. Ventriculogram not performed. His BP drops, intraaortic balloon pump placed. Due to his age and lack of comorbidities, it is decided to place a drug-eluting stent in LAD artery. Aside from some VT during case and one episode of ventricular fibrillation, Mr. Schnerd tolerates his procedure remarkably well. He is transferred to ICU.

After the dust settles, hospital administration comes to take patient’s valuables and to register Mr. Schnerd. They inquire about his insurance: he has none. Hospital clerk notes situation (annual income $17,400, 15% tax bracket (Taxes $2,193 per year) – knows patient has little means to pay his bill and gets on the horn to social work. A social worker arrives and tries to apply on his behalf for Public Aide to pay for the cost of his hospitalization. The patient is responsible for a “spend down” of approximately $500-$1000. Unfortunately, because he is male, employed part time, and has no dependents, he does not qualify for Public Aide. The hospital then submits its bill for his care to the Medicaid program. He will be enrolled in the public clinic at the hospital to receive his follow-up care after discharge.

Mr. Schnerd is started on Toprol XL 25 mg daily, lisinopril, aspirin, Plavix, and simvastatin (to limit his out-of-pocket expense) – all at the doctor’s discretion. Mr. Schnerd develops congestive heart failure on day two, requires ongoing balloon pump support. Echocardiogram performed to assess LV function. Balloon pump eventually is weaned on Day #3. He leaves ICU on Day 4. Mr. Schnerd’s room outside the ICU is private (due to infection control efforts, they say) and equipped with a flat screen TV from which he orders his food (it is, after all, a brand new heart hospital that has been tastefully appointed.) He spends two more days on the ward and then is discharged to follow-up in Clinic in one month.

Pt returns home and does not receive a bill for his hospital stay and and receives follow-up care via the public clinic at the hospital. He is still somewhat short of breath.

Despite his care, Mr. Schnerd continues to have ongoing angina. Because of his recurrent pain, he is admitted and another angiogram performed which was unchanged. It is decided that because of his young age and pain refractory to medical therapy, he is referred to bypass. He is seen by the surgeon the same day, and elective surgery scheduled for the next day.

His post operative stay is uncomplicated and he returns home in 4 days. Again the cost of his inpatient stay and surgery is submitted to Medicaid and his follow-up care arranged via the public clinic.

Approximately 6 weeks later, Mr. Schnerd notes palpitations and lightheadedness. He returns to ER where his is found to be in sustained monomorphic ventricular tachycardia. He is cardioverted. Another angiogram performed and his bypass vessels are patent and his native vessels unchanged. An dual-chamber ICD is scheduled for next day (he had atruial fibrillation before) of the doctor’s choice*. Again, Mr. Schnerd is seen by the social worker and arrangements made for this hospitalization to be paid by Medicaid as well. If it is determined that he signficantly disabled as a result of his current illness, Mr. Schnerd could be eventially be enrolled in Medicare. The device is implanted uneventfully and he returns home.

Mr. Schnerd follows up in two weeks after his surgery with his electrophysiologist and every three months thereafter. Home monitoring of his ICD is instituted on his first follow-up visit and the device company sends the monitor to his home, free of charge.

* In reality, hospital has asked doctor which company’s devices he’s willing to work with and hospital negotiates bare bones pricing on ICD and up charges device approximately two to three times cost to provide margin for hospital operations.

Now, head on over to Sarah Clarke’s blog from the UK and read these same patient’s care as rendered by the British health care system.

Disclaimer: The dollar amounts entered here are only very gross estimates of costs incurred. Both patients and their scenarios are COMPLETELY fictitious, but rather used to illustrate important clinical care differences between the two health care systems today.Finally, I would be remiss to not thank Dr. Clarke for her hard work in getting this done after many hours of overseas travel and a full day of megaclinic.
-WesMusings of a cardiologist and cardiac electrophysiologist.

*This blog post was originally published at Dr. Wes*


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