POSTING #110

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Getting Sick in the South

Three rules are drilled into Canadians going south for a winter vacation.

Rule One: Don't get sick.

Rule Two: If you insist on breaking the first rule and decide that you must get sick, make sure it is between 8.30 AM and 5.30 PM, Monday to Friday, so you can go to a walk-in medical centre (center) and NOT to a hospital emergency department, which are all exorbitantly expensive.

Rule Three: Call your Canadian insurer BEFORE seeking treatment.

On our recent trip to Florida, I broke the first two rules.

Here's what happened.

On a Wednesday toward the end of our holiday I was feeling lousy---a temperature and a lot of coughing.

I called the Canadian insurance company hotline to find out what I should do if I had to see a doctor. The woman explained that if things got worse, I should call the company and it would find a walk-in clinic or hospital and make arrangements for me to be seen.

She offered to start a claim file 'just in case' but I said that it might be just a cold and that I would increase my asthma medication to try to reduce the coughing.

Early Saturday morning---about 3 AM--- I was much worse, couldn't stop coughing and was having trouble breathing. I called the insurance company and after listening to my symptoms the agent said she had a list of clinics and hospitals in the Bonita Springs area. She would contact them and call me back.

Half an hour later she called back to say that she couldn't find a clinic that was open but had found a hospital that would treat me in its emergency department. The hospital had agreed to bill the company directly so I wouldn't have to pay anything 'out of pocket'. She had faxed the billing details to the hospital.

Pat and I got to the hospital---owned by a private, for-profit company---around 6 AM. The ER receptionist told us that they had indeed received a fax but it was not satisfactory. I would have to pay for the treatment and then claim it from the insurance company.

She showed me the fax.

It said that the hospital was authorized to bill the insurance company directly and provided details on how to submit a bill.

It looked OK to me.

 I asked what was wrong with the fax. She said that it didn't have a statement saying that the insurance company would guarantee to pay 100% of all charges levied by the hospital.

"We've had trouble in the past with insurance companies from up there'", she said. "So if you want treatment, you'll have to pay yourself and claim it."

I tried to call the insurance company but after spending half an hour listening to classical music and repeated messages that 'your call is important and an agent will be with you shortly', I gave up.

I agreed to pay.

I was escorted into a palatial examining room, lined with marble and glass, with a single bed. In Canada, an examining room that size would have had at least three beds, with curtains separating them.

The staff, who were competent, didn't seem rushed and appeared to spend a good bit of time recording billable items and having me sign witnessed statements designed I suppose to cover their derrieres in the event of a malpractice suit. I signed individual statements agreeing to be examined, saying that I understood the diagnosis, and that I agreed to follow the drug and medical treatment being recommended.

In addition to an examination by a nurse and a doctor, I had an x-ray, some blood tests and a treatment to ease my breathing.

The diagnosis was upper respiratory infection and acute bronchitis, and I was given prescriptions for three drugs---an antibiotic and two asthma medications that were different from the ones I had been using---and an appointment to see a pulmonologist in three days.

Two hours after I had arrived I was released and directed to a booth to wait for the bill to be totalled.  

Twenty minutes later, the ER receptionist slid a bill across the counter---for $2372!

After she had waited for me to catch my breath, she said that there might be additional charges. She explained that this was just an interim bill but when I came back in a few days for the final bill---the one that I would need to submit to my insurance company--- I would be told what the extra charges would be.

I handed over a credit card.

On the way back to our condo, I filled the antibiotic prescription, and swallowed the first pills. I decided not to fill the asthma prescriptions until I had talked to my Canadian doctor.

By Monday, I was feeling a great deal better---just as the doctor had predicted. He had said that the antibiotic he was prescribing worked very quickly. I decided not to fill the asthma prescriptions or see the pulmonologist.

Later on Monday, I called the hospital business office to ask whether the final bill was ready. A snippy clerk told me that it wasn't ready because the business office didn't work on weekends.

I called again on Wednesday and was told that the bill was now ready and I could come in and pick it up.

"Oh, by the way, there will be additional charges."

"How much?"

"They total $345."

"What are they for?, I asked.

There was a pause, and I could hear the computer keys being tapped.

"Oh, you won't have to pay the additional charges, after all. The hospital will absorb them."

I was left with the impression that if I hadn't asked what the charges were for, I would have had to pay them.

Strange.

Anyway, she had said that the final bill was ready. That meant that I could take it home with us when we left Florida in three days and then submit my claim to the insurance company as soon as we arrived in Virgil.

Pat and I decided to rush to the hospital business office right away, before they closed for the day.

Half way to the hospital I looked down at my feet. In the rush, I hadn't switched to the deck shoes I normally wore outside.

I was wearing slippers.

Now, they are nice slippers, Lands' End, sheepskin moccasin-type slippers in a dusky blue.

But still slippers.

There wasn't time to go back and change.

I tried to reconcile myself to the fact that with slippers and elderly (but clean) shorts I would be going to the business office looking like an escapee from the hospital's ward for memory-challenged patients.

When we got to the hospital I shuffled down a long, marble-tiled hall to the business office. Bending down to talk through a small hole in a bullet-proof glass partition (two to three inches thick), I explained why I had come.

After checking her computer, the clerk told me that the hospital person I had been talking to on the phone was wrong---the final bill was not ready.

She explained that it would take several more days at least to collect all the charges and then they would have to be entered into the computer. Furthermore, the computers couldn't be updated until after midnight the day the bills were received. And then the bill would have to be reviewed by another unit to make sure all the charges had been included.

She told me not to worry about any additional hospital charges. The person I had talked to on the phone had been right about the $345 additional charges being absorbed by the hospital.

However, there would probably be some bills from doctors who had reviewed the x-ray and blood reports to make sure the ER staff had interpreted them correctly. The doctors would bill me directly. (In fact, two doctors submitted bills, but they went directly to the insurance company. The company tells me that it paid them, after requesting and receiving 'discounts'. Don't ask!)

I expressed disappointment that it didn't appear that I would be able to have the final bill before we left for Canada.

The clerk behind the bullet-proof glass didn't seem concerned---her hands were tied---but  perhaps she could do something. She worked at the computer and produced an interim bill that showed the amount I had paid. Unfortunately, it also showed the $345 dollars of extra charges as 'unresolved'. The computer wouldn't let her delete the $345.

I explained that if I submitted that bill to the insurance company, they would want an explanation of the unresolved charges, and this would delay payment of my claim.

The clerk shrugged her shoulders.

I then asked if I could talk to her manager. She made a phone call.

While I was talking with the clerk, Pat was studying a picture on the wall at the end of the corridor. In the centre of a water-colour of a pastoral scene was a bird, a shiny black bird.

Pat leaned over and whispered, "You don't suppose that shiny bird is actually a camera to monitor the corridor?"

I looked up for a security camera but couldn't see one.

Nodding at the bullet-proof glass, I used that very Russian expression, "Who knows?"

Soon a woman appeared from an office up the corridor and joined us in front of the bullet-proof glass.

"I'm the hospital's 'Patient Advocate'. May I help you?", she said, in a pleasant voice.

I started to explain the situation, but then thought it would be better if we could sit down somewhere. This would make it easier for Pat's artificial knees and perhaps give me a chance to hide my slippers (and my shorts) under a table.

She seemed disappointed that she wasn't going to be able to complete her 'advocacy' role in the corridor but led us to her office.

When we were sitting, I pointed out that I was sure that in a large, well-organized hospital like this, there must be some way to produce a final bill. I pointed out that one of her hospital's employees had promised me on the phone that I could come in and get the final bill.

She was very sympathetic but said there was nothing that she could do. Computers, and all that.

I said that I understood that at her level she couldn't solve the problem but that my experience of large organizations was that there was always someone who could cut a Gordian Knot.

I asked if we could see the hospital's CEO (in my slippers and shorts).

After some phone calls, she reported that the CEO was in meetings. She said that the Chief Financial Officer would have been delighted to meet us but he was in a conference call that would last at least another half hour.

I said that was fine, we would wait---in her office.

More phone calls and then she said the CFO had been able to end his conference call and would be right down. As we waited for him, she busily cleaned her desk, organizing files and papers into neat piles.

The CFO, a well-nourished young man in a good suit, listened sympathetically to me (the hospital did 'sympathy' very well---probably an empathy training course). Unfortunately, neither he or the CEO could over-rule the computers. He did think of a way of tricking the computer so they could give me an interim bill that no longer showed the famous $345. I could submit that to the company and in the meantime the hospital would complete the final report with all the costs broken down by codes for the diagnosis and treatment, and would mail that to the insurance company.

Accepting that I had got as much as I could get, I threw in the towel and walked out of the hospital, trying to pretend that I was wearing shoes, not slippers.

When we got home to Canada, I sent all the documents to the insurance company.

Nearly two months went by as the company requested and then waited for the hospital to send the final bill. It had to be an original and this meant it had to come by US mail---no faxing, or scanning and emailing.

Finally, after some prodding from us, the insurance company agreed to send a cheque for the full amount without waiting for the final bill.

The cheque has now been received and is resting comfortably in our bank account.

I have decided not to worry about whether the hospital ever sends the final bill to the insurance company.

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Originally, I had planned to end this Posting by offering some sage comments on the light that my ER experience might shed on the conundrum that has always puzzled me about the American health care system: how can a nation that spends far more per-capita on health care than other industrialized counties still have 40 million people without health care coverage.

However, I have decided to let you---the reader---try to solve that conundrum on your own.

Instead, may I end with a story that keeps popping into my head whenever I think about the ER experience.  

It's a story about steam locomotives.

I know, there doesn't seem to be any connection, but bear with me.

A friend with a substantial engineering background had a passion for steam locomotives. Happening to be in a  city that had a railway museum, he dropped in.

He loved the museum. He sat in the engineer's seat, wore the striped grey and white engineer's cap, leaned out the window pretending to look down the track, and pulled the chain to blow the steam whistle.

Then he went to an exhibit that showed the internal workings of the steam engineer, the cylinders, pistons and valves.

He told me that the exhibit was excellent but one feature bothered him.

A guide had described the tolerances that the machinists worked to in milling the huge cylinders and pistons. My friend, who was used to working on internal combustion engines with their tolerances of a few thousands of an inch, was astounded by the casual standards used in steam locomotives. I forget the numbers, but let's say the tolerance was an eighth or a quarter of an inch---that's the order of magnitude.

My friend's point was that a good bit of the steam that was injected into the cylinders to drive the pistons would in fact escape along the gap between the pistons and the cylinder walls.

The steam locomotives had been wonderfully successful in carrying freight and passengers from coast to coast.

But my friend couldn't get over how inefficient they were.

"I suppose', he said, shaking his head, 'coal was so cheap that it didn't matter."

We chatted about the diesel locomotives and how much more efficient they are, with their close tolerances.

But the introduction of the more efficient diesels was controversial. Railway unions fought to keep fireman in the locomotive even though there was no longer a steam boiler to stoke.

'Railway towns', protested the changes arguing that they would lose many well-paid jobs because fewer workers would be needed to operate and service the diesel locomotives.

Some towns, like Stratford,  found alternative ways of creating jobs but other communities have still not fully recovered.

In the end, change came. Efficiency increased dramatically, and society benefitted enormously.

Thus endeth the lesson.

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See you on April 17th for Posting #111 with more stories from our family’s universe! If you have comments or suggestions, please leave a comment at the bottom of this posting,  or email me at johnpathunter@gmail.com.