In an article in the New York Times on Sunday, we are introduced to Peter Drier, a 37-year-old man in need of neck surgery. He and his insurance company negotiate fees with his surgeon and anesthesiologist, both of whom are in his insurance network. His surgeon, for example, agreed to charge $6,200 for the procedure.
At some point, however, an assistant surgeon was called in without Drier's knowledge, and from outside his insurance network. Afterward, the assistant surgeon sent Drier a bill for his services: $117,000, almost 19 times as much as the in-network primary surgeon had charged. Rather than fight the bill, Drier's insurance company chose to pay the full amount.
And Drier's experience is far from unique. As Elisabeth Rosenthal puts it:
" .... in an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives.
The practice increases revenue for physicians and other health care workers at a time when insurers are cutting down reimbursement for many services. The surprise charges can be especially significant because, as in Mr. Drier's case, they may involve out-of-network providers who bill 20 to 40 times the usual local rates and often collect the full amount, or a substantial portion."
As Rosenthal points out, the cheaper, in-network surgeon in such cases often gets a share of the enormous payment to the out-of-network colleague that he or she calls in to "assist". In most other lines of work, that would be called a kickback, but in the medical industry it is perfectly legal in most states.
Such stories add to the mountainous evidence that the self-correcting features of the free enterprise system that work fine in other areas are absolutely incapable of regulating the medical industry. The information imbalance between the patient and the provider is much too vast; the power discrepancy between patient and provider is much too vast; the process is too complex. In short, when medical decisions are left "to the patient and his or her doctor," the patient is at a huge disadvantage.
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