Final June, Jay Consolation flew to the USA from his house in Switzerland to attend his solely daughter’s wedding ceremony. However the week earlier than the ceremony — on a Friday night — Consolation stated he discovered himself in “excruciating ache.”
“I attempted to intestine it out for 3 hours due to the insurance coverage scenario,” stated Consolation, a retired trainer and American citizen who has Swiss insurance coverage.
When the ache grew to become insufferable, Consolation known as his brother, who drove him and his spouse, Nazuna, just a few miles to the closest emergency division, on the College of Pittsburgh Medical Middle’s hospital in Williamsport, Pennsylvania.
Each bump of the drive was “like somebody taking one thing and simply jabbing it into my stomach,” he stated.
On the hospital, Nazuna Konishi Consolation handed over her husband’s Swiss insurance coverage card, which confirmed protection by Groupe Mutuel. Jay recalled the employees making copies of his insurance coverage card after which treating his acute appendicitis. Docs carried out emergency surgical procedure to take away the infected appendix.
Diagnostic checks confirmed he had a uncommon most cancers, which medical doctors in Switzerland later eliminated with one other surgical procedure after he returned house. “It was a miracle,” Consolation stated, including that the most cancers was fully eliminated.
After his appendectomy, Consolation recalled vomiting after which ready in a restoration room. In all, he spent about 14 hours at UPMC Williamsport earlier than being launched. He attended his daughter’s wedding ceremony and, ultimately, traveled again to Switzerland.
Then the invoice got here.
The Affected person: Leslie “Jay” Consolation, 66, a retired educator who labored in Japan and Switzerland. Consolation pays a month-to-month price and deductible for Switzerland’s necessary fundamental medical health insurance, which he has with the Swiss-based Groupe Mutuel. His advantages — and the costs for procedures — are outlined by the Swiss authorities.
Medical Service: Emergency laparoscopic appendectomy and diagnostic checks, which confirmed Consolation had a uncommon subtype of most cancers known as goblet cell adenocarcinoma.
Service Supplier: College of Pittsburgh Medical Middle Williamsport, which is about 3½ hours northeast of Pittsburgh. The UPMC well being system is one of many state’s largest employers, with 40 hospitals.
Whole Invoice: $42,156.50, protecting emergency surgical procedure, scans, laboratory testing, and three hours in a restoration room. His insurer has stated it is going to pay him about $8,184 (7,260.40 in Swiss francs), which is double the process’s worth in Switzerland. This left him to cowl the remaining roughly $34,000.
What Provides: Though Consolation has well being protection, his Swiss insurance coverage had no contract with the U.S. hospital the place he underwent emergency surgical procedure — or with some other supplier exterior Switzerland.
With what is taken into account a superb well being system, Switzerland has the very best costs for medical care in Europe. As within the U.S., the nation depends on personal insurers and hospitals. However the price of care in Switzerland is considerably decrease than what’s charged within the U.S., so the reimbursement his insurer provided is a fraction of what Consolation owes the U.S. hospital.
“I’m making an attempt to do the best factor and say I’m prepared to pay my duty,” he stated.
Groupe Mutuel doesn’t have agreements with overseas suppliers, similar to UPMC, and doesn’t cope with them straight, stated Lisa Flückiger, a spokesperson for Groupe Mutuel. The insurer initially agreed to reimburse Consolation what would have been paid in Switzerland for a similar therapy in a public hospital after which double that as a result of it was an emergency out of the country — a complete of 4,838 in Swiss francs, or about $5,460.
Whereas useful, Consolation stated, that quantity wouldn’t repay the $42,156.50 he owes UPMC.
UPMC has expanded its attain all through Pennsylvania and is now the most important supplier of care in lots of components of the state. In 2016, it bought a smaller well being system and now runs two main hospitals, UPMC Williamsport and UPMC Williamsport Divine Windfall Campus.
Research present that in areas the place hospital consolidation is excessive, costs go up. As a result of there may be much less competitors, hospitals have extra energy to cost what they need when sufferers have personal insurance coverage or are paying out-of-pocket.
Within the U.S., the quantities charged for medical care are “all around the map,” stated Johnathan Clarke, vp of technique and enterprise improvement at Penfield Care, a medical cost-containment firm in Canada. The corporate negotiates medical payments on behalf of people, together with worldwide guests to the U.S., however isn’t concerned in Consolation’s case.
Clarke stated he would count on an appendectomy to be priced between $6,500 and $18,800, based mostly on his evaluation of Medicare funds within the Pittsburgh space. Healthcare Bluebook — which evaluates insurers’ claims information to offer price estimates based mostly on what insurers have paid, moderately than what suppliers cost — says a good worth for a laparoscopic appendectomy in Williamsport is about $14,554.
Consolation stated a “cheap worth estimate” based mostly on his personal web analysis could be between $7,500 and $12,000.
Consolation’s care included an X-ray and an EKG, or electrocardiogram for his coronary heart, as a result of “there was no info regarding previous medical/surgical historical past for this affected person,” wrote Susan Manko, vp of public relations at UPMC. The employees additionally performed pathology work that recognized most cancers.
However these further providers didn’t absolutely clarify the hole between price estimates and what the hospital charged. For example, UPMC charged $8,357 for Consolation’s three-hour keep within the restoration room.
Manko stated Consolation’s complete invoice aligns with UPMC’s commonplace fees.
The price disparities spotlight the stark distinction in worldwide pricing. Price estimates final 12 months confirmed the common quantity paid for an appendectomy within the U.S. was “almost precisely double” that paid in Switzerland, stated Christopher Watney, chief govt of the Worldwide Federation of Well being Plans, an business affiliation whose members embrace well being insurers on six continents.
Well being care in Switzerland, although, is commonly costly in contrast with different European nations, Watney stated. The Swiss pay double for an appendectomy in contrast with Germans, and greater than thrice that of these in Spain, he stated. Throughout the globe, Watney stated, many nations embrace an in a single day keep in the price of an uncomplicated appendectomy in distinction to Consolation’s expertise, which was billed as outpatient care.
Consolation, who has twin residency in Switzerland and Japan after almost three a long time working overseas, stated he labored within the U.S. lengthy sufficient to qualify for Social Safety advantages and Medicare. He stated he had beforehand tried to achieve Medicare protection at one level however nonetheless isn’t enrolled, after being transferred to a few workplaces and “enjoying telephone tag.”
Nonetheless, in contrast to many sufferers coping with a five-figure medical invoice, Consolation stated he isn’t involved about UPMC harming his monetary popularity. The well being system doesn’t “appear to place dangerous marks in opposition to folks’s credit score file — and I don’t have credit score in the USA. I’ve been out for 30 years.”
Manko confirmed that, saying UPMC reviewed and up to date its assortment coverage final 12 months; it states the well being system is not going to have interaction in “extraordinary assortment actions” similar to lawsuits, liens on properties, arrests, or reporting to credit score businesses.
She stated the well being system — which, as a nonprofit system, is tax-exempt — maintains a “sturdy monetary help program” for sufferers unable to pay. However “to our data” Consolation has not utilized for monetary help, Manko informed KFF Well being Information.
The Decision: Consolation stated he spent months ready for a invoice and eventually reached out to UPMC as a result of, if the invoice had arrived this 12 months, he would have needed to pay his insurance coverage deductible once more on prime of the fees.
Consolation obtained a full UPMC invoice six months after his surgical procedure. Manko stated there was “confusion” on the time of Consolation’s ER registration. Consolation’s spouse offered the insurance coverage info, she stated, “however there was no documentation within the sufferers file for deal with, coverage quantity or coverage holder info.”
As soon as Consolation obtained his invoice, he realized it was a lot larger than his Swiss insurance coverage reimbursement and, annoyed, contacted KFF Well being Information.
Flückiger stated the unique cost quantity Consolation’s insurer calculated was by episode and didn’t embrace the scan or laboratory prices. After receiving questions from a KFF Well being Information reporter, Groupe Mutuel “realized that now we have not included the laboratory evaluation and the CT scan,” which aren’t routinely a part of an appendectomy, Flückiger wrote.
After KFF Well being Information offered an in depth abstract of the UPMC invoice, the insurer elevated the quantity it could pay Consolation. In all, the insurer stated, Consolation ought to obtain 7,260.40 in Swiss francs, or about $8,184.
Consolation nonetheless hopes to barter straight with UPMC to scale back what he owes.
“I don’t wish to attempt to stroll away, saying I don’t owe you something,” Consolation stated. “That’s not proper. We’re ethical folks, you realize. However in case you’re going to attempt to gouge me and play the ability journey and suppose you’re going to attempt to get every thing you’ll be able to out of me, I gained’t play that sport.”
The Takeaway: Although the Reasonably priced Care Act was meant to offer insurance coverage to extra People and produce down the price of care, hospital payments stay terribly excessive and extremely variable.
For a nonemergency, Consolation may have tried to match costs at different hospitals. However most hospitals within the space the place he fell sick are owned by UPMC. And an infected appendix can’t await comparability buying.
Clarke, the cost-containment skilled, stated the “solely factor” Consolation may have carried out in a different way was to buy a journey medical health insurance coverage earlier than leaving Switzerland. Whereas costs for well being care in continental Europe are corresponding to Switzerland, the excessive price of care within the U.S. means Groupe Mutuel insurance coverage is “inadequate.”
That’s particularly essential for guests to the U.S. since, as Robin Ingle, CEO of journey insurance coverage firm Ingle Worldwide, stated: U.S. costs are “form of loopy numbers.”
Invoice of the Month is a crowdsourced investigation by KFF Well being Information and NPR that dissects and explains medical payments. Do you might have an attention-grabbing medical invoice you wish to share with us? Inform us about it!