Shortly after she shaved her head, my friend got a $1,600 bill in the mail.
Just 39 years old, she was diagnosed with breast cancer recently. She had surgery to remove the cancer and both her breasts. And even though she is young and her tumor was very small, there was cancer outside of one of her lymph nodes.
Barbara Rubino
Unfortunately, that meant her ordeal was not over as quickly as she had hoped. Next came planning for chemotherapy, which also meant she’d need another short surgery to have a port placed under the skin.
Chemotherapy ports are standard care, making chemotherapy receipt easier on patients and reducing its side effects. After a smooth surgery, resulting in a very uncomfortable port, she started chemotherapy. Two weeks later, her hair started falling out in clumps and she shaved her head. And then the bill came from the insurance company for the port insertion surgery.
Although it was pre-authorized by her insurance plan, occurred at an in-network facility, and was performed by a surgeon in her plan’s network, her insurance company said anesthesia and medications required for surgery to numb the pain, which are standard care, were not part of the pre-approval. So, my friend was billed for the anesthesia she needed and was required.
As a physician myself, I know the surgeon could not have done surgery without the anesthesiologist and anesthesia medications. Most adults receive local anesthesia and sedation for the procedure.
The confusion around health care practices and coverage exists throughout the health care system.
Until Oct. 2, Senate Democrats have a Request for Information out to the public outlining plans to redesign the health insurance system in this country. They’re looking for information and responses to proposals on mitigating costs, protecting patients and expanding health insurance coverage. This makes sense, as Americans repeatedly cite cost as the biggest problem with our health care system.
“Addressing cost is critical, but forcing sense into the system is the real challenge.”
Although cost is appropriately the subject of widespread focus and scrutiny, there’s more under the surface: the pieces of the U.S. health care system needed for people’s care are disconnected. Addressing cost is critical, but forcing sense into the system is the real challenge.
First, doing surgery without anesthesia for every patient simply doesn’t make sense. Even before the advent of modern anesthesia almost 200 years ago, ancient civilizations knew this. But in the current U.S. system, a standard procedure of surgery with anesthesia is under separate consideration — once for surgery and another for anesthesia.
This type of disconnect happens for people regardless of having health insurance. And those who have health insurance through their jobs may experience it more often than those with public insurance.
Additionally, doctors and the buildings they work in often are considered separately for contracting and billing. The United States passed the No Surprises Act in 2022 because people were getting bills for having care at in-network hospitals by out-of-network doctors.
This means people were going to a hospital that was in their health insurance network but being treated by doctors who were not. These basic pieces are not inherently connected.
It might seem intuitive that someone in the middle of their prenatal care, or receiving chemotherapy for cancer, should be able to continue to see the doctor who knows them.
“This fragmentation is not only costly, but also likely bad for our health.”
But, the federal government and almost all states have had to enact laws to ensure a patient can continue to get treatment from a doctor they’re seeing if that doctor leaves an insurance company’s network. Which insurance someone has largely dictates which doctors they can see, and changing health insurance plans leads to more emergency room visits and a disruption in primary care.
To be sure, there are numerous piecemeal laws attempting to bridge gaps in the system and protect people from insurance denials, although they often differ depending on the type of insurance. But these regulations often burden patients and providers, putting the onus back on those seeking care to use cumbersome pathways to get their care covered.
This fragmentation is not only costly, but also likely bad for our health.
My friend is working through the appeals process, between naps and chemotherapy appointments. If as a doctor I can’t help her navigate some wholly illogical gaps in her care, maybe it’s time to overhaul a system that has foundational flaws.
Elected officials, health care providers, insurance companies, advocates and communities must address the disconnect and work together to heal a flawed system.
During a time when most every American is increasingly concerned about cost, it’s critical not to lose sight of the most basic and common-sense connections that are missing for patients.
Barbara Rubino is an internal medicine physician and a Public Voices Fellow on Public Health with The OpEd Project and Blue Shield California Foundation.