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Healthcare Costs Actually Matter for Patients Paying Out of Pocket


Bringing costs into the healthcare equation, and in particular inserting them as a mistress in the doctor-patient relationship, is replete with challenges.

In the not-distant past, after a routine office visit, I wrote this letter:

To Whom It May Concern:

Thank you for the bill. I am looking forward to paying for my clinic visit. However, prior to sending
a check, I’d appreciate if you’d a.) send me your pricing list, so I can better understand the charges; and b.) send me a copy of my medical record from the visit so I can put it in my personal files. Thank you.


Bryan Fine

I’m fairly confident that most medical office personnel don’t routinely deal with a physician who dabbles in health policy and economics. Many of the questions I’ve asked over the past years, during my unexpected, patient-side encounters with the healthcare system, have been answered with shrugs, frustrated sighs, and straight-up disdain. And that’s not counting my conversations with the collection agency.

About one year ago, I switched to a high-deductible health plan, meaning that the first several thousand dollars of medical bills each year I pay out of pocket. Ostensibly, the purpose is that I - as the patient - would take on increased ownership of my healthcare costs, ask more questions, and maybe even “shop around” so as to create the impression of market competition.

So what do you think happened when, during my routine sorta-old-guy exam, I told the internal medicine doctor that way back, I used to have some heart palpitations and he suggested that we get an EKG “just to be complete?”

Even I, the experienced policy wonk and self-described master negotiator, swallowed my mojo and quietly acquiesced. Instead of politely asking “How much does that cost?” I sat and nodded and shrugged my approval. I’m fairly confident that Dr. Internal Medicine would have had no idea anyway and rightfully so, because the answer might be, “It depends on our contract with your insurance.”

Bringing costs into the healthcare equation, and in particular inserting them as a mistress in the doctor-patient relationship, is replete with challenges. Most overtly, people at the point of access often won’t know the answers - and that’s in a comfortable, planned setting for a lab test or a routine appointment. Mumbling about costs or charges with an endotracheal tube down your throat probably would be difficult. And neither of these situations addresses the unspoken awkwardness that develops between doctor and patient when, say, someone asks the price of an EKG.

On another occasion, I presented to an out-of-state emergency department with an ankle injury. Several weeks later, I received a non-itemized bill for about $1,000, which was the balance after my insurance had paid its share.

You won’t be surprised to learn that I wrote a letter. In response, I received an itemized bill that, amongst other things, charged me $700 for two superficial cultures, $600 for the 45-minute use of the ED, several hundred dollars for the X-rays, and various other expense essentials. (My insurance paid part of the bill, indemnity-model.)

There are people who, as insurance company employees, get paid a nice salary to come into my hospital and do utilization reviews. That is, they look at charts and make sure lengths of stay are justified and procedures performed are appropriate. They communicate regularly with the insurance company, often daily, to update the plan of care. They help make sure that the insurance company dollars are well spent.

There was no utilization reviewer for my ankle injury at “Out of State Hospital.” So, I had to do it myself.

To Whom It May Concern:

Thank you for sending me the itemized bill. I am looking forward to paying. Before I do, I would much appreciate if you could send me a.) the justification for two wound cultures on a superficial ankle injury; b.) evidence that the culture results were reviewed by a clinician; and c.) a copy of my medical record from the visit, for my personal files.


Bryan Fine

This letter led to the first of my conversations with a collection agency, which continued for several months and led to my having a personal discussion with the hospital accounts manager.

This letter then led, ultimately, to my charges being written off. That’s not what’d I’d asked for - in fact, I told them I was willing to pay - but the burden of customer service and providing information apparently wasn’t worth it for them.

Healthcare being a unique commodity is an accepted cliché these days, though we’re still trying. I’m enjoying my foray into the capitalism of healthcare (from the patient side), because I mostly understand the process and have the means to be in this game.

But for most other people? It’s tough to envision an easy solution.

Find out more about Bryan Fine and our other Practice Notes bloggers.

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