The case of the $1,206 toenail clipping

A patient went to Brigham & Women’s Hospital to get her (potentially infected) foot checked out.  A dermatologist cut part of her toenail off, sent it off to the lab, and sent the lady home.  Her total charges: $1,206.  Here is the breakdown:

Office Visit — $248.00;Biopsy — $182.00; Treatment Room — $328.00; AMB Clinic — $117.00; Pathology Lab — $165.00; Laboratory Services — $166.00; Total — $1206.

Now, I’m not sure how an “office visit” does not also include a “treatment room”, nor how the “pathology lab” fee does not also include the “laboratory services” fee.  Maybe this is because I’m a lawyer, not a medical billing specialist, or maybe it is because our medical billing system is set up so that everything is atomised.  A mechanic will charge for parts and labour, but will not charge you for warehousing the parts, a “garage fee” for putting the vehicle into the shop so that it can be worked on, or two different diagnostics fees.  But Medicare and Medicaid break down every service into a part, then demand the best prices, so the rest of us can’t ask for all-inclusive (and therefore more logical) billing.

It’s a bit odd to head into an ER to deal with this type of thing (a “minute clinic” would be a far better option if her primary care physician couldn’t accommodate her), but it’s also odd to charge people for an “office visit” and to charge $300 for a treatment room.  I could get a hotel in NYC for 21 hours for that price; it’s a bit insane to charge someone that for an hour of sitting on a cot.

Note to the geniuses on Beacon Hill

Okay, fine, several notes to those geniuses. First, obesity is a problem with children in teens, but so are anorexia and bulimia.  (It is a problem for young men, too.)  While a letter home to parents stating that a child is obese may or may not make that child healthy, these letters and this screening could very well trigger eating disorders in young women and men.  Functionally, you are turning these fragile teens into guinea pigs in a social engineering experiment, attempting to find out whether or not quantifying a student’s ‘obesity’ is going to do more good than harm.

Second, BMI is a miserably terrible way to measure obesity.  It’s epically flawed.  A muscular person can be ‘obese’ and have nary an extra ounce of fat; an unhealthy couch potato can be a ‘normal’ weight, due to having a small frame but lots of extra weight.  Muscle weighs more than fat, which is why people (especially teenagers) can gain weight when they get in shape, although they may drop a dress size.  (Back when I was 19 or 20, a nurse at my doctor’s office weighed me; I was just under 130 lbs, and I’m 5’8.  She then told me that I should try to maintain that weight for the rest of my life.  Yeah, that’s a healthy, realistic goal for a middle-aged woman – try to maintain her college athlete weight.)

In fact, BMI is so absurd that it makes no distinction between men and women – it assumes that a healthy weight for a man is a healthy weight for a woman, and vice versa.

Finally, let us remember that this entire exercise is predicated on the notion that a parent cannot tell when his or her own child is not a healthy weight.  These parents have nurtured their children since birth, fed them every day, buy their clothes, see them every day, talk to them, know what sports they are playing (or not), and know how much time they spend in front of the TV.  Yet our government thinks that they need to tell parents when their children are not a healthy weight?  Japan and China are kicking our collective scholastic arses, and school systems are now spending their limited resources telling parents that their kids are fat?  Rather, no wonder why Japan and China are kicking our academic arses: we’re spending our time telling athletes that they are fat, couch potatoes that they are skinny, and getting everyone into sex ed, and they are teaching calculus.

A Smorgasbord of Health Care News

Okay, I’ve been busy and neglecting things at The Fog of Law.  Here’s what I’ve been reading but haven’t had time to blog about:

From The Pioneer Institute: A New Agenda for Cost Control in Massachusetts by Amy Lischko, Ph.D.

The Galen Institute: States rebel against ObamaCare.

STD rates are soaring in New York City.

The Sebelius cover-up: how ObamaCare exchanges need scrutiny. (Hat tip.)

A small, insect-eating dinosaur has been named after Obama.  Discuss.

The Pioneer Institute on the “Cadillac Tax” that will hit Massachusetts residents

Full brief is here.

As Josh Archambault explains, Massachusetts has very high premiums and health care costs.  The “Cadillac tax” is the Scylla of ObamaCare: get too fancy a health care plan, pay a penalty.  (The Charybdis element – get too basic a health care plan, like one that doesn’t cover contraception, and pay a fee – is more well-known.)

As Archambault explains, many middle-class families in the Commonwealth will pay this penalty:

For the 10 years following the introduction of the tax:

• Business employee on a family plan will owe $86,905 in additional taxes.
• Police officer on a family plan will owe $53,907 in additional taxes.
• Teacher on an individual plan will owe $20,807 in additional taxes.

I’m not a RomneyCare fan.  We all know that.  But RomneyCare at least helps Massachusetts remain as the mecca for the best medical care in the world.  ObamaCare does the opposite: it reduces payments for Medicare (which accounts for 50% of hospital spending in Massachusetts), taxes health care plans that pay for MGH and Brigham & Women’s, and taxes medical devices at 2.5% of total sales.

The RomneyCare of 2012 is not the RomneyCare passed by Gov. Romney

Today, residents of Massachusetts must purchase health insurance that meets 43 different requirements, such as limiting prescription drug co-pays to $250 per year and all deductibles to $2,000 per year per individual.  A lot of 80/20 plans (in which the insurance covers 80% of the cost, the patient covers 20%, and out of pocket maximums are in the range of several thousand dollars per year) do not meet “minimum credible coverage” guidelines.

As I’ve been saying for a year, the requirement in Massachusetts is not “buy insurance or pay a fine.”  It’s “buy really expensive insurance, loaded up with things you may not need nor care about, or pay a fine – even if you have pretty decent health insurance.”

As Amit Roy explains in Forbes, this is not what Gov. Romney envisioned nor passed into law.  Romney’s initial plan was to have people carry catastrophic health insurance (or a bond for the same), covering everything over $10,000, which would offset the free-rider problem arising from EMLATA.  (It also has the nice effect of ensuring that almost no one will declare bankruptcy over medical expenses, because very few people declare bankruptcy over four figures of debt.)

Gov. Romney’s mistake was to leave the details of “minimum credible coverage” to an administrative agency (the Health Connector board), rather than to sign a bill into law that explicitly states what qualifies as credible coverage.  There is always a danger that a law will be amended over time, with new goodies given out to voters at the expense of someone else – even the voters themselves – but such amending is done in the full light of day, by state representatives who may be telephoned, petitioned, lobbied, or voted out of office.