Saturday, March 19, 2011

Surgery Expenses

When we were contemplating a special needs adoption, one thing we thought about was the cost of addressing the special needs. In this case, cleft lip and cleft palate. Here in California, a month before we were matched with Tate, our state legislature passed a law that requires medical insurance to cover the expenses associated with treating cleft lip and cleft palate. It was one of the things that made me feel a little better about taking the leap--

As it turns out, in California there is also a program that covers the expenses not already covered by your private insurance- if your child is born with a congenital condition like cleft palate and has the condition when you adopt him. So long as you use a state-approved provider. For us, that was Children's Hospital, which is also our in-network provider for our private insurance.

Now, don't get me wrong, we pay a lot for private insurance. We don't have a fancy schmancy policy or anything super high end. We just have regular insurance, with set co-pays and deductibles. But we still pay what seems to me like a lot in premiums each month. I pay more than double what we were paying when I was a teacher-- and more than double what we have paid for any insurance from any private employer for whom Jason has worked. I don't mean this as a complaint-- it is what it is.

Honestly, I have not paid much attention to the health care debate because to date, we have been lucky enough to have decent health insurance. But when I got our hospital bills for Tate's surgery, I must admit I was pretty shocked. I mean, I expected the bills to be what they were (in the neighborhood of $25,000 if you include both surgeons, the medications, the recovery room, the overnight hospital stay, the anesthesiologist, etc., etc., etc.). I put this out there so that others who may be searching for information about the cost of cleft palate surgery can find out what it really costs. And, mind you, we only stayed one night in the hospital, and Tate's surgery lasted-- including both the ENT and the plastic surgeon, only about an hour and a half.

What surprised me was the price negotiated by our insurance. For some of the items, our insurance company had pre-negotiated with the hospital a 98% discount. That's a huge discount. Of course, the insurance company still pays most of the bill after our deductible/co-pay. But this got me to thinking about the people who are not insured. I mean, the reason they are uninsured is because the insurance premiums are too high. So how is it that they are also stuck with a bill 98% higher than the bill I would have to pay? That somehow seems backwards to me. I mean, I get that there are volume discounts and such. And I admit that I have no idea how the insurance companies negotiate the payments with the providers. No idea at all. But it seems odd to me that someone who can afford health insurance pays, oh let's say $3,000 (I don't have the bill in front of me, so I don't remember the actual price tag) for a surgery and someone who cannot afford the premiums, for the same surgery, might be asked to pay $25,000.

Does anyone else think this is backwards?

Of course, I'm grateful for the "discount," and I feel so, so fortunate that the price of a surgery to correct such a correctable special need did not keep us from finding our way to Tate-- he really is perfect for us. This talk of money might seem crude-- but it's not something to ignore when making such a big and important decision. And yet I feel so lucky that this particular expense is not something that we have had to worry about . . .


Johnny said...

We've experienced this same "gaming" of the system as well. In theory, the "gross" bill of my wife's emergency room and ICU care was close to $998K, in reality it was not. But it was only because insurance told the hospital, "No, we're paying THIS amount."

Andrea B said...

We were also very lucky with Caitlyn's bills for her cleft-related surgeries and treatments. Before we changed insurance this January, our insurance had paid almost $100k for her bills. Very thankful to have had great insurance and a supportive employer who kept inclusive coverage.

Keely said...

I agree. It's totally backwards. I think my bill for my appendectomy was around $28k. I paid $250 copay and my insurance paid $2200. that was it.

But, remember most of our health plans are capitated. The doctors get paid by the insurance just for having you as a patient whether you ever see them or not. At least that's how it is for primary care docs...not sure how that works for specialists.