ARI SHAPIRO, HOST:
Imagine you have a pain that a simple, affordable injection eliminates for months at a time. Then imagine returning for the exact same treatment, only to discover that it now costs 10 times more. Well, that's what happened in our latest Bill Of The Month. Dr. Elisabeth Rosenthal from our partner Kaiser Health News is here to talk to us about it.
ELISABETH ROSENTHAL: Hi, Ari. Nice to be here.
SHAPIRO: Tell us who we're meeting today.
ROSENTHAL: Today we're meeting a mother and daughter. Kyunghee Lee is the patient. She lives in Ohio. But her daughter Esther, who lives in Honolulu, helps her with her medical care, even though she lives far away.
SHAPIRO: That is some long-distance medical care. Let's listen to this piece from reporter Stephanie O'Neill, who spoke with the family.
STEPHANIE O'NEILL, BYLINE: Kyunghee Lee of Mentor, Ohio, lives with severe arthritis that her daughter, Esther Lee, says becomes debilitating if left untreated.
ESTHER LEE: As she's gotten older, she's developed pretty bad arthritis in - mostly in her hands, in particular her right hand. The middle and ring finger hurt the most.
O'NEILL: Now 72 years old, her mother's retired from the family dry cleaning business, but she still works as a freelance seamstress. And that requires a lot from her hands, as does caring for her husband and herself.
LEE: So she does a lot of cooking, a lot of chopping, washing dishes. She also likes to garden a lot, so that also requires intensive use of her hands.
O'NEILL: At first, Kyunghee managed the pain with over-the-counter meds. As it worsened, Esther says, the doctor prescribed pills.
LEE: But then, as the pain has gotten more intense, she's gotten steroid injections when it's gotten really bad.
O'NEILL: It used to be a shot a year. Now it's more than that. How often exactly, Esther doesn't quite know. That's because her mom doesn't like to complain, even to Esther, who works as a registered nurse in Honolulu. But a huge increase in the cost of the last injection prompted her to ask Esther for help.
LEE: Because she'd been getting the same procedure, the same office for multiple years now, and it had always been a $30 personal copay.
O'NEILL: That's $30 out of pocket for each injection, which always seem reasonable. But then...
LEE: The last bill she got, the copay she's responsible for jumped up to $354.
O'NEILL: We're talking more than 10 times her other bills. And weird thing was, it was the same doctor providing the same treatment in the same building. But her mom noticed a puzzling line item on the latest bill.
LEE: It said operating room services. And she was like, I never went to any operating room. I went to the same doctor. I did the same procedure in the same office. Why is it all of a sudden saying operating room?
O'NEILL: So with Esther in Hawaii and Kyunghee in Ohio, the two began making calls. Turns out the local university health system owns the doctor's practice, and that meant Kyunghee's arthritis injection was, technically speaking, provided in a hospital setting. And that allows a provider to add a so-called facility fee for operating room services even when the visit takes place in a plain old office. What's more, there's no law requiring providers inform patients before adding such fees.
Esther says that's wrong. But while also frustrated, her mother, a Korean immigrant, wanted to just quietly pay the bill.
LEE: And I think that's in line with, like, the first-generation immigrant experience, is to just work hard, keep your head down, you know, don't cause trouble, try to assimilate. And then I'm second-generation. I'm born here, and I'm like, no, we have rights. Like, if something's wrong, we need to fight for it.
O'NEILL: And that, Esther Lee says, is why she's speaking out for her mom and for the many others now facing surprise facility fees.
For NPR News, I'm Stephanie O'Neill.
SHAPIRO: And we are back here with the Kaiser Family Foundation's Elisabeth Rosenthal. Elisabeth, we're talking about the same doctor, same treatment, same building, 10 times more expensive. What's going on?
ROSENTHAL: Classic U.S. medicine. So it's all about the branding of the room where you get the procedure. Is it considered a doctor's office or part of a hospital or called an infusion center? There's, in the U.S., a room rental charge called a facility fee, which depends on that. The problem is that many providers have been doing a lot of creative rebranding.
SHAPIRO: Was there anything at all different here - I mean, something that the patient might not have noticed?
ROSENTHAL: No. Nothing. It's an old, cheap, generic steroid she got. She's gotten it many times before. And it's a quick shot, not an infusion that drips into a vein where you might need a nurse to put in an IV, and the patient would stay there for a period of time, sometimes hours.
But, you know, in our system, it doesn't matter if you need or want the kind of room you're sitting in for your procedure. It's as if you booked an economy airline ticket, and they put you in first class and then made you pay for it, but you don't even get the drink and the nice meal.
SHAPIRO: Do we know how widespread this is?
ROSENTHAL: Unfortunately, it's very widespread, particularly as hospitals buy up doctors' groups and practices. Rebranding is a great way to gin up more revenue if you call, you know, a simple room an operating room. But insurers, Medicare and patients unfortunately pay the price.
SHAPIRO: So what can patients generally and the Lee family specifically do about this?
ROSENTHAL: Well, researchers have been pushing for Medicare to institute what's called site-neutral payment, so wherever you get the procedure, you pay the same price. And many procedures could be performed in different types of rooms. In the meantime, patients should always ask when they schedule a procedure, from injections like this patient's to colonoscopies, if there's a facility fee and how much. Is there a cheaper setting where the procedure could be performed? Because many doctors perform the same procedures in different settings on different days of the week. There shouldn't be a facility fee in a doctor's office, so the Lee family might want to find a doctor that's not part of a hospital where there isn't a facility fee in order to get the injection.
SHAPIRO: That's Dr. Elisabeth Rosenthal.
Thank you for joining us once again.
ROSENTHAL: Thank you.
SHAPIRO: And if you have a confusing or outrageous medical bill that you want us to take a look at, go to NPR's Shots blog and tell us about it.
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