Lower costs for care, but at what price?

By Frances Stead Sellers / The Washington Post

Published Apr 3, 2014 at 12:01AM

I didn’t expect to be billed. I thought that emergency care in the Britain’s National Health Service was free, particularly for a British citizen like me.

But after falling off a horse when I was on vacation there last September and landing in the hospital under the care of a “polytrauma” team, I got a call. It was from Jacqueline Bishop, the hospital’s Overseas Visitors Coordinator. She told me that the NHS is a residence- not citizenship-based system and that since I live in the United States, I’d be treated like any other foreign visitor: I would have to pay full freight.

With visions of U.S. health-care dollars dancing in my head, I lost a little sleep that night. I thought about the bills from the orthopedic surgeon (for my broken pelvis and ribs) and the charges from the general surgeon (for my punctured lung); I imagined the costs of the CT scans and bedpans, of the blood thinners and painkillers and of the nurse’s hasty consultation with a doctor in the middle of one night when my blood pressure plunged, and I panicked. And I felt a wave of relief that the team had decided to treat my injuries “conservatively”; I would be spared the expense (and pain!) of surgery.

When the bill arrived, I was in for another surprise. It was a “package” deal comprising just six items, and it didn’t separate the hospital from the physician fees. There were no charges for the army of attentive doctors and nurses who met me in the ER, nor for the monitoring, blood tests and drips there. But from the moment I was admitted on a Wednesday morning until the following Saturday, when I was discharged to recuperate with relatives, the bill came to 3,464 pounds.

Or $5,572.54.

Talk about sticker shock.

That would have covered little more than one day’s stay in a U.S. hospital, which a 2012 report by the International Federation of Health Plans put at $4,287. That allows for an array of hospital charges such as labs and imaging but not, of course, physician fees. (The IFHP based its number on the average negotiated amount actually paid by U.S. insurers, not the far higher prices that providers typically charge.)

A philosophical difference

Britain, like other industrialized countries, spends far less on health care than the United States. A 2012 analysis of care in 13 countries showed that “health care spending in the U.S. dwarfs that found in any other industrialized country.” (It’s 9.3 percent of GDP in Britain, for example, compared with 17.9 percent here). “Higher prices” and “greater use of more expensive medical technology” are key factors in that spending, according to the analysis, which was authored by David Squires of the Commonwealth Fund, a New York-based group that supports independent health-care research.

Underlying it all is a philosophical difference, explains Uwe Reinhardt, an expert on health care economics at Princeton University.

“Unlike England, that has a budget, we don’t have any of that” in the United States, he says. “It’s absolutely honorable here for everyone in the chain to try to extract as much money as they can from the economy, and that adds up — the drug companies and the medical device makers and then the hospital, which makes the biggest markup it can. Rehab, home health care, you name it. That becomes a cost to you.”

Those factors would have made my treatment several times more expensive in the United States, Reinhardt and other experts say.

Take my CT scans. Tom Sackville, chief executive of the IFHP, the global network of health insurers, views scanning as a good illustration of pricing differences.

“For the same machinery in a similar facility with the same level of staffing — assistants. nurses and so on — there are very different costs.” According to IFHP data, a pelvic CT scan, for example, costs $175 in the NHS, while the average price paid to a U.S. hospital is $567 — and many insurers shell out far more. (See accompanying graphic.)

Not that Sackville, a former Conservative government health minister, is a fan of Britain’s taxpayer-funded system. “It’s a classic rationed system,” he says, “with delays and waiting lists.” Those are well-publicized criticisms of the cash-strapped NHS, which prioritizes care according to medical urgency and sometimes fails to meet guidelines for acceptable waiting times for non-urgent care (no more than 18 weeks from a primary-care referral until hospital care begins).

Differences and similarities

As a patient with potentially life-threatening injuries, I experienced none of those problems. But I did wonder where the NHS was saving money that might have been spent on me if a horse had bucked me off in rural Virginia rather than in rural England — and what effect that could have had on my treatment.

In the Royal Sussex County Hospital, I shared a bay in the trauma ward with four other women. One night, when beds in the men’s bay were in short supply, a nurse asked if a man could join us. Nobody objected, so he was wheeled in behind a heavy screen to give us (and him) some privacy.

Would that have happened in America? I doubt it. Did it affect my care? I don’t think so. The other patients were a more or less welcome distraction, though the nights were noisy.

More important, I didn’t really understand who was in charge of my care. The Royal Sussex County is a teaching hospital, where doctors did their morning rounds with teams of junior doctors and medical students. On the few occasions I had a question, the nurses seemed to turn to a different doctor every time. My discharge papers were signed by a physician I don’t even remember having met. The whole approach left me unclear about who the point person was if anything went wrong.

But when I returned to the States, I heard similar concerns. “That is why ‘hospitalists’ were invented,” a former Post health reporter told me, referring to the physicians who specialize in coordinating patients’ hospital care.

And despite my initial relief at having avoided surgery, I continue to wonder whether anything more should have been done. Six months on, one bone in my pelvis hasn’t fully healed. It still hurts.

Several British doctors suggested that if my accident had happened in America I would likely have had surgery to insert screws and plates and fix my fractures. In the U.S. fee-for-service system, the argument goes, doctors have an incentive to treat what their salaried British counterparts believed would heal with time (and without the risks of cutting me open). As a 2011 report comparing health systems put it, the United States “does a lot of elective surgery — the sort of activities where it is not always clearcut about whether a particular intervention is necessary or not.”

One British friend, a surgeon, thought I could find a range of legitimate opinions, which is pretty much what I learned from Greg Osgood, who took over my care when I returned to this country. He’s an orthopedic trauma surgeon at Johns Hopkins Hospital (where, incidentally, technicians have taken three X-rays of my pelvis from three different angles on each outpatient visit, as opposed to the single X-ray taken at each follow-up visit in Britain).

My case lay in a “gray area,” Osgood said. “Pelvises like to heal,” he told me. “They have a good blood supply.” And for the one bone that continued to cause discomfort, he recommended ultrasound to hasten healing rather than a trip to the OR.

And the multiple X-rays? Higher cost, more radiation, yes. But they offer a more complete view of the pelvic ring, and doctors here don’t want to risk missing a thing. “A large part of what U.S. doctors do is medical-legal,” said Hopkins chief orthopedic resident Savyasachi Thakkar, alluding to the costs of medical liability, which are far higher here than in Britain where the NHS also administers the legal aspects of medical practice.

Both doctors exemplify the sort of individualized attention that a place such as Hopkins stakes its reputation on. As Sackville put it, “About half the population in America get the best treatment in the world.”

But I am hard-pressed to see how I would have been better off here than in Britain. And a comparative study of how seven countries’ health systems function ranks the United States below Britain — in fact, last — “on dimensions of access, patient safety, coordination, efficiency, and equity.”

Complications

As it turned out, I needn’t have wasted a minute worrying about the bills I was running up in Britain. My husband confirmed very quickly with our U.S. health insurance company that it covered treatment overseas.

But the possibility of foreigners’ freeloading on the NHS has become politically contentious. “What we have is a free National Health Service,” Prime Minister David Cameron said last year, “not a free international health service.” While I waited in England for my lung to heal enough for travel, I’d hear echoes of that sentiment on the nightly news, as a vitriolic debate evolved over whether the problem was real or a reflection of the Conservative government’s anti-immigrant stance.

Once back in the States, I got another surprise: a letter from the Royal Sussex County Hospital saying my bill hadn’t been paid, along with a note saying that failure to pay could result in “a future immigration application to enter or remain in the UK being denied.”

What followed was the flurry of phone calls and emails familiar to any American who has haggled with a health insurance company.

First, the copies of the forms I emailed in were deemed illegible.

Then, in early February, I found out that my claim had been denied by my insurer, on the grounds that the British hospital did not get pre-authorization for admitting me — a step that nobody had told us was necessary.

I appealed, and was told it might take 60 days for the appeal to be considered.

Worrying about what might happen when I next tried to enter Britain — even with a British passport — I appealed the appeals process and asked for it to be expedited.

In mid-March, payment finally came through — and I contacted Bishop back in Sussex to let her know. She has become something of an expert on overseas patients and has been invited to speak before a parliamentary committee.

Unless they ask for private care, overseas visitors are treated clinically just like NHS patients, Bishop explained. But while legal residents receive free care, people like me are asked to pay the NHS package rate for procedures that is set by the government. It’s a fairly straightforward process, and Bishop handles overseas visitor billing for the Royal Sussex County and five other sites, which have about 780 inpatient beds. Billing for private care can get more complicated.

In the United States, billing is a business unto itself. “A typical academic health center will have 300 to 400 billing clerks,” Reinhardt reckons. “And each will have his counterpart in the insurance industry. To handle the billing of one hospital, you need 800 people. That would be unthinkable in England.”

How my $5,572.54 British bill might have ballooned here, not only because of “higher prices” and “greater use of more expensive medical technology,” but if it had been caught up in the administrative quagmire of U.S. billing — costs that Reinhardt estimates account for a quarter of U.S. health spending.

Feeling lucky

Being badly hurt does funny things; it makes you selfish, turns your focus inward. But as visions of those U.S. health care dollars spiraled upward in my head, I realized how fortunate I was to have received the care that Britain provides for all its people and how lucky I am to be in what Sackville described as the half of the American population that gets the best treatment in the world.

Because ultimately there’s the rub.

What about the other half?