Final June, Jay Consolation flew to the USA from his residence in Switzerland to attend his solely daughter’s wedding ceremony. However the week earlier than the ceremony — on a Friday night — Consolation mentioned he discovered himself in “excruciating ache.”
“I attempted to intestine it out for 3 hours due to the insurance coverage state of affairs,” mentioned Consolation, a retired instructor and American citizen who has Swiss insurance coverage.
When the ache turned insufferable, Consolation referred to as his brother, who drove him and his spouse, Nazuna, a couple of 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 mentioned.
On the hospital, Nazuna Konishi Consolation handed over her husband’s Swiss insurance coverage card, which confirmed protection by Groupe Mutuel. Jay recalled the workers 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 residence. “It was a miracle,” Consolation mentioned, including that the most cancers was utterly 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, finally, 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 charge and deductible for Switzerland’s necessary primary medical 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 referred to 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.
Complete Invoice: $42,156.50, masking emergency surgical procedure, scans, laboratory testing, and three hours in a restoration room. His insurer has mentioned it’s going to pay him about $8,184 (7,260.40 in Swiss francs), which is double the process’s value in Switzerland. This left him to cowl the remaining roughly $34,000.
What Offers: 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 every other supplier outdoors 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 supplied 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 keen to pay my accountability,” he mentioned.
Groupe Mutuel doesn’t have agreements with overseas suppliers, akin to UPMC, and doesn’t take care of them immediately, mentioned 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 mentioned, 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 elements 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 “everywhere in the map,” mentioned 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 mentioned he would count on an appendectomy to be priced between $6,500 and $18,800, primarily based on his evaluation of Medicare funds within the Pittsburgh space. Healthcare Bluebook — which evaluates insurers’ claims information to offer value estimates primarily based on what insurers have paid, quite than what suppliers cost — says a good value for a laparoscopic appendectomy in Williamsport is about $14,554.
Consolation mentioned a “cheap value estimate” primarily based 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 referring to previous medical/surgical historical past for this affected person,” wrote Susan Manko, vp of public relations at UPMC. The workers additionally performed pathology work that recognized most cancers.
However these extra providers didn’t absolutely clarify the hole between value estimates and what the hospital charged. As an example, UPMC charged $8,357 for Consolation’s three-hour keep within the restoration room.
Manko mentioned Consolation’s complete invoice aligns with UPMC’s normal costs.
The fee disparities spotlight the stark distinction in worldwide pricing. Value estimates final yr confirmed the typical quantity paid for an appendectomy within the U.S. was “practically precisely double” that paid in Switzerland, mentioned 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 mentioned. The Swiss pay double for an appendectomy in contrast with Germans, and greater than thrice that of these in Spain, he mentioned. Throughout the globe, Watney mentioned, 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 practically three many years working overseas, mentioned he labored within the U.S. lengthy sufficient to qualify for Social Safety advantages and Medicare. He mentioned he had beforehand tried to achieve Medicare protection at one level however nonetheless isn’t enrolled, after being transferred to a few workplaces and “taking part in telephone tag.”
Nonetheless, in contrast to many sufferers coping with a five-figure medical invoice, Consolation mentioned he isn’t involved about UPMC harming his monetary fame. The well being system doesn’t “appear to place dangerous marks towards folks’s credit score report — 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 yr; it states the well being system won’t have interaction in “extraordinary assortment actions” akin to lawsuits, liens on properties, arrests, or reporting to credit score companies.
She mentioned 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 mentioned he spent months ready for a invoice and eventually reached out to UPMC as a result of, if the invoice had arrived this yr, he would have needed to pay his insurance coverage deductible once more on high of the costs.
Consolation acquired a full UPMC invoice six months after his surgical procedure. Manko mentioned there was “confusion” on the time of Consolation’s ER registration. Consolation’s spouse offered the insurance coverage info, she mentioned, “however there was no documentation within the sufferers report for deal with, coverage quantity or coverage holder info.”
As soon as Consolation acquired his invoice, he realized it was a lot greater than his Swiss insurance coverage reimbursement and, pissed off, contacted KFF Well being Information.
Flückiger mentioned the unique fee 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 we have now 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 will pay Consolation. In all, the insurer mentioned, Consolation ought to obtain 7,260.40 in Swiss francs, or about $8,184.
Consolation nonetheless hopes to barter immediately with UPMC to scale back what he owes.
“I don’t need to attempt to stroll away, saying I don’t owe you something,” Consolation mentioned. “That’s not proper. We’re ethical folks, you already know. However in the event you’re going to attempt to gouge me and play the facility journey and suppose you’re going to attempt to get all the pieces you’ll be able to out of me, I gained’t play that recreation.”
The Takeaway: Although the Inexpensive 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 might have tried to check 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 look ahead to comparability buying.
Clarke, the cost-containment skilled, mentioned the “solely factor” Consolation might have performed in a different way was to buy a journey medical insurance coverage earlier than leaving Switzerland. Whereas costs for well being care in continental Europe are similar to Switzerland, the excessive value of care within the U.S. means Groupe Mutuel insurance coverage is “inadequate.”
That’s particularly vital for guests to the U.S. since, as Robin Ingle, CEO of journey insurance coverage firm Ingle Worldwide, mentioned: U.S. costs are “sort 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’ve gotten an fascinating medical invoice you need to share with us? Inform us about it!