Beating the Chargemonster: Thoughts on Steven Brill’s Brilliant Assessment of the Health System

Have you read Steven Brill’s brilliant exposé “Why Medical Bills Are Killing Us?” that appeared in last week’s Time magazine? Brill shines a particularly harsh light on the modus operandi of hospitals (those con artists). The article is an eye-opener and I urge you to read the whole thing (link to the article is at the end of this blog). Brill’s article could save you a lot of money. It could save you your house. Or your life. I want to share a few crucial things from Brill’s article that made me shout.

One of the most important things that Brill discussed is the way that hospitals calculate patient fees. Hospitals use an enormous computer-operated system called the chargemaster, which sets the costs for everything from doctor services to gauze pads. Apparently no one in the health industry has a clue how the chargemaster actually works or even exactly what it is. I think of it as an extra-terrestrial beast that lives in a giant computer and absconds with the life’s savings of 70% of the American middle class. I have renamed it in my head the “chargemonster.” Hospitals feed like leeches off patients by over-ordering tests, such as X-rays, blood and urine work, CT Scans, MRIs, etc. Doctors order these like crazy all day every day for patients during their stay in the hospital and they also over-order them for patients receiving outpatient care and ER services. Brill mentions a person who was charged more than $4,000 per day for blood tests during his hospital stay. That $4,000 was calculated by the chargemaster. The chargemaster puts a price on everything a patient uses or accesses while in the hospital. For instance, the chargemaster at Seton Medical Center in Daly City, California charges diabetic patients $18 each for blood sugar test strips when a box of 50 test strips costs less than $30 at the pharmacy. Hospitals charge patients (at arbitrary overblown chargemaster rates) the purchase price for gowns worn by the operating room staff, even though these gowns are laundered and reused. Beware:  the chargemaster is likely to charge you $5 for one ibuprofen.

Brill explains that a hospital bill is simply a starting point for negotiation, and most people don’t realize this. The bill is based on the crazy chargemaster rates. Insurance companies negotiate with hospitals about what they will actually pay based on real costs for things; and hospitals compromise. Medicare negotiates best of all because (after researching the real price) they have the ability to state the real cost and then tell the hospital that’s what they will pay. Medicare pays much less than the chargemaster rates for everything, except for pharmaceuticals, because federal law prohibits Medicare from negotiating the cost of drugs (and that’s a problem that needs to be fixed, according to Brill). Ordinary people can also negotiate. I have always done this. I call a health care provider when I get the bill for my portion of the cost after the insurance has paid their portion. I say that I have to pay this out of pocket and I ask if they can reduce it. Usually they do. And if it’s for more than $100, I set up a payment plan because they don’t charge interest so it’s cheaper for me to make payments directly to the health care provider than to my credit card. Just last year I negotiated an emergency room bill down by $1,200 and negotiated the separate doctor bill down by $600. Brill reveals in his article that people with seriously outrageous hospital bills are now hiring “medical billing advocates” at $100/hour to bargain their bills down. Wow, I could probably start a new career as a medical billing advocate. This whole scenario reminds me of that Monty Python routine where the merchant has a fit because the buyer hands him money while the merchant wants to bargain. “No, no, no, you’re supposed to haggle,” the merchant tells the buyer, refusing the money.

Maybe the most important part of Brill’s article is when he talks about the fact that hospitals don’t lose money on Medicare patients. Jonathan Blum, deputy administrator of the Centers for Medicare and Medicaid Services, provides proof that hospitals make enough money to cover the cost of serving Medicare patients (in fact they make a profit) and he says that hospitals actively recruit Medicare patients. Blum says that if you doubt him, you should drive through central Florida and notice how many hospitals post ads on billboards in their effort to recruit more Medicare patients. So Brill suggests, if this is the case, why not extend Medicare to everyone and pay for it all by charging people under 65 equivalent premiums to what they would pay to private insurance companies? (Duh, ya think?) Brill lays out a compelling argument for the single-payer approach to health care, which is used by most developed countries. How long do I have to wait for people to stop watching Fox News long enough to read Brill’s article and evolve a basic ability to comprehend how the health system works (or doesn’t) so they quit freaking out over the perceived “socialism” of a single-payer system? Argh.

Get this:  there are nearly 3,000 nonprofit hospitals in the country and they don’t pay taxes. They are making money hand over fist while sending patients to financial ruin. What do they do with their profits? They pay their upper echelon executives and administrators obscene salaries, they buy more equipment, they build more buildings for their medical complex, they buy rival hospitals (to create a regional monopoly on services), and more. When the New York Times ran a story about how a federal deficit deal could reduce hospital payments, Steven Sayfer (chief executive of a nonprofit medical center) angrily told the media that reductions in hospital payments would result in reductions in services to patients. Sayfer earns $4,065,000 a year, his CFO earns $3,243,000, his executive VP earns $2,220,000, and the head of his dental services earns $1,798,000. I would say that they could make up the difference in any reductions in hospital payments by scaling back some of their administrative costs, wouldn’t you? For a nonprofit, Sayfer’s hospital is making an awful lot of profit.

It really pissed me off to read about nonprofit hospitals asking for charity. They hold fancy fundraisers and mount direct mail campaigns to solicit donations. But actually, the amount of income these nonprofit hospitals make from charitable donations is less than 1% of their income. They go begging because they can make money at it and because they like to maintain their image as charitable organizations. Furthermore, hospitals boast about how much charitable care they provide (and talk about how federal hand-outs to hospitals will impact this charitable work), but the actual dollar amounts they come up with for their charity work are far beyond what it really costs them to provide services for free to impoverished individuals because they use the inflated chargemaster prices to calculate how much charity they provide. While in truth, the actual cost to them of serving charity patients is a fraction of what they say it is. A hospital lobbyist in Washington recently declared that hospitals provided nearly $40 million in charitable care for the poor last year. But the actual cost of that care was more like $5 million when recalculated at real costs (by Medicare) as opposed to chargemaster-calculated costs.

I could go on, but this blog post is getting long. Brill offers his suggestions for beginning to fix the broken system, and they are very, very good suggestions. My favorite is extending Medicare to everyone in a single-payer system. But check out his article to see what he says. Here is the link to the full articleonline. It’s long. Take your time. I predict that this will be considered the most important piece of journalism this year. Brill should win a Pulitzer for it.

Heavy blog this week. Here's some bonus material. This will give you a laugh!

The Washington Post's Mensa Invitational once again invited readers to take any word from the dictionary, alter it by adding, subtracting, or changing one letter, and supply a new definition. 
Here are the winners: 
1. Cashtration (n.): The act of buying a house, which renders the subject financially impotent for an indefinite period of time.
2. Ignoranus: A person who's both stupid and an asshole.
3. Intaxication: Euphoria at getting a tax refund, which lasts until you realize it was your money to start with.
4. Reintarnation: Coming back to life as a hillbilly.
5. Bozone ( n.): The substance surrounding stupid people that stops bright ideas from penetrating. The bozone layer, unfortunately, shows little sign of breaking down in the near future.
6. Giraffiti: Vandalism spray-painted very, very high
7. Sarchasm: The gulf between the author of sarcastic wit and the person who doesn't get it.
8. Inoculatte: To take coffee intravenously when you are running late.
9. Osteopornosis: A degenerate disease. (This one got extra credit.)
10. Karmageddon: It's like, when everybody is sending off all these really bad vibes, right? And then, like, the Earth explodes and it's like, a serious bummer.
11. Decafalon (n.): The grueling event of getting through the day consuming only things that are good for you.
12. Glibido: All talk and no action.
13. Dopeler Effect: The tendency of stupid ideas to seem smarter when they come at you rapidly.
14. Arachnoleptic Fit (n.): The frantic dance performed just after you've accidentally walked through a spider web.
15. Beelzebug (n.): Satan in the form of a mosquito, that gets into your bedroom at three in the morning and cannot be cast out.
16. Caterpallor ( n.): The color you turn after finding half a worm in the fruit you're eating.

Purim and Grandma's Kipfel

Today is Purim, probably the least-known Jewish holiday to non-Jews. It’s also the most frivolous and fun. The twitter version of the Purim story is that the Jews were saved from extermination in Ancient Persia by Esther (yay, a woman did it) who foiled the attempt of Haman (the king’s nasty advisor) to put all Jews to death. Dodging a genocide is truly cause for celebration among my tribe because it is something that rarely occurred in our entire history, which is fundamentally a string of exterminations that chased us around the globe as we ran from pillar to post trying to save our skins, since we had no homeland (until Israel). It’s a wonder any of us are left.

The Purim story is recounted in the Biblical Book of Esther, or Megillat Esther, and if you want to know the story you can literally read “the whole megillah” in the old testament. Purim is the big eat, drink, and be merry holiday. Celebrants are supposed to drink until we don’t know the difference between Haman and Esther, which is a rather dubious measure of drunkenness. Not your local cop’s breathalyzer test. We eat poppy seed pastries called hamentashen, shaped in triangles because Haman wore a three-cornered hat. On Purim we dress up in costumes; and cross-dressing is much encouraged. We read the Book of Esther out loud, and every time Haman’s name is said, we make a holy racket:  hollering, spinning noisemakers, stamping our feet. When I was a little girl, we wrote “Haman” on the bottom of our shoes with chalk so we could stamp his name out. Purim celebrants are instructed to turn everything on its head so that confusion reigns. Purim reminds us to take a break from reality and the value of getting a new perspective on things by stepping outside our routines, stepping outside the comfortable organization of our lives, taking a vacation from our usual selves, and basically shaking things up.

For many years I have been meaning to figure out a gluten-free version of my Grandma Wachspress’s terrific hamentashen recipe and yesterday I decided was the day to do it. Her hamentashen were so delectable because she used a traditional Hungarian kipfel dough. Kipfel is a heart attack on a cookie sheet. I have seen a number of recipes for kipfel and all of them have heavy fat content. Grandma W’s recipe uses a half a pound of butter and a half a pound of high-test full-strength cream cheese. In fact, this recipe lends itself well to gluten-free conversion since the flour is buried in mounds of fat and therefore unrecognizable as a significant ingredient. Yesterday I made Grandma W’s hamentashen recipe, converting the wheat flour to brown rice flour. The result was the most outrageous gluten-free pastries, like straight from the old country.

So I took my life-altering hamentashen to synagogue last night for the Purim Party. I slipped them inconspicuously on the food table in among the mountains of food and the plates and plates of hamentashen. I put a little sign on mine that said they were gluten-free and that I made them, to let people know they had no gluten and in case anyone wanted to come tell me that they had an epiphany when they bit into my hamentashen. I quietly waited for the festivities to grind to a halt as my hamentashen brought everyone to their knees. To understand the full extent of my fantasy, you have to picture the volume of hamentashen of every imaginable type at this event. I’m talking plates overflowing with prune-filled, chocolate, marmalade, strawberry, traditional poppy seed, and raisin/walnut hamentashen. I’m talking whole wheat, flaky white flour, other gluten-free styles, and vegan hamentashen. When our congregation does Purim, we be hamentashen.

Here is what actually happened. I received a few modest compliments and then an elderly member of the congregation, who is an outstanding cook and who has made the most marvelous Jewish cuisine for many synagogue events, this one elderly woman sought me out to tell me that my hamentashen were delicious and that it had been a long time since she had tasted such a fine Hungarian kipfel. She made my night!  There are probably few Jews still living who know what a real old-world Hungarian kipfel tastes like. I think that no one, except this elder, at last night’s Purim Party could even recognize an authentic kipfel. So much is lost to us when our elders pass on. But today I am still celebrating my inheritance from Grandma W:  hamentashen with real kipfel for breakfast (EKG and resuscitation at noon). Here is the link to the hamentashen recipe (which includes instructions for making kipfel). 

(Not mine, just a stock photo. I'm no photographer, 

but wanted those who don't know to see what hamentashen look like. 

Mine look a lot like these.)

War Tax Resistance

This past week I provided my 2012 tax information to my accountant (whom I refer to as my financial therapist—he’s the best). Entering into this year’s tax season has made me think back to the years when I was a war tax resister. The first year that I paid taxes was 1979. I was no longer in college and I worked a regular job (not work-study or a fellowship) so I had to file income taxes for the first time. The more I learned about federal spending allocations, the worse I felt about paying taxes. I don’t mind paying taxes, but I would like to have the right to select what programs my taxes should go toward. I resent paying for weapons development and for war.

I don’t remember how I found out about the War Tax Resisters League (WTRL) in the days before the internet. They were an organization based in Seattle that had set up a way to help people conscientiously resist paying taxes for military use. I used their services. This is how it worked. They created a pie chart that showed how the federal budget (each year) was allocated. It was painfully clear from the pie chart that the lion’s share of the federal budget went to the military. I (as did many others) used the annual WTRL pie chart to determine what percentage of my taxes would go to the military. Then I subtracted that percentage from the total taxes I owed. Next I opened a war tax resistance interest-earning savings account through the WTRL and I mailed a check for the portion of my taxes that I would refuse to pay to the IRS to Seattle instead, where the WTRL deposited the funds into my account.

When I filed my taxes, I wrote a letter to the IRS explaining that I had put the percentage of my taxes that would have gone to violence (military, defense, weapons, war) into a bank account and I would save it there for the feds until the government quit waging war on other nations (both covert and outright). I then wrote a check made out to the U.S. Department of Health and Human Services for the difference (the percentage that went to non-military purposes) and mailed that in with my tax forms to the IRS. There were consequences, of course. As you can imagine, I received increasingly threatening letters from the IRS telling me I owed them tax money.

Having taken the plunge and become a war tax resister, I persevered for several years afterward. I learned that if I declared a lot of dependents on my W4 when I was hired for a job, then I would have hardly any money withheld and I would owe a lot of taxes in April. That method made it possible for me to refuse to pay very nearly all of my income taxes that would have gone to the military when I filed my taxes each year. I used the annual WTRL pie chart to get the percentage and then I subtracted that portion from my taxes. I always made a point of paying for the percentage that goes to veterans benefits. But I sent the portion that would have gone to fighting wars and making weapons and all that defense/military stuff to the WTRL to put in my savings account. I also sent additional money to the WTRL account to cover the cost of fines and interest that would be charged when the IRS eventually collected, as I knew they would. They are a bully with enormous muscle.

If you can believe it, I successfully resisted paying war taxes from 1979 to 1984. Over the years, the letters from the IRS became more frightening. They said they would impound my car, turn me out of my apartment, garnish my wages, arrest me. I diligently responded to their threats, told them the account number of the savings account at the WTRL where I had put the money for them. Patiently and politely explained that I was a pacifist and I did not approve of the government’s use of my money. I told them they could have it if the government stopped waging war.

Finally the IRS got fed up with me. Or I should say with us, because by then I was married and Ron and I resisted war taxes together. One day the IRS swooped in and cleaned out our bank accounts. Poof, like that. Not the one in Seattle at the WTRL, but our regular, daily-use bank accounts. I was outraged that the IRS had the power to just pluck my money straight out of my bank account. We literally had no money to buy food. We had no credit cards in those days (I applied for my first one after this fiasco with the IRS happened). Our money disappeared to the IRS during the year that I was staying home with my first baby. I called the WTRL in a panic and they were terrific. They wired us some money to help get us by until they could mail us a check for the large sum of money we had stashed in our account with them over the years. The IRS held us accountable not just for all our back taxes, but also the interest the money would have earned for the IRS over the years according to their calculations, plus they levied a fine. Even after they wiped out our bank accounts, we still owed more to them, and I decided to finally pay it. I had a child to think about and I could not handle the stress and uncertainty of resisting paying war taxes. So we settled up with the IRS.

I have paid my taxes ever since that time. For many years, I made my income tax check out to the U.S. Department of Health and Human Services or the U.S. Department of Education, just to make a point. When the canceled check came back (because in those days you could still get one), it always had “IRS” stamped on the back. Oh well. I always wrote a letter stating that I did not wish to have my money go to the military. I wondered if the IRS agent would read it and if it would cause any thought on that subject.

When I googled War Tax Resisters League, I couldn’t actually find the organization in Seattle that helped me back in the early 80s. I did find the War Resisters League (WRL) and they do create a pie chart every year to show the federal budget allocations. Here is the link to the WRL.  And here is the link to their pie chart.  Here, below, is a pie chart I downloaded that shows government budget allocations for 2013.

I continue to find it difficult to pay my taxes, knowing what the money goes toward. By paying taxes I am complicit in murder and torture. My taxes pay for the waterboarding of political prisoners and the bombing of children, they pay for construction of nuclear weapons and sophisticated heat-seeking missiles. They pay for the grief, anguish, pain, and loss of others in countries less prosperous or privileged than my own. This is a fact of my life that I must live with and frankly it makes me feel ashamed.

Blizzard

As the Northeast is blanketed in snow, and I check in with friends and family who live there, I am reminded of the upside of big weather – the great fun of living outside the daily norm that big weather often gifts to us. When I was growing up in Schenectady, NY, we often had snow storms and ice storms that shut everything down and knocked out the power. I remember sitting by the radio and listening to the school closings. What a thrill when they read the name of my school! An unexpected day of freedom.

The house that I lived in until I was 11 years old had many white birch trees in the yard. During ice storms, the birches would become coated and would bend over so that the top branches often touched the ground, like women stepping out of the shower with long wet hair and bending over to wring it out. Robert Frost wrote a famous poem about those bent over birches. (Here is the link to it if you like poetry.) If I recall, we lost a number of our birches to ice storms when they snapped from the weight. But I will always remember the graceful beauty of those bent birches, glittering, cased in ice.

Once we had a huge blizzard when my cousins were visiting us and their family couldn’t return to their home on Long Island because of the weather. It was the best thing we cousins could have hoped for. We spent days playing in the snow until we were soaked and freezing and then we’d go inside and drink hot cocoa and play board games until we warmed up and then we’d go back out again to build igloos and ride our sleds. We must have made our mothers crazy because they couldn’t use the dryer and we were soaking through every stitch of clothing we had from our expeditions into the winter wonderland outside. We slept rolled up in sleeping bags in the living room in front of the fireplace where our fathers had stoked up the fire for the night because the power had gone out. At one point my uncle and aunt packed up and piled my cousins into the car and attempted to go home, but the NY State Thruway was closed so they had to turn back. Imagine how delighted me and my brothers were to have our cousins returned to us for more fun and games. That storm gave me one of my very favorite childhood memories.

We often lost our power in winter rain or wind storms up at the Ranch during our years living out on the land. It snowed there very occasionally, which made our dirt road impassable. Also one of my favorite memories is one night during our first winter at the Ranch when it was pouring rain and the power had gone out. Ron was working that night and I was at home alone with the children, age infant, 4, and 7. I was in the midst of reading James and the Giant Peach to the older ones. So I lit a candles and we wrapped up in blankets and piled onto my bed with the baby kicking and gurgling happily beside us and I read chapter after chapter. That was the night that Akili made his famous comment about the caterpillar’s singing. I have never been known for being able to carry a tune. The caterpillar in that book sings a lot. So I would make up some sort of tune and attempt to sing the caterpillar’s words. After one such attempt that night, Akili commented, “That poor caterpillar can’t sing very well, can he Mom?”

Big weather gave us some of our most fun family moments at the Ranch. Once Ron cooked a pizza in the woodstove because the oven didn’t work when the power was out. It was an amazingly delicious smoky pizza. I remember many a night playing cards or board games with the children by lantern light. Housebound as a result of flash flooding along Highway 101 on one New Year’s Eve, Ron, Sudi, and I played Clue until 3AM. In the early years we had no backup generator so we had no water (we had a well that pumped using electricity) when the power went out. But after we got the generator, we would fire it up once a day for everyone to take a shower and check email whenever we lost our power.

I love the photos of the winter wonderland caused by the big Blizzard of 2013 (they call it Nemo); photos of children playing in the snow, patios covered up to the tip-top of the lawn chairs, snow piled up against the window, people snowshoeing and skiing. I love the stories about community fun during the big weather. I’m sure there will be lots of stories in the news about death and disaster, but I prefer to take a moment to celebrate the delights brought to us when Mother Nature forces us to pause and step outside the daily usual.

Silver birches along the road.

Elephants

Sometimes the behavior of animals makes me ashamed of the behavior of humans. Sure nature is savage. Absolutely. And sure, animals behave with shocking brutality in their instinctive efforts to survive (and often to dominate). But we humans can be equally brutal and grossly dominating; and we have much to learn from animal communities. We need to set aside our condescension toward other species and open our receptors.

Elephants have always struck me as one of the wisest and most spiritual of animals. They have such a complex and highly developed social structure. Perhaps the most important thing that we can learn from them is the value of basing communities on raising our young. Elephant communities are built around nurturing young elephants, raising them to be healthy, strong, and capable. So really, what more is there to say? In my work with communities all over the country, what I have found is that the healthiest communities, those that are safest and that are ranked as the “best places to live,” are the ones that have placed the raising of their children at the heart of community life. These are the communities that have as their mission to raise healthy, happy, safe, intellectually inquisitive children; children supported and capable of fulfilling their potential for being their best selves. In the process, the adult members of the community become their own best selves. Elephants already know this truth that humans seem largely unable to comprehend. (Witness how little money is put into education compared to defense spending.)

Elephant communities are matriarchal. Older female elephants teach younger female elephants how to care for elephant calves and the calves are raised communally by all the mothers. Elephants have the largest brain of any land animal and the cortex of the elephant brain has as many neurons as a human brain. As smart as humans? Probably smarter. Elephants grieve over their dead, exhibit a sense of humor, and, of course, play. They can be taught and they show interest in learning. They create art, use tools, demonstrate altruism and compassion, and they have good memories. They speak to one another in a language that includes vocalizations beyond the range of human audibility and that can carry over great distances.

I was prompted to write today about elephants after reading an amazing elephant story. Conservationist Lawrence Anthony is the author of the book The Elephant Whisperer, which relates his experiences rescuing troubled and troublesome elephants at his Thula Thula Conservation Reserve in South Africa. I confess that I have not yet read his book, but I will be reading it very soon now that I have heard this astounding story of how the elephants, whose lives Anthony saved, came to say goodbye to him when he died in March 2012. There are two herds of wild South African elephants at the vast Thula Thula Reserve, and both of these herds traveled for at least 12 hours to pay their respects to Anthony after he passed away. How did these elephants know that their friend and advocate had died? No one can answer that question. The two herds of elephants (who had been rescued by Anthony years earlier) walked across the Zululand bush until they reached Anthony’s house. These are not tame elephants either. These are wild elephants.  These elephants had been dangerous, violent, rogue creatures, who were hunted by the locals only a few years before (and they would have been shot if not for Anthony’s efforts). Anthony “rehabilitated” them so that they could live safely and without causing harm at the reserve. Once the elephants arrived at the Anthony family compound, they remained in the yard for two days to “pay their respects.” They had not “visited” Anthony’s house in nearly two years. It has long been known that elephants mourn their dead (not just other elephants who have died, but people who have died as well). What mystifies and astonishes me is that they knew Anthony had died and that they immediately set out and traveled such a great distance to honor him and offer comfort to his family.

I look forward to reading Anthony’s whole story about his relationship with the elephants in his book when I get my hands on a copy (I’m in line at the library). In the meantime, I am reminded to pay closer attention to the other species with whom I share this earth; and I am reminded that people are not the smartest ones here.

Here is one of the elephant herds arriving at the Anthony family's rural compound to pay respects.