America’s Healthcare System Is Too Complex and Broken to Be Saved

Anyone who lives in America knows our healthcare system is broken. My headline isn’t exactly making news, so to speak. Anyone who’s been unfortunate enough to have a lengthy experience inside our healthcare system also knows the complexities are so great that most employees in the system don’t know how it works either. It’s actually somewhat awe-inspiring in its awfulness, really.

Yet we still talk about “fixing” our system as if that’s possible. It’s laughable, really, if you’ve ever actually experienced it from the patient’s perspective. Now, I understand that when most people say “fix” the healthcare system what they really mean is “make our system more accessible and affordable for all people.” Sure, that might be possible. But let’s call it that, then. Because actually fixing the system? That’s impossible unless we scrap the whole thing.

To get a real idea of how broken this system is we need to look at all of its parts, on an administrative level in particular. Regardless of your opinion on the solution, procedures and tests aren’t going to suddenly become free entirely. Someone somewhere is paying for this. Looking at how those processes work gives us a good idea of how unsalvagable our system really is.

Nonsensical costs, nonsensical billing

Now, this piece is not a uniquely American problem, but it still represents a problem nonetheless. Say you need a colonoscopy. How much does that cost? No idea, right? Search online and you’ll get a wide variety of prices. The more complex the surgery/test/treatment, the pricier and the wider the range you’ll see. Heart valve replacement? Maybe $80,000. Maybe $200,000. That’s not exactly a small difference. It’s about two years’ salary, pre-tax for most Americans.

I’m willing to let a bit of this slide as there could be unforeseen complications in surgery, some places may have better technology (with a higher cost), more seasoned surgeons may charge a different rate, etc. The fact remains though, in no other field do you buy something without knowing the cost. Construction projects maybe, but even then the costs themselves tend to be firm, it’s just overruns and unexpected delays that add to the tally.

Imagine instead you’re at a restaurant — another place where you receive some tangible items and some service prior to paying. Now you get your menu and it looks like the below:

• Chicken dish: $24 — $93*
• Steak dish: $43–$111*
• Pork dish: $19–$78*
• * — additional charges may apply

Realistically, that’s what estimating healthcare costs is: random, but with some categories thrown in for the sake of appearing organized, and a big caveat at the end. If you’re fortunate enough to have insurance, determining the costs is even more complex. That said, even cash-paying customers don’t have an idea what they’ll pay until the bill comes. Even then, the bill is realistically just a starting point in negotiations if you’re paying cash. Now it’s about finding out if the hospital will accept 30 cents on the dollar rather than sell your debt to collections.

And if you have insurance? It’s simple, right? Whatever my surgery costs is sure to be higher than my maximums, so what I owe is just whatever my plan says my out-of-pocket maximum is, right?

Not so fast, greenhorn. Which maximum? Annual year maximum? In-network maximum? Out-of-network maximum? Somewhere between? Try asking the hospital before you go in. They won’t know either. It’ll be a small miracle if someone even tries to help you figure it out.

Insurance (n): A nightmarish hellscape of labyrinthian mazes designed to confuse you

So you read the above and said to yourself “I always make sure I’m in-network. I know better.” Sure, your hospital may be in-network, but what about the people in it? Because, like the rest of our system, this part is a nightmare.

Let’s go back to our restaurant. We’ll say it’s Longhorn Steakhouse, but it works like our medical system. So while it is true that you will get an overall bill from Longhorn Steakhouse, it will only be a percentage of your real bill. You’ll get a separate invoice from the hostess for her hosting services, the waiter for his congeniality, the front-of-house manager for administrative fees, the chef who cooked your meal (supplies + labor), and the real estate holding company that owns the parking lot. In total, your meal will be billed about 14 times.

Now while Longhorn is in-network for your meal plan, unfortunately, the waiter and hostess are not. See, the hostess was sent over from the Cheesecake Factory that day and the waiter actually works for Outback. So they’ll both cost you twice as much and directly from your personal funds, thank you.

A few years ago I had the good fortune to be in the hospital for 9 days. Now while my insurance wasn’t the best, it also wasn’t horrible by any means. I had a $2,000 deductible, then 20% coinsurance up to a $4,000 out-of-pocket maximum (in-network). Plus a hospital stay cost of $100 per day that may or may not have counted towards those totals. After a few calls, I gave up on trying to have that one answered, as I got 3 different responses to a yes/no question all from the same company.

I hadn’t used my insurance once in three years. So rather than try and figure out the intricacies of that I just assumed I’d be at my maximum of $4,000 plus $900 (9 days at $100) = $4,900. Simple. Yeah right.

Specialists came, specialists went. Some sent their bills to insurance before I was even discharged. The others all sent it day-of. Nearly all of them got the same response: patient deductible/maximum not met, the patient has the responsibility of $4,000.

So I received somewhere between 12 and 16 bills (I forget) for $4,000. Then the main hospital one for another $4,000. One guy was out-of-network and billed $8,000 because I had a different maximum for him. I never consented to see him and wasn’t informed of his out-of-network status, but still. Whatever.

So my total due was $60,000, paltry in comparison to the total billings of about a quarter-million, which itself was against a personal maximum of either $4,000 or $8,000, plus or minus $900 for the hospital stay. Confused yet?

I paid the out-of-network guy 20% of every dollar after paying $2,000, which appeared to be in accordance with my coinsurance policy. Then I picked a random doctor and paid the difference between what I’d spent so far and my maximum of $4,000. For the rest, I sent information from my policy that said my deductible and maximum had been met (from Aetna’s own patient portal) and informed them to re-bill the insurance company. Then I called the insurance company about 10 times to straighten out the billing.

Most of it was sorted out, kind of. One specialist decided to die on the hill of me owing him $4,000. I let it go to collections after speaking to his office and getting two people who agreed I owed them nothing and one who said I owed them $4,000. Once it hit my credit report I contested it with the bureaus, showing evidence from my insurer and classifying it as a debt that wasn’t really owed. Surprisingly, they agreed and removed it from my credit. I suppose the actual legal judgment remains somewhere, though.

Ultimately I paid more than double what any of my maximums said they were, even ignoring the judgment. I couldn’t find any other way.

That’s my experience, and I’m someone who’s fairly intelligent, has a comfortable salary, decent insurance, and is healthy enough to fight a bit. Imagine you’re not in that position?

Oh, and no one knows what they’re doing

It’s amazing how all these details seem to always be no one’s responsibility. Believe me, I think our medical professionals have more than enough to worry about without dealing with this nonsense. Plus, if they did, there would be no time for actual medicine. It’s too time-consuming.

Still, someone at a doctor’s office, hospital, or urgent care should know what things cost, whether they sent a pre-authorization to insurance, which copy of the bill is most recent, etc. Yet try and get answers to these questions and you’ll often get nowhere.

My better half recently had a diagnostic procedure scheduled. Her insurance company required a pre-authorization before covering it, which the doctor’s office said they would submit. Medicine was also required prior to the procedure that required pre-authorization as well.

They sent the forms, scheduled the procedure, then failed to follow up on the status. My significant other, the patient, did and found it had either never been received or never approved (couldn’t get an answer as to which). She called the office 4 times and was told by them that yes, the procedure was approved by the insurance, so come on in.

She decided to postpone while she sorted this out, hoping not to get hit with a massive unexpected bill. She called the same office to reschedule and was told she couldn’t reschedule until the procedure was approved. But they just said it was? She canceled entirely and received a call two hours later from yet another person at the office looking to reschedule the appointment.

This is all ridiculous and needs to be looked at. Fixing the affordability issue of healthcare for Americans mostly revolves around shifting the costs somewhere. That’s fine if we’re taking a one-step-at-a-time approach and focusing solely on patient costs.

The problem with those solutions is that all of the above problems remain. Service problems, administrative problems, knowledge problems, etc. Imagine the healthcare system and government interacting with each other. Everything would take 20 years and lead to bankruptcy for one party or both if nothing changes.

As we continue to have conversations on our broken system we need to also address these administrative issues if a real solution is to be found. Anything short of that is unacceptable.