Healthcare benefits advisor Matt Cole knows the industry inside and out, but he hadn’t personally experienced the system beyond a few minor treatments, the birth of his child and the standard wellness visit. That all changed when an unexpected and unsatisfying 4-day stay at the hospital made him wonder: How could this have gone differently?
From Soccer Game to Emergency Room
The day started as most do. I was up at 5 a.m. for a quick workout and then off to the races with meetings, emails and other appointments. It was a Thursday, which meant I would be meeting friends in the Detroit area for a game of soccer — and hopefully a delicious beer afterward.
On the field, everyone was enjoying themselves until a single play changed everything. Trying to telegraph a pass from the other team, I ended up tangled with another player who lost his footing. My leg was extended in an awkward position as I helped break his fall and everyone heard the snap. I thought maybe I just sprained an ankle, but it seemed everyone around me knew the injury was much more severe.
Fortunately, a friend was able to drive me to an emergency room near home. When we arrived, the staff placed me in a wheelchair. I spoke to a woman at the front desk and another took my insurance information. Then I sat for about 45 minutes before receiving medical attention.
As you can imagine, I was in some severe pain by this time, with what I would later find out was a broken tibia and fibula.
Treatment and Care Are Two Different Things
Finally, after a long wait, I was seen by the ER physician to determine if any time-sensitive issues needed to be treated right away. He gave the all-clear and I was sent to x-ray and admitted to the ER.
Let’s consider how long that process took: The injury had occurred around 5 p.m. on Thursday. Friday morning was fast approaching as I sat in a bed in the ER. Why the delay? The medical staff was waiting for the orthopedic specialists to review my records and determine the treatment course.
Late in the evening, I was told I was being discharged. I was relieved until the medical staff came in again to let me know that the orthopedic specialist finally had a chance to review my x-rays and determined that I would spend the night after all: My leg needed to be reset, and I had to be prepped for surgery the next day.
I was thrown off by the 180-degree change as much as the opioids and other pain meds I was given. On that note, much of my time spent in the hospital is a bit blurry. From what I can recall, here are some frustrating events that came up during my stay and treatment:
- I had little say in my treatment plan. I recall several times asking to speak to medical staff on options, outcomes and best practices. I essentially was left with minimal explanation.
- I wasn’t given multiple treatment options. Surgery was presented as the only course of treatment, and I wasn’t given any alternative options.
- I didn’t know the recovery rate of my injury. Likewise, I wasn’t informed of any of the long-term side effects of such a traumatic injury.
- Ididn’t have any information about my surgeon. Despite my med-induced fog, I was able to do some quick research about him and was relieved that he had extensive experience with the procedure.
I was getting the correct treatment (I could only assume) from a qualified expert (from what I could tell based on hasty research). Going in for surgery is scary enough. Getting emergency surgery without enough information, patient advocacy or presence of mind? That’s terrifying.
Based on that experience, I’d say I received treatment — but I can’t say I received quality care.
The Damage: Someone Could Have Bought a Mercedes Benz S-Class
I remember trying to go home Saturday evening because I was tired of being in the hospital. I felt okay enough to leave, but soon realized my pain levels were so low because of the nerve block the doctors gave me. Once that wore off, I was uncomfortable again. After a quick phone call with my wife, I decided to stay until Sunday.
In total, I entered the ER on Thursday, May 31 and was discharged Sunday, June 3. I was confident that my $7,000 out-of-pocket maximum was going to be met. The grand total for my 2018 medical expenses was $91,000!
Before this injury, I had seen the doctor for my annual wellness visit. That’s it. In less than 4 days, I accumulated tens of thousands of dollars in medical expenses.
When did treatment for a broken leg get this expensive? How is the average person supposed to recover both physically and financially from an injury that sets them back 6-12 months and over $7,000?
I am fortunate to have an employer who supported me throughout my recovery and someone who offers their employees great healthcare by today’s standards, but when this situation arose, it was a rude awakening to the flaws we have developed in our system.
The Aftermath: Dealing With Billing
The bills started to roll in before I made it home from the hospital. I knew they were going to be big, but I underestimated the number of invoices and their complexity. Surgery bills, anesthesiologist bills, bills from physician practices, bills from doctors that I never met and, if I did, do not remember.
All in all, I had about 10 different bills sent to me in the mail for my three-and-a-half-day treatment.
For the first few weeks, I let the bills stack on the counter. I wasn’t ready to try and make sense of the madness. Plus, I wanted to make sure my insurance carrier, BCBSM, had a chance to review the invoices and guide me, as a member, on what to pay.
Easy enough, right? Not exactly. I had over 20 listed claims in my member portal on my carrier’s website for the time I was in the hospital. The claims had various doctor names, physician practice names and listings, even though my whole stay was at the same place.
As I tried to sort through this confusing mess, I kept coming back to the same questions:
- How could this be so difficult?
- Why would I be left to sort this mess out?
- How hard could it possibly be to get a single bill from the hospital that performed the services with my insurance carrier’s stamp of approval?
What Could Have Gone Better? Lots, Apparently.
Dissatisfied with the care I received and the exorbitant cost of my emergency care, I decided to get in touch with my friends at Apostrophe to play a little game — kind of like those old Choose Your Own Adventure books. How would this have been different if Apostrophe was handling things?
Apostrophe’s Intelligent Health Benefits deliver excellent health plans at a fair price for self-insured employers. They developed their platform and exceptional member care services to eliminate legacy insurance carriers like my own.
Apostrophe prides themselves as the health plan that’s fixing America. We decided to audit my bill and overall experience together, and what they found was eye-opening.
Solving Problems with Simplicity, Transparency and Love.
Nothing’s going to make a broken leg painless, but Apostrophe’s Intelligent Health Benefits could have helped with some of the headaches Matt encountered along the way. Here are a few ways Apostrophe’s Member Care team could have made Matt’s experience go much more smoothly.
1. Guided decision-making for critical care
Problem: Matt had little say in his treatment plan and wasn’t given any multiple solutions.
Solution: Matt could have called Apostrophe’s member care team — yes, from his hospital bed — for a second opinion from a medical expert. He also could have consulted with our member care specialists to learn more about his doctors and surgeons. We have access to industry-leading databases about providers across the country and use these resources to recommend quality care for our members.
2. Negotiated rates for lower total costs
Problem: Matt’s hospital stay and surgery ended up costing $91,000 — the longer he stayed, the longer his bill grew.
Solution: Apostrophe links provider payments to the Medicare pricing schedule so that costs are transparent to members and tied to a hospital’s actual costs — rather than the billed amount, which is set by the hospital. Medicare pays about $13,000 for an inpatient stay for a fractured tibia, which would have been Apostrophe’s starting point for the cost of the treatment.
3. Eliminated unknowns with transparent pricing
Problem: Matt didn’t know his total medical expenses until he got home from the hospital, and was amazed by how many costs had accumulated in just four days.
Solution: Apostrophe pays hospitals based on a multiple of Medicare, so charges are based on your diagnosis, not a list of itemized charges. This means the hospital gets paid the same amount regardless of how long you stay or what services you receive during your stay.
4. Simplified, easy-to-understand billing and flexible payments
Problem: The hospital bills kept stacking up, and Matt couldn’t get a straight answer from his insurance company about what he owed and what he didn’t.
Solution: Apostrophe provides single, fully-audited bills for members on a monthly basis. No one needs to get piles of bills to sort through and reconcile, especially after a major medical treatment. Members can also take advantage of single payment plans for all medical bills. Pay bills down over a period of time that works for you and your budget.
Another option: Apostrophe’s Member Care team could have directed Matt to a vetted surgery center with a much lower price before he was admitted to the hospital. All it takes is one call to Member Care find high-quality care at a fair price.
If you’re ready for a change,
You have so much more control over your health plan than you might realize. There are better options out there for you. Let’s find them.