He Returned to the US for His Daughter’s Marriage ceremony. He Left With a $42,000 Hospital Invoice. – KFF Well being Information

Final June, Jay Consolation flew to the USA from his dwelling 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 scenario,” mentioned 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, a number 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 employees making copies of his insurance coverage card after which treating his acute appendicitis. Medical doctors carried out emergency surgical procedure to take away the infected appendix.

Diagnostic assessments confirmed he had a uncommon most cancers, which docs in Switzerland later eliminated with one other surgical procedure after he returned dwelling. “It was a miracle,” Consolation mentioned, 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 payment and deductible for Switzerland’s obligatory fundamental 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 assessments, 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 the state’s largest employerswith 40 hospitals.

Whole Invoice: $42,156.50, masking emergency surgical procedure, scans, laboratory testing, and three hours in a restoration room. His insurer has mentioned it can 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 exterior Switzerland.

With what is taken into account a wonderful well being system, Switzerland has the 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 correct factor and say I’m keen to pay my duty,” he mentioned.

Groupe Mutuel doesn’t have agreements with overseas suppliers, reminiscent of UPMC, and doesn’t cope with them instantly, 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 abroad — 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 biggest supplier of care in lots of components of the state. In 2016, it purchased a smaller health system and now runs two main hospitals, UPMC Williamsport and UPMC Williamsport Divine Windfall Campus.

Studies show that in areas the place hospital consolidation is excessive, costs go up. As a result of there’s 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 growth 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 anticipate 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 knowledge to supply price estimates based mostly on what insurers have paid, relatively than what suppliers cost — says a good value for a laparoscopic appendectomy in Williamsport is about $14,554.

Consolation mentioned a “cheap value estimate” based mostly on his personal web analysis can 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 data regarding previous medical/surgical historical past for this affected person,” wrote Susan Manko, vp of public relations at UPMC. The employees additionally carried out pathology work that recognized most cancers.

However these extra providers didn’t totally 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 mentioned Consolation’s whole invoice aligns with UPMC’s normal prices.

The price disparities spotlight the stark distinction in worldwide pricing. Cost estimates last year confirmed the common quantity paid for an appendectomy within the U.S. was “practically precisely double” that paid in Switzerland, mentioned Christopher Watney, chief government 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 usually 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 realize Medicare protection at one level however nonetheless isn’t enrolled, after being transferred to a few workplaces and “taking part in cellphone tag.”

Nonetheless, not like many sufferers coping with a five-figure medical invoice, Consolation mentioned he isn’t involved about UPMC harming his monetary status. The well being system doesn’t “appear to place dangerous marks in opposition to individuals’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 collection policy final yr; it states the well being system is not going to interact in “extraordinary assortment actions” reminiscent of 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 “strong monetary help program” for sufferers unable to pay. However “to our information” Consolation has not utilized for monetary help, Manko advised 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 fees.

Consolation obtained 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 supplied the insurance coverage data, she mentioned, “however there was no documentation within the sufferers file for handle, coverage quantity or coverage holder data.”

As soon as Consolation obtained his invoice, he realized it was a lot increased than his Swiss insurance coverage reimbursement and, pissed off, contacted KFF Well being Information.

Flückiger mentioned 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 supplied an in depth abstract of the UPMC invoice, the insurer elevated the quantity it could 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 instantly 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 mentioned. “That’s not proper. We’re ethical individuals, . However if you happen to’re going to attempt to gouge me and play the ability journey and assume you’re going to attempt to get every thing you may out of me, I received’t play that recreation.”

The Takeaway: Although the Inexpensive Care Act was meant to supply 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 check costs at different hospitals. However most hospitals within the space the place he fell in poor health are owned by UPMC. And an infected appendix can’t anticipate comparability procuring.

Clarke, the cost-containment professional, mentioned the “solely factor” Consolation may have completed otherwise was to buy a journey medical insurance coverage earlier than leaving Switzerland. Whereas costs for well being care in continental Europe are akin 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, mentioned: U.S. costs are “sort of loopy numbers.”

Invoice of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical payments. Do you will have an attention-grabbing medical invoice you wish to share with us? Tell us about it!