Health Care Insanity


The High Cost of Clutching Your Chest


I NEVER wanted to die like Dr. Zhivago, at least not the way he did in my play-it-again-Sam memory of a middle-aged man with a neglected heart condition who dashes off a crowded bus and collapses, surrounded by strangers.

Which brings us to my wife’s chest pains. And a morality tale that drove home the stark disconnect between the care that prudent medical professionals routinely recommend and what some insurance companies – apparently mine, anyway – seem willing, at least at first glance, to reimburse. This is not about a $15 co-payment.

We’re talking expenses that might make the average person think twice before high-tailing it to a hospital for potentially lifesaving emergency care.

Dr. Zhivago succumbed to what the American Heart Association calls "the movie heart attack." In contrast, "most heart attacks start slowly, with mild pain or discomfort," the association says, adding, "Often people affected aren’t sure what’s wrong and wait too long before getting help."

So when my wife called me at work to say she felt an inexplicable heaviness in her chest and had for days, I told her to call our internist immediately.

Our internist is wise and not one to panic. "Sit tight" is his typical, and usually effectual, prescription for garden-variety aches and pains. But when he heard my wife’s symptoms, and knowing that her father had a history of angina, he could not have been clearer: "Go, go, go to the emergency room!"

She walked the few blocks to NewYork-Presbyterian on Manhattan’s East Side (the heart association recommends calling 911), arrived around noon and received prompt and compassionate care.

She was tethered to heart monitors. Intravenous tubes were inserted. Tests were conducted. A number of potential sources for the pressure on her chest were ruled out, but still, nothing was ruled in. When a dose of nitroglycerine temporarily relieved the pain, our internist, Harvey Klein, and an attending cardiologist, Allison Spatz, decided that indigestion, which produces some of the same symptoms as heart attacks, was probably not the cause. They recommended – ordered, is more like it – that she be admitted overnight (it took until 11:30 to find a bed) so she could be observed and undergo stress tests the next day.

No food was offered to her in the emergency room (an elderly patient who was offered food was wailing about the dry string beans and mashed potatoes). So around 9 p.m. I went out to a pizzeria and got her some ravioli.

Later that night, I dutifully followed the instructions on my insurance ID card and called Empire Blue Cross and Blue Shield to say that my wife had been admitted. An operator efficiently took the information, assigned a case number and cheerfully wished my wife well.

She was released around 6 p.m. the next evening and urged to take still more tests, including an echocardiogram and a heart scan, since the others had been inconclusive and the possibility remained that leaky valves or other heart-related defects had caused the pain.

Just three days later, we received a letter from Empire thanking us for our "medical service authorization request." It was denied. The stated reason: "Not medically necessary." The letter, signed by a doctor, elaborated that "using evidence-based criteria," the company was "unable to approve the requested coverage for acute inpatient hospital stay for evaluation of chest pain." The letter continued:

"Information received indicates stable vital signs, negative cardiac enzymes and that that patient was discharged to home the next day after a negative stress test. There is no indication of abnormal EKG, previous history of unstable angina or heart attack. As such, the evaluation of this patient, including stress test, could have occurred in a setting other than acute inpatient."

The letter added, helpfully, "Please be aware that if you proceed with this service, all medical charges will be the member’s responsibility." We are appealing that decision.

It is possible, of course, that the letter was a mistake. "The standard for chest pains is very clear," said Dr. Michael A. Stocker, Empire’s president and chief executive. "If a layperson thinks it’s an emergency, it qualifies for payment." Not necessarily for overnight hospitalization, he said.

A week later, the hospital bill arrived: $4,949.51. That was followed by more bills: $500 from the cardiologist; $900 from the internist; $1,308 from the hospital for additional tests ordered by the internist; $1,718 for more tests. Forget the ravioli, the gift shop purchases and other bills that we’re still getting for ancillary and miscellaneous expenses. They seem too petty to whine about. Suffice it to say, following our doctor’s advice, going to the hospital and undergoing some, not all, of the recommended tests have cost $9,375.51 so far. Even if Empire decides that these and all the other expenses, except the overnight stay, are "reasonable and necessary" and decides to reimburse us for 80 percent of them, following our doctor’s advice will still have cost us more than $4,400. Talk about chest pains.

Unlike about one in three Americans, we are lucky enough to have private health insurance, but it’s not free. In addition to whatever my employer pays, I "contributed" about $4,200 in premiums last year, not counting dental, vision or long-term-care coverage. And granted that I am form-challenged, most of the mail we get from various insurance companies is a printed list of coded, arcane, incomprehensible explanations of why they are denying reimbursement for one service or another.

But this experience raises an even more fundamental question. What happens the next time my wife has chest pains? Or I do? Or do any of the people to whom we spilled our guts about this episode in sheer outrage? Will they weigh their response or their treatment too carefully because, as the insurance company seemed to suggest, this might be only their first episode of unstable angina or a heart attack? How sanguine would any of us be about following the American Heart Association’s warning not to wait longer than five minutes before calling 911 and getting to a hospital?

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