A case study shows why Clinton shouldn't cap Medicare Your bill: $1,575? We pay: $222

S. S. Neumann

October 26, 1993|By S. S. Neumann

ALL signs indicate that President Clinton will try to put a cap on Medicare.

Please, Bill, don't do that until you find out how shamefully inadequate Medicare reimbursement to patients already is.

A few years ago I retired after 35 years in the work force, including 11 years at each of my last two employers. I got a small lump-sum payout from a 401(k) plan, but no pension and no medical benefits.

I signed up for Medicare, Parts A and B. (Later I winced upon learning that the premiums for Part B, which covers doctors' bills, will increase by 15 percent this year.)

I also bought a Blue Cross and Blue Shield Medigap policy. Though stunned by the size of its premiums for individuals who are not part of a group plan, I knew it was essential for my peace of mind to have this extra protection.

I had an excellent medical history, no major illnesses or surgery. Through the years my medical bills had been modest. My late husband and I ate sensibly, never smoked, drank in moderation, exercised regularly, stayed slim and had annual checkups.

I somehow thought I'd be healthy until the grim reaper came for me. Nature had other plans.

This year I got a diagnosis of ovarian cancer. I was terrified about the necessary surgery to remove my ovaries, terrified that exploratory surgery would find me an advanced and hopeless case, in dread of the chemotherapy to follow.

The one thing I didn't worry about was the bills; after all, I had Medicare and Medigap.

But second only to the shock of the diagnosis was the one I suffered when I saw the size of my medical bills and how much would turn out to be "patient responsibility."

I'm not crying poor mouth. I live on Social Security and the modest income from the savings I put away for my old age. I have a roof over my head and plenty to eat, pay my taxes on time and can even afford a nice annual vacation.

Bill, I guess I'm part of the middle class you've promised to take care of.

I'll try not to give you an organ recital. But four days after I was discharged following surgery, I suffered gastrointestinal bleeding and was taken by ambulance to a second hospital.

An endoscopy revealed that I had developed stress ulcers and they were hemorrhaging. I spent 10 more days in the hospital.

CIt would take half a page in this newspaper to list all the charges along the way: CAT scans and a host of other diagnostic tests, two hospital stays, biopsies, X-rays, drugs, transfusions, an ambulance, lab tests, chemotherapy . . . you name it, I've had it.

Let me give you a sample of my bills and what I got in reimbursement. The critical point is that Medicare pays 80 percent of what it "allows" -- what it deems the appropriate fee for a given service.

In most cases my Medigap policy picks up the remaining 20 percent, but subject to the same catch: it's based not on what I'm charged but on what Medicare allows. The balance is "patient responsibility."

For starters, Medicare had a $652 deductible for each of my two hospital stays. (It has since gone up 3.7 percent.)

Every four weeks I had chemotherapy as an outpatient. The monthly charge was $1,488; Medicare paid $853 and Medigap $213, leaving me to pay $422 a month.

Like many providers, the chemotherapy clinic did not "accept assignment" -- in other words, accept the amount that Medicare and the insurer would pay.

My total bill had to be paid at the time of each treatment, and I then had to wait weeks, sometimes months, for reimbursement.

The first cycle of chemotherapy went on for six months. Including weekly checkups and blood work, the cost for the series was $10,320.

Despite all my insurance, I had to pay more than $3,000 of it out of pocket.

A few more examples. As part of the diagnostic procedure, my doctor had ordered an echo exam of my pelvis and another of my abdomen, plus a tissue exam by a pathologist. The radiologist charged $475. Medicare paid $169. The pathologist charged $195. Medicare paid $58. A subsequent microscopic cell examination cost $80. Medicare paid $26.

After the cancer diagnosis was made, I had a first consultation and thorough examination by the surgeon. He charged a modest $125. Medicare paid $26. Upon admission to the hospital, I was required to have a chest X-ray. Charge: $45; Medicare's payment: $7.78.

On the day of surgery, a hospital pathologist performed lab analyses on 11 tissue samples, did a microscopic cell examination and had two pathology consultations with the surgeon. He charged $2,530. Medicare paid $771. The anesthesiologist charged $1,575. Medicare paid $222.

For the initial consultation and the physician's care on the three days after surgery, I was billed $675. Medicare paid $148. The surgeon at the second hospital billed $460; Medicare paid $217; I ended up paying $188. For each of these procedures, the payment was 80 percent of what Medicare allowed; Blue Cross and Blue Shield paid another 20 percent.

Bill, you and Congress need to give a lot of thought to my generation, trapped between declining health and the high cost of medical care.

I know about your budget problems. But think of mine.

Go ahead and cap the profits of the drug companies. Cap doctors' fees when they become obscene. Examine hospital charges. Try cutting the paperwork required by endless medical regulations. Do something about malpractice suits that increase costs for everyone.

Examine the bureaucracy of Medicare itself; I bet you can realize substantial savings through greater efficiency in that humongous organization!

But please don't cap Medicare reimbursements to the sick. They are shamefully low and, if anything, should be raised. It's terrifying enough to face grave illness. Having to spend off one's savings to pay for it makes it even worse.

S.S. Neumann is a writer in Wilton, Conn.

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