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how to Occupy Healthcare!

By leigh | January 6, 2012

…Just kidding. I don’t really know how to occupy anything. But I do want to tell you some things about the politics of MRIs.

Have you ever had an MRI? Brief review: Magnetic Resonance Imaging uses a magnet – an very large “superconducting” magnet, using liquid helium. (Actually, not just even liquid, but cold liquid helium, about 455 degrees below zero [F]. That’s cold!) MRI basically looks at soft tissues. It’s good for looking at a tumor, or at your brain. Dye can be used to show blood flow in the area.

This is a cup of cold helium.

In my opinion, for most purposes, the sophistication of the results has outstripped our ability to interpret them. For example, it’s well known that people can have terrible-looking spine MRIs without chronic back pain or limitation in activity at all. Also, people with terrible daily back pain can have a very normal appearing spinal MRI. This shows that it is not a very good test for chronic back pain in most cases. I almost never order an MRI for any reason. If I think you have a brain tumor, I’m going to call a neurologist first (in a hurry!), and see what they think is the best way to investigate.

However, that is not what I want to tell you about.

Let’s just imagine that people are only getting MRIs when the MRIs are really truly going to produce important and accurate information that really truly will help us know how to fix a problem. Could getting this very-necessary test drive a family into the poorhouse?

Telephone interviews identified 639 patients whose illness contributed to bankruptcy: the debtor or spouse in 77.9% of cases; a child in 14.6%… At illness onset, 77.9% were insured… For patients who initially had private coverage but lost it, the family’s out-of-pocket expenses averaged $22,568.
…Nonstroke neurologic illnesses such as multiple sclerosis were associated with the highest out-of-pocket expenditures (mean $34,167), followed by diabetes ($26,971), injuries ($25,096), stroke ($23,380), mental illnesses ($23,178), and heart disease ($21,955).
…There is ample evidence that the financial burden of illness is increasing.
[Note Elizabeth Warren as 3rd author.]

They were saying that back in 2007 – which for many of us were the economic “good old days”!

[I know that conservatives dispute these numbers - see this by the group powered by Dick Cheney, Newt Gingrich, Ken "Enron" Lay, and their pals. They often don't believe that such misfortune happens often (it doesn't happen often to them, of course), and/or they can't understand how debts that they regard as nonsignificant can be insurmountable. However, I happen to know quite a number of former conservatives, who suddenly came to think otherwise - after the car crash, or after the diagnosis, or after the complications resulting from surgery.]

Anyway… how much does it cost to get an MRI, if you have to pay out of pocket for it?

Local sources (people that perform MRIs) tell me $1250-1500, for a lumbar spinal MRI, for example – double that, if contrast dye is used ($2500-3000). That includes the radiologist’s fee for interpreting the pictures. If you pay 20% on the spot, they will give you 10% off and a payment plan. Hope you have $600 in your pocket when you go there.

The Health Care Blue Book gives these estimates for our zip code:
Spine MRI (no contrast) – $517. Price includes the total amount for both physician (interpretation) and technical (imaging) fees.
Spine MRI (with and without contrast) – $753. Price includes the total amount for both physician (interpretation) and technical (imaging) fees.

In your dreams! The Blue Book’s prices for a lot of stuff do not correspond in any way to prices on the ground, unfortunately.

Would having a sit-in at the hospital bring the prices down? …Just kidding! People who actually need MRIs are too sick to sit-in anywhere.

Here are some data about why MRIs cost so much.

MRI machines can range in cost between $1 and $3 million. Construction of MRI suites can easily add another $500,000 to the total cost.

… Aside from the initial cost of purchasing the MRI equipment, there is the additional cost of $800,000 each year on average to operate the scanner… Add to that the cost of hiring employees with the technical skills to operate and repair [it].

…The life[span] of a new MRI machine is typically assessed at about seven years. However, because of the high cost, most facilities try to get more in the line of 12 to 14 years of use out of the equipment.

…The average annual salary for an MRI technologist ranges between $50,000 to $55,000… It isn’t uncommon for qualified repair engineers to earn salaries in the six-figure range.

How to buy a used MRI machine:
Have the MRI inspected… This will cost you somewhere between $1,500 – $3,000 but it is well worth the cost.

…Expect to spend around $10,000 for a deinstallation… The exit pathway is important and in many cases can be the biggest unexpected cost associated with an MRI purchase… First floor removals and rooms adjacent to exterior walls are the norm but there are exceptions. For a ‘normal’ removal, expect to spend approximately $10,000 – $12,000 to get it safely onto your truck! For a non standard removal… way more!

…It will need to move quickly to avoid excessive helium ‘boil-off’ once it is off power… Expect to spend around $5,000-$10,000 for overland domestic transport.

…The installation of your MRI is a complicated project… Expect to spend between $50,000 and $80,000 for a ‘typical’ installation.

Joke: Did you hear about the MRI that had to come out in little pieces?
Punchline: It’s in the basement.

American prices are not the same as prices in other lands.

NPR: Professor Yekagami, a health care economist in Japan… Do you know how much a MRI costs in Japan?

Prof. YEKAGAMI: Hundred and sixty dollars.

NPR: You know exactly the number?

Prof. YEKAGAMI: Right.

NPR: …How does that work? I mean, costs are costs, right. We have to buy MRI machines. So does Japan. We have to pay the electricity bill. So does Japan. There are staff and supplies. You can’t just force cost to be low.

Prof. YEKAGAMI: Two thousand dollars, I would think, is a state-of-the-art MRI, most expensive type.

Professor GERARD ANDERSON (Health Policy and Management, Johns Hopkins University): …When you go and you buy it from Siemens or General Electric or any of the manufacturers, you will be paying about twice as much in the United States for the exact same machine.

NPR: …They charge more here in the U.S. because we will pay more. How come? Well, I called a number of American hospitals and doctors and I got basically two reactions. The first and most popular: a shrug. We could never get those prices. That’s just how it is. And the second: some were surprised… Health care prices even to them are something of a mystery.

Comment on this story:
As a radiologist I read different types of MRI’s from many different facilities. Quality is all over the place. MRI scans from rural Texas are done by incompetent techs with inferior machines and are very difficult to interepret. I’m sure pathology is being overlooked. MRI’s done at the big medical center are state of the art and in the right radiologists hands can find disease. The problem with our system is that both scans get paid the same.

Per the Radiologic Society of North America (RSNA), using data from 2009: With a median salary of $454,205, diagnostic radiologists’ compensation increased by 3.7 percent in 2009, while interventional radiologists reported a median salary of $478,000, which was unchanged from the year before.

Radiologists and healthcare economist types discuss.
Radiologists have been content to live off the fat of the land, working bankers’ hours and outsourcing inconvenient night and weekend duties to teleradiology firms rather than taking call themselves. Even when they’re around, radiologists in general don’t do a good job of serving the physicians who refer to them, staying in their dark rooms and not being proactive or even responsive. As radiology groups are finding, if they demonstrate they’re not crucial to the success of a hospital on nights and weekends, that also makes a pretty good argument for why they’re not necessary during weekdays either. Once hospitals understand the truth they can dispense with the local, intransigent radiology group entirely.

The quality of e.g. brain readings by any trained neuroradiologist in India is as good or higher than that of a general radiologist in the states, and since the images are easily transferable and are interpreted with the actual patient unseen, outsourcing is entirely doable.
Moreover, the technical component of radiologic exams (generating the actual images) are highly standardized, and if imaging facilities competed on price, studies would only cost a fraction of what they cost now.
…There is an easy bureaucratic fix that would allow us to keep all radiologic services in the country: just pay the radiologist the average time that it really takes him/her to interpret the pics and to generate a reading. Interpreting pics is not more stressful than seeing patients and should be compensated grossly similarly (of course one can make modest adjustments for education and risk of litigation).

The handwriting is on the wall for academic medicine… This is nothing more than a plea to shift the money flow from private teleradiology firms competing in an open market to academic radiologists who can’t get out of their own way, and will be content to have residents read the work while they sit in their offices.

The teleradiology I’m referring to is done by US board certified radiologists, though some of the commenters don’t seem to realize it. Many of these teleradiologists are in the US, but some are based overseas. Often the teleradiology companies hire radiologists out of fellowship and set them up in a remote time zone, e.g., in Australia or Hawaii. That way they can work during their day when it’s night in the US. It’s a pretty attractive gig… The issue of Indian or other low-cost radiologists is an interesting one but not addressed here. The US radiologists are managing to commoditize themselves quite nicely despite erecting guild-like barriers to entry.

We decided to check our local MRI prices. [Most likely Santa Clara, CA.] We called 5 hospitals and 5 outpatient imaging centers in our area asking for the full price for an MRI of the brain with dye.
Two hospitals were unable to give us the price (didn’t know!) and one outpatient center refused to divulge its cash prices over the phone.

MRI Price Range:
Hospitals (3) – $1750 to $2200
Outpatient Imaging Centers (4) – $700-$1000

…We called back and asked for a discount. Results:

Hospital 1 offered a 10% discount if paid in full
Hospital 2 offered to split payments in half
Hospital 3 asked us to “come to the Radiology department”

Outpatient center 1 refused to discount (price was $900)
Outpatient center 2 told us the “manager had to approve any discounts”. We left a message but didn’t hear back.
Outpatient center 3 gave us a 20% discount, reducing the price of the test from $1000 to $800.
Outpatient center 4 offered to give us a discount but only if we faxed in the doctor’s order.

I am an Aussie living in America (18 months) and have unfortunately had the ‘opportunity’ of using the American Health system… Wow, what an absolute calamity! In Australia, the cost to the public is around $10 to $20… We just got a bill for (wait for it…) $1,800! …Heaven help us all, if we ever need to rely on the US health system for something serious.

I hurt my back at a water park in Ukraine and went to a private hospital… The cost of my doctor consultations and a spinal MRI came to $90! That’s NINETY DOLLARS!

I’m from Italy and I lived in USA. Weeks ago I needed a breast MRI, hospital asked me to pay almost 8000! It’s a shame, I came back to Europe and I had the MRI for 65 Euros in 3 days. [Approx $83 US.]

I live in small town Texas… No imaging centers here so I was told by my (most horrible insurance company in the world) insurance company it would cost over $3000 because I had to meet my $1300 deductible first then pay 20% and of course I have an out of pocket max per year of $2500 and on and on and on, and when I ask what that means, I get – you pay it all… This is getting worse and worse. Pretty soon we will all be just like in George Orwells 1984 or Solyent Green or better still Red Dawn. What has happened to our world? We cannot afford the things they are telling us we have to pay for and our doctors tell us they cannot help us unless we do what they tell us to do. Unless I give up everything I have (left) and go on welfare, I cannot afford to live and I do mean live. One day, I will probably die from not getting treatment because I cannot afford any of the tests needed to help me. Pretty soon I will not be able to afford the drugs either like so many other poor people in America. What has happened? I’m not some kind of radical. I am a 61 year old grandmother who can’t get a job any more. Something has to change.

How to find out the price of an MRI or other medical tests:
1. Start with finding out the CPT code of the test your doctor has ordered. This stands for Current Procedural Terminology and is a unique identifier for every medical test that exists… Try Googling for this info… Note that a test that requires the use of contrast dye is a different CPT code than a test that does not require contrast dye.

2. It’s always easier to get prices from the stand alone radiology facilities or basically any center that is not directly owned by a hospital… Call the imaging center and ask the person that answers the phone how much a person who has to pay out of pocket will pay for such-and-such a test… If your doctor has requested that the test include contrast dye be sure to tell them that as well.

3. To get the price from a hospital you really must have the aforementioned CPT code… Ask for either the Cashier’s Office or the Billing Office… If the first place you reach doesn’t have the info, ask to be transferred to the other office. Also ask about the physician’s reading fees… but don’t be surprised if the person you are speaking to doesn’t know the answer. It’s not their fault. Frequently physician’s fee billing is done through the physician’s private office.
Also, always ask if there is a discount for self-pay patients, and how to qualify for this discount, as sometimes this entails additional paperwork.

How can we occupy healthcare?

The idea of Occupy is really that incremental change is happening way too slowly for people’s health or safety. Many people now have nothing left to lose. Others are very aware that they soon, or with one false step, also will have nothing left to lose. They may not be sure how to fix the problem. All they may know is that they can’t wait.

From my perspective, in one of the save-the-world professions, is that people are literally getting sick and dying right now, right down the street – with chest pain when they go up a flight of stairs, with uncontrolled seizure disorders, with enormous quantities of pain medications, with severe blood loss anemia, unable to sleep or work due to lung disease, becoming skeleton-thin from intractable vomiting – not because of political problems, but because of medical problems. But if they are to navigate the current healthcare system and get the evaluation and treatment they need, they really need to have a ton of energy, determination, ingenuity, education, and cash. Which they often do not have. Note: these people do not look different from anybody else. You can not identify their predicament by looking at them. They are your relatives. They are your neighbors.

We can’t wait. I think the politics of MRIs – how much the machine costs here and elsewhere, how much radiologists are paid and why, how difficult it is to even find out how much the test costs, and what happens to people after they leave the doctor’s office with the order in their hand – these give us a little snapshot of something very important.

They show us that the system – the elected officials, from city council to the white house, hospital and insurance administrators, drug and “medical device” corporations, economists and the talking heads who report on teevee every night that “the recovery” might be “stalled” – is dangerously out of touch.

The danger is palpable. The danger is directly to someone’s health and safety. Many of my patients are too sick to “Occupy.” But they, too, have nothing left to lose.

You may say to yourself, Well then, Dr. Leigh, what are you doing about this terrible situation? Short answer: I’m being a doctor in a particular way.

Is that a cop-out? Not really! I do believe that people need to heal and recover and grow strong, in order to organize and take charge of their destinies, including organizing against the unfair costs and inaccessibility of conditions that promote and protect good health.

One of the things they need to heal and recover from, is usually a long history of seeing paternalistic doctors who mystify their situation, who often use words that hurt them, who appear not to listen, and who may recommend plans that make no sense to the individual.

This is strongly disempowering, and makes it hard for people to take charge of their health. It often drives people into superstitious and rigid health beliefs, and into the hands of charlatans and quacks.

My biggest wish, if I could make a magic wish, would be for my patients to be organized, to “Occupy Healthcare” and make their voices heard – before it’s too late.

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