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The English teacher from Eureka, California, has always been sensitive to the ingredients found in skin creams and cosmetics. This time, however, the antifungal cream that had been prescribed to treat her persistent rashes seemed to make matters worse. Was she allergic to that too?
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Winston, 56, who works at Humboldt State University, knew that the dermatologist in his rural town in northern California was booked months in advance. So, as she often does for specialized treatment, she turned to Stanford Health Care, which is about a six-hour drive south. She was finally hoping to eliminate her itching and learn what else she might be allergic to – for years she had avoided lipstick and other skin products.
Winston said that 119 tiny plastic containers containing allergens had been attached to his back for three days. Winston finally learned that she was allergic to, among other things, linalool (consisting of lavender and other herbs), gold-plated metals, nickel and cobalt, ketoconazole cream prescribed to treat her persistent rash, the antibiotic neomycin, a dye for clothing, and a common preservative used in cosmetics.
Her doctor, a Stanford affiliate, had warned her that the extensive skin tests she needed would be expensive, Winston said, but she was not too worried. After all, Stanford was a network provider for his insurer – and his insurance, one of his benefits as an employee of the state of California, had always been reliable.
Then the bill arrived.
Patient: Janet Winston, 56, of Eureka, CA, English professor at Humboldt State University
Total bill: $ 48,329, including $ 848 for the time Winston spent with his doctor. Anthem Blue Cross, Winston's health insurer, paid Stanford a negotiated rate of $ 11,376.47. Stanford charged Winston $ 3,103.73 for its 20% share of the negotiated rate.
[documentcloud url=”http://www.documentcloud.org/documents/5018858-BOTM-Oct-2018.html” responsive=true]Service Provider: Dr. Golara Honari of the Stanford Health Care Outpatient Dermatology Clinic in Redwood City, California.Medical Procedures: In-depth skin allergy patch tests to determine which substances are responsible for contact dermatitis or rashes in Winston.
Winston, a professor at Humboldt State University, looks at her bill at home."I'm grateful to have had such good care at Stanford," said Winston, "but I was pretty outraged that they could lay charges." … nobody cut me. Nobody gave me anesthesia. I had partially open plastic containers filled with liquid stuck on my back.
What's Happening: Medical billing analysts told Kaiser Health News that Stanford's accusations about the Winston patch test seemed excessive. They were surprised to learn that Winston's insurer, Anthem Blue Cross, had paid Stanford over $ 11,000 for treatment.
The Stanford catalog price, however, is $ 399 per allergen.
"This accusation is astronomical and delusional," said Margaret Skurka, a retired health informatics professor at Indiana University and a medical coding and billing consultant who advises hospitals and service providers. She reviewed Winston's bill.
The "usual, usual, reasonable" charge for testing a single allergen in the expensive Bay Area of San Francisco is about $ 35, said San Francisco-based medical billing expert Michael Arrigo. who also reviewed Winston's bill. "The data seems pretty conclusive that the charges in this case are inflated."
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According to the type of allergy skin patch test received by Winston, the average amount billed by physicians to Medicare – an important data point for private insurers – was about $ 16 per allergen in 2016, according to Medicare payment data.
A spokesman for Anthem noted that one of the insurer's reviewers had reviewed the bill but could not say whether it had been further examined because of its high cost. "We are trying to strike a balance between protecting affordability and providing a broad network of suppliers to create choices," said Eric Lail in a statement.
The Winston case highlights the fact that some health care providers set exorbitant rates, knowing that they will receive a lower amount. Patients rarely pay these rates – called "chargemaster" or list prices – and they can generate aspirin titles at $ 100. But these list prices, as a starting point for negotiations and discounts, help to determine the amounts insurers pay and, ultimately, what patients pay as a share of the costs.
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Stanford Health Care also has a lot of power to deal with insurers like Anthem Blue Cross. The university medical system includes hospitals and outpatient clinics in the San Francisco Bay Area, as well as several large medical practices in the area. This type of consolidation and market power can drive up health care prices. Insurers in the region have long struggled with Stanford's high costs, sometimes removing the health system from their networks. But the breadth and depth of the academic medical system – not to mention its popularity with high-end clients in the San Francisco Bay Area – is preventing insurers from excluding a network like Stanford's.
Some of the products tested by Winston on allergy skin patches revealed that she could no longer use.A study recently published in Health Affairs revealed that such consolidation in California has resulted in soaring health care costs for both patients and insurers.
Patrick Bartosch, a spokesman for Stanford Health Care, said Winston's doctor had customized his treatment rather than using standard patch tests. The university health system operates a vast bank of allergens, he said.
"In this case, we performed a full assessment of the patient and her environmental exposures and carefully selected the appropriate allergens, which required obtaining and preparing potential allergens on an individual basis," Bartosch said in a statement. communicated.
Leemore Dafny, a health economist at Harvard University, said large health systems like Stanford, which has multiple hospitals and outpatient clinics, can put pressure on insurers to pay big.
"Everyone wants to point the finger at suppliers, but … a lot of times [insurers] taxi and pay the rates, "she said.
In other words, Stanford charged Winston's insurer $ 48,000 because he could.
Janet Winston's original bill from Stanford Health Care. The bill showed costs of $ 48,329.00 for allergy skin tests. Winston has negotiated its share of the bill down 50%.Resolution: After some negotiations with Stanford's billing department, Winston finally paid $ 1,561.86 from his pocket. She claimed that her doctor had told her that the cost per allergen would be about $ 100, not nearly $ 400 that Stanford eventually charged to her insurer.
Keep in mind: insurers often tell patients to "shop around" to get the best price and to make sure they choose integrated providers to avoid surprises. Winston did everything right and still got caught. As a state employee, she had excellent insurance and Stanford was a network provider. Winston said her doctor had warned her that the test would be expensive, but she had never thought it could be close to $ 50,000. Do not hesitate to ask for precise figures: "expensive" and "cheap" can have extremely different meanings in the very expensive American health care system.
Obviously uncomfortable with the charges, Winston's doctor advised him – in advance – to challenge him with Stanford's billing department. That's what she did and Stanford granted her a discount of almost 50% on her share of co-insurance on the bill. It's never bad to ask.
Winston's allergy skin tests revealed that she was allergic to many metals and other substances, including linalool, a naturally occurring terpene alcohol found in many flowering and flowering plants. spices. Winston can still handle roses in her garden containing linalool, but she can not wear perfumes or cosmetics containing the compound.Nevertheless, Stanford and its insurer received over $ 12,000 in allergy patch testing, a cost borne by policyholders and taxpayers. The researchers linked the consolidation of northern California suppliers such as Stanford and Sutter Health to higher health costs for consumers in the region. A local union of health workers has also decided to cover Stanford's costs with two city voting initiatives that try to limit what Stanford and other health providers can impose on patients in Palo Alto and New York. Livermore.
"I was grateful to have taken out so many assurances and networked, and I could afford the [final] bill, "said Winston." On the other hand, I thought, "How can they get by?" Most Americans could never afford this procedure, at least in this establishment, and it made me think of the grand piano in the lobby. "
NPR produced and edited the interview with Elisabeth Rosenthal for broadcast. April Dembosky, from KQED member station, provided an audio report.
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