Tag: Doctors

Readers and Tweeters Decry Medical Billing Errors, Price-Gouging, and Barriers to Benefits

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

— Dr. Raghu Venugopal, Toronto

A Plea for Sane Prices

I just read your story about the emergency room billing for a procedure that was not done (“A Billing Expert Saved Big After Finding an Incorrect Charge in Her Husband’s ER Bill,” Oct. 25). We too had a similar experience with an emergency room and a broken arm that was coded at a Level 5, and it was a simple break. No surgery needed, and it took them only 10 minutes to set and wrap the broken arm but charged us over $9,000. I disputed the charges, and it took six months to get them to reduce the bill but they never admitted that they coded a simple break incorrectly to jack up the price of the bill. If it had been a Level 5 issue, we would not have sat in the waiting room for six hours before being seen. It was a horrible experience, and I think ERs all over the nation are doing this to make up for the non-payers they treat every day. It is robbery.

— Terrence Campbell, Pocatello, Idaho

— Ed Gaines, Greensboro, North Carolina

As you said, CPT codes should always be examined. This case is probably more than “just an error.” As a retired orthopedic surgeon, chief of surgery, and chief of staff at a North Carolina hospital, I have seen care such as this coded exactly like this with the rationale that, “Hey, this was a fractured humerus and it was manipulated and splinted.” 24505 is correct IF that is the definitive treatment, which it was not here. Even code 24500 would indicate definitive treatment without manipulation. This was just temporary care until definitive care could be done later. It should be billed as a visit and a splint. The visit for this, if it was an isolated problem (no other injury or problems), would qualify only as a Level 2 visit. That frequently gets upcoded as well by adding a lot of non-pertinent family, medical, and social history and a complete physical exam (seven systems at least) and a whole lot of non-pertinent “medical decision making.” All of that should be documented in the medical records even if the hospital stonewalls on the CPT codes.

Look closely at medical records and you will find frequent upcoding, if you are familiar with the requirements for different levels of treatment.

— Dr. Charles Beemer, Arvada, Colorado

— Shashank Bhat, San Francisco

A number of years ago, I was billed using a code that described a treatment that was not carried out. In similar fashion, I talked with my insurance company, which basically said it did not care whether the treatment took place or not as all it required was for a valid code to appear. I also contacted the Virginia Bureau of Insurance, which approves the various policies, and it said it had no jurisdiction over claims. I decided to let the hospital sue me for the disputed amount and defended myself in district court. Despite their attorney and four “witnesses,” the case was thrown out because the hospital was both unwilling and unable to justify the charges to the satisfaction of the judge. They did not want anybody in power to testify because of the questions they would have been asked, so they left it to people who were completely clueless. The takeaways from this were:

  • Hospitals make up the numbers and leave them grossly inflated so they can claim that they are giving away care when they give discounts on the made-up numbers.
  • Hospitals turn employees into separate billing entities so they can double-charge.
  • Hospitals open facilities such as physical therapy in hospital locations because insurance companies will pay higher amounts when treatment is carried out in a hospital environment.
  • Insurance companies and state insurance agencies do not act as gatekeepers to protect their clients/taxpayers.
  • The insurance companies and the providers have a shared interest in the highest possible ticket prices and outrageous charges because the providers get to claim how generous they are with “unremunerated care,” and if the prices were affordable then they could not justify the high prices for insurance premiums and the allowed administration/profit share of 20% would be based on a far smaller amount.

In any other industry, this would have resulted in multiple antitrust suits. U.S. health care is a sad example of government, health care industry, and insurers all coming together against the interests of consumers. After this court case, I wanted to form a nonprofit to systematically challenge every outrageous charge against people who, unlike myself, did not believe or know how to defend themselves. If hospitals and other providers were forced to go to court to justify their charges on a systematic basis, pricing sanity would eventually prevail.

— Philip Solomon, Richmond, Virginia

— Barry Ritholtz, New York City

Patients as Watchdogs

Thank you for the article on Lupron Depot injections (Bill of the Month: “$38,398 for a Single Shot of a Very Old Cancer Drug,” Oct. 26). Last year, I was diagnosed with prostate cancer, though my case is not anywhere as severe as that experienced by Mr. Hinds.

Last month my urologist scheduled an MRI update for me at a facility owned by Northside Hospital Atlanta. At the suggestion of my beloved wife, I called my insurance company, UnitedHealthcare, to make sure the procedure was covered. Fortunately, it was. That being said, the agent from UnitedHealthcare mentioned that Northside Hospital’s fee was “quite a bit higher than the average for your area.” It was. Before insurance, the charge for an MRI at Northside was $6,291. I canceled the appointment at Northside and had the MRI done by a free-standing facility. Their charge, before insurance, was $1,234.

Every single encounter that I have with the health care system involves constant vigilance against price-gouging. When I have a procedure, I have to make sure that the facility is in-network,. that each physician is in-network, that any attending specialist such as an anesthesiologist or radiologist is in-network (and their base-facility as well). If I have a blood test, I have to double-check if the cost is included in a procedure or if it is separate. If it is a separate fee, I have to ensure that the analysis is also covered, and, if it is not, that it is not done through a hospital-owned facility but instead through a free-standing operation.

I have several ongoing conditions in addition to my prostate cancer — Dupuytren’s contracture, a rare bleeding disorder similar to thrombocytopenia, and arthritis. Needless to say, navigating our byzantine, inefficient, and profit-driven health care system is a total nightmare.

Health care in the United States has become so exceedingly outrageous. I cannot understand why it is not an issue that surfaces during election years or something that Congress is willing to address.

Again, thank you for your excellent reporting.

— Karl D. Lehman, Atlanta

— Brian Murphy, Austin, Texas

I was a medical stop-loss underwriter and marketer for over 30 years. Most larger (company plans for 100-plus employees) are self-funded, meaning the carrier — as in this case, UnitedHealthcare — is supplying the administrative functions and network access for a fee, while using the employer’s money to pay claims.

Every administrator out there charges a case management fee, either as a stand-alone charge or buried in their fees. Either way, they all tout how they are looking out for both the employer and the patient.

Even if this plan was fully insured, wouldn’t it have been in the best interest of all parties when they became aware of the patient’s treatment (maybe after the first payment) to reach out to the patient and let them know there are other alternatives?

The question in these cases is who is minding the store for both the patient and the employer. The employer, the insurer, and the patient could have all saved a lot of money and pain, if someone from case management had actually questioned the first set of charges.

— Fred Burkacki, Sarasota, Florida 

— Amanda Oglesby, Neptune, New Jersey

‘Bill of the Month’ Pays Off

I received a $1,075 refund on a colonoscopy bill I paid months earlier after listening to the KHN-NPR “Bill of the Month” segment “Her First Colonoscopy Cost Her $0. Her Second Cost $2,185. Why?” (May 31) and finding out the procedure should be covered under routine health care coverage. Thank you!

— Cynthia McBride, University Place, Washington

— Erica Warner, Boston

Removing Barriers to Benefits

In the story “People With Long Covid Face Barriers to Government Disability Benefits” (Nov. 9), you stated: “Many people with long covid don’t have the financial resources to hire a lawyer.” This is incorrect. When applying for disability, you don’t need financial resources. There are law firms that specialize in disability claims and will not charge you until you win your claim. And, according to federal law, those law firms can charge only a certain percentage of the back pay you would get once the claim has been won. Also, if you lose the claim, and the law firm has appealed as many times as possible, you don’t owe anything. Please don’t make it more difficult for those who are disabled with misinformation.

— Lorrie Crabtree, Los Angeles

— Ron Chusid, Muskegon, Michigan

Vaccine Injuries Deserve Attention, Too

I read your long-covid article with interest because many of the barriers and some of the symptoms faced by people with long covid are similar to those experienced by people with vaccine injuries. I’m really concerned about how there is even less attention and support for people who suffered adverse vaccine reactions.

Long covid and vaccine injuries are both issues of justice, mercy, and human rights as much as they are a range of complex medical conditions.

It’s nearly 20 months since someone I know sustained a serious adverse reaction, and it is heartbreaking how hard it has been for her to find doctors who will acknowledge what happened and try to help. There’s no medical or financial support from our government, and the Countermeasures Injury Compensation Program is truly a dead end, even as other countries such as Thailand, Australia, and the United Kingdom have begun to acknowledge and financially support people who sustained vaccine injuries.

I’ve contacted my congressional representatives dozens of times asking for help and sharing research papers about vaccine injuries, but they have declined to respond in meaningful ways. Similarly, my state-level representatives ignore questions about our vaccine mandate, which remains in place for state employees, despite at least one confirmed vaccine-caused fatality in a young mother who fell under the state mandate in order to volunteer at school.

There have been a few articles, such as …

… but no new ones have come to my attention recently, and it is concerning that the media and our political and public health leaders seem OK with leaving people behind as collateral damage.

Please consider writing a companion piece to highlight this need and the lack of a functional safety net or merciful response. My hope is that if long covid and vaccine injuries were both studied vigorously, new understanding would lead to therapeutics and treatments to help these people.

— Kathy Zelenka, Port Angeles, Washington

— Matthew Guldin, West Chester, Pennsylvania

More on Mammograms

The article “Despite Katie Couric’s Advice, Doctors Say Ultrasound Breast Exams May Not Be Needed” (Oct. 28) does a disservice to women and can cause harm. An ultrasound is saving my life. I had two mammograms with ultrasounds this year. Although the first mammogram showed one cyst that was diagnosed as “maybe benign,” I knew it wasn’t. Why? Because I could feel the difference. I insisted on a second, and sure enough a large-enough cyst that’s definitely malignant was found. I had breast surgery on Oct. 31, followed by radiation treatment and, if needed, chemotherapy later. This article will deprive other, less aggressive and experienced women who do not have health care credentials or a radiologist for a husband to be harmed by being lulled into complacency.

— Digna Irizarry Cassens, Yucca Valley, California

— Patricia Clark, Scottsdale, Arizona

Your article on breast cancer screening neglected to present the supplemental option of Abbreviated Breast MRI (AB-MRI). The out-of-pocket cost at many clinics ranges from $250 to $500. For a national listing of clinics that offer this supplemental screening option, please go to https://timetobeseen.org/self-pay-ab-mri. For benefits, just Google “Abbreviated Breast MRI.”

— Elsie Spry, Wexford, Pennsylvania

— Donald H. Polite, Milwaukee

Preparation Plans for Seniors: All for One and One for All

At least 120 people died from Hurricane Ian, two-thirds of whom were 60 or older. This is a tragedy among our most vulnerable population that should have been prevented (“Hurricane Ian’s Deadly Impact on Florida Seniors Exposes Need for New Preparation Strategies,” Nov. 2).

Yes, coming together and developing preparedness plans is one way to protect seniors and avoid these kinds of tragedies in the future, but since this is not a one-size-fits-all situation, organizations that help seniors across the country must first look internally and be held accountable by making sure their teams always have a plan in place and are prepared to activate them at a moment’s notice.

During Hurricane Ian, I saw firsthand what can happen when teamwork and effective planning come together successfully to protect and prepare seniors with chronic health conditions like chronic obstructive pulmonary disease who require supplemental oxygen to breathe.

Home respiratory care providers and home oxygen suppliers worked tirelessly to ensure our patients received plenty of supplies to sustain them throughout the storm, and when some patients faced situations where their oxygen equipment wasn’t working properly inside their homes, staff members were readily available to calmly talk the patient through fixing the problem. After the winds receded, mobile vans were quickly stationed in safe spaces for patients or their family members to access the oxygen tanks and supplies they needed. If patients were unable to make it to these locations, staff members were dispatched to deliver tanks to their homes personally and check in on the patient.

Patients were also tracked down at shelters, and a team of volunteers was formed around the country to find patients who could not be reached by calling their emergency backup contacts, a friend, or family member. Through these established systems, we were able to remain in contact with all of our patients in Ian’s path to ensure their care was not impeded by the storm.

Organizations should always be ready and held accountable for the seniors they care for in times of disaster. I know my team will be ready. Will yours?

— Crispin Teufel, CEO of Lincare, Clearwater, Florida

— Ashley Moore, San Francisco

The Tall and the Short of BMI

I am amazed that in your article about BMI (“BMI: The Mismeasure of Weight and the Mistreatment of Obesity,” Oct. 12) you never mentioned anything about the loss of height. If a person goes from 5-foot-2 to 4-foot-10, the BMI changes significantly.

— Sue Robinson, Hanover, Pennsylvania

— Steve Clark, Lee’s Summit, Missouri

Caring for Nurses’ Mental Health

During the pandemic, when I read stories about how brave and selfless health care heroes were fighting covid-19, I wondered who was taking care of them and how they were processing those events. They put their own lives on the line treating patients and serving their communities, but how were these experiences affecting them? I am a mother of a nurse who was on the front lines. I constantly worried about her as well as her mental and physical well-being (“Employers Are Concerned About Covering Workers’ Mental Health Needs, Survey Finds,” Oct. 27). I was determined to find a way to honor and support her and her colleagues around the country.

I created a large collaborative art project called “The Together While Apart Project” that included the artwork of 18 other artists from around the United States. It originated during the lockdown phase of the pandemic, a time when we were all physically separated yet joined by a collective mission to create one amazing art installation to honor front-line workers, especially nurses. Upon its completion, this collaboration was recognized by the Smithsonian Institute, Channel Kindness (a nonprofit co-founded by Lady Gaga) and NOAH (National Organization of Arts in Medicine). After traveling around the Southeast to various hospitals for the past year on temporary exhibit, the artwork now hangs permanently in the main lobby at the University of Virginia Medical Center in Charlottesville, Virginia.

I wanted to do something philanthropic with this art project to honor and thank health care heroes for their dedication over the past two years. It was important to find a way to help support them and to ensure they are not being forgotten. Using art project as my platform, I partnered with the American Nurses Association and created a fundraiser. This campaign raises money for the ANA’s Well-Being Initiative programs, which support nurses struggling from burnout and post-traumatic stress disorder and who desperately need mental and physical wellness care. Fighting covid has taken a major toll on too many nurses. Some feel dehumanized and are not receiving the time off or the mental and physical resources needed to sustain them. Many are suffering in silence and have to choose between caring for themselves or their patients. They should not have to make this choice. Nurses are the lifeline in our communities and the backbone of the health care industry. When they suffer, we all suffer. Whether they work in hospitals, doctors’ offices, assisted living facilities, clinics or schools, every nurse has been negatively impacted in some way by the pandemic. They are being asked to do so much more than their jobs require in addition to experiencing greater health risks, less pay, and longer hours. Nurses under 35 and those of color are struggling in larger numbers.

The American Nurses Foundation offers many forms of wellness care at no charge. They rely heavily on donations to maintain the quality of their offerings as well as the ability to provide services to a growing number of nurses. I am an artist, not a professional fundraiser, and I have never raised money before. But I feel so strongly about ensuring that nurses receive the support and care they deserve, that I am willing to do whatever it takes to advocate and elevate these health care heroes.

The Together While Apart Project’s “Thank You Nurses Campaign” goal is $20,200, an amount chosen to reflect the numbers 2020, the year nurses became daily heroes. So far, I have raised over $15,500 through gifts in all amounts. For example, a $20 donation provides a nurse with a free one-hour call with a mental health specialist. That $20 alone makes a big difference and can change the life of one nurse for the better. The campaign has provided enough funding (year to date) to enable 940 nurses to receive free one-hour wellness calls with mental health specialists.

The online fundraiser can be found at https://givetonursing.networkforgood.com/projects/159204-together-while-apart-fundraiser.

— Deane Bowers, Seabrook Island, South Carolina

— Employee Assistance Professionals Association, Arlington, Virginia

Readers and Tweeters Take Positions on Sleep Apnea Treatment

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

On a ‘Woke’ Journalist’s Journey

I found Jay Hancock’s piece rather intriguing (“Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution,” Oct. 3). While I agree that positional therapy is often overlooked as a first-line treatment for obstructive sleep apnea, one has to look at this serious, life-threatening health issue in a bit more detail. First, Mr. Hancock’s diagnosis was central sleep apnea, which suggests either a neurologic and/or breathing control etiology. Sleeping on the side may prevent airway obstruction, but the underlying cause has likely not been addressed. Second, the danger here is that — a bit like hypertension, with which there are little or no perceived symptoms — a catastrophic event might occur with little or no warning. Third, it sounds as if the positional therapy in this case alleviated the condition — but as one gets older, the condition will likely worsen.

Bottom line: Why does this particular patient have this condition and what can be done to address the root cause instead of taking a symptomatic approach? My fear is that, left untreated, the patients fall asleep with a false sense of security to never wake up the next morning.

— Dr. Dave Singh, an adjunct professor in sleep medicine at Stanford University, Oakland, California

— Liz Beaulieu, Yarmouth, Maine

Finally! Jay Hancock exposed the sleep apnea medical racket. I have another treatment option: During covid, many inpatients were intubated in the prone position. I was curious about that and did some Googling. Not only does sleeping on your stomach increase lung capacity, the gravity on the throat is a natural treatment for sleep apnea. While difficult to adapt to, it’s better than a CPAP. Again, doctors don’t mention it. No money in a simple gravity solution.

— Peg Keohane, Syracuse, New York

— Stanley Morrical, San Francisco

I want to thank you for this very timely article. I have suspected there was more to the question of apnea than was being reported. As stated, it is a big industry that perpetuates the idea that everyone is affected.

The reporter’s discovery that side-sleeping is the answer is absolutely valid, as I determined long ago. The article should be widely disseminated as it is of extreme importance to millions who are falling for the hype!

— Lawrence Dee, Chino Valley, Arizona

— Robert Roy Britt, Phoenix

My mouth dropped open when I read Jay Hancock’s piece about sleep apnea. You are the harbinger of a tidal wave, my friend. The party is just getting started.

Empowered Sleep Apnea is a project we created to protect individual patients from the “conveyer belt” of the American health care system, as it’s poised to deal with tens of millions of new diagnoses of sleep apnea, which will soon be made in primary care and dental offices all over our great land, using automated, wearable technology. That time is coming within 18 months.

You suffered because there was inadequate coaching for a terribly complicated disease. Simple as that. All those who will be subjected to a cloudburst of automated diagnostics will have the same journey to make. Out of necessity, your solution was to slog through your own research to get yourself some sane direction. You empowered yourself. Good on you.

My solution was to take my life’s work as a patient-centered sleep medicine physician and turn it into something beautiful to behold, so that everyone can benefit from sane coaching. Our project hinges on patient empowerment. Our website is a nice introduction. Our podcast is also a blast that I think your readers would find very interesting.

— Dr. David E. McCarty, owner and CEO of Empowered Sleep Apnea, Boulder, Colorado

— Dr. Art Sedrakyan, New York City

As president of the American Academy of Sleep Medicine (AASM), I write to address several concerns about the recent article “Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution” (Oct. 3). While I commend the author for seeking medical help for his daytime drowsiness and snoring, I fear his article may mislead readers in a way that could jeopardize not only their own health and safety but that of others as well.

The author is clearly dissatisfied with the care he received; however, using this to suggest that nearly everyone diagnosed with sleep apnea should simply treat it on their own “for free” is dangerous. Sleep apnea is a common and chronic medical condition that increases the risks for numerous physical and mental health consequences, diminished quality of life, motor vehicle crashes, and premature death.

Positional therapy (which typically requires the use of a device to maintain a side-sleeping position), though useful for some patients with sleep apnea, is not the best treatment for most patients, especially those with moderate to severe sleep apnea. Positive airway pressure (PAP) therapy is the best-supported, evidence-based treatment for sleep apnea. The most recent systematic review and meta-analysis included 80 randomized controlled trials investigating the use of PAP therapy to improve outcomes. Millions of patients with sleep apnea can attest to the life-changing — and even lifesaving — impact of PAP therapy. Treatment selection is an important decision that should be made together by a patient and their treating provider.

Furthermore, it is inappropriate for the author to use his experience as justification to malign our entire organization and our 12,000 members. AASM strongly refutes the implication that support from industry biases our clinical practice guidelines and policies. Our guidelines are based on a review of the latest research by a task force of experts who determine the strength of evidence for a given treatment. The AASM also ensures conflicts of interest are mitigated through a stringent clinical practice guideline development process. While the author claims our organization “finances its operations” with industry support, this is simply untrue. Industry support represents roughly 1% of our annual revenue and is guided by a clear policy that helps ensure transparent interactions to prevent undue influence and support public health. Likewise, the implication that our members are prescribing PAP therapy as part of a revenue-generating scheme is fallacious. The vast majority of PAP devices are sold by durable medical equipment suppliers, not by sleep centers or sleep doctors.

I hope that readers struggling to get a good night’s sleep will seek information from credible sources and talk with a trusted health care professional to determine which treatment best addresses their specific situations.

— Jennifer L. Martin, president of the American Academy of Sleep Medicine, Darien, Illinois

— Timothy Noah, Washington, D.C.

I just saw Jay Hancock’s article on my Google feed and read it, as I suffer from serious sleep apnea as well. I’ve received tailor-made mouthguards, so to speak, which appear to work rather well.

But I’ve also been reading books on breathing, starting with “Breath, the New Science of a Lost Art” by James Nestor, and then on to “The Oxygen Advantage” by Patrick McKeown. I realized I was a mouth breather and that that contributes to the apnea problem as well and have since been trying to learn to breathe through my nose at all times — thus far with mixed results, but the subject is very interesting as it pertains to a lot more than just how to get a good night’s sleep.

— Dimitri F. Frank, Málaga, Spain

— James Hughes, Savannah, Georgia

Treating Trauma — Followed by Billing Trauma

I’m an emergency physician who also works at urgent care. While I appreciate patients trying to be fiscally responsible with their choices, the urgent care did precisely the right thing in this case (Bill of the Month: “Turned Away From Urgent Care — And Toward a Big ER Bill,” Sept. 29). Urgent care can typically manage fender benders or other minor accidents, but someone whose airbags deployed and whose car rolled three times and wound up “crushed” up into a tree should always go to the emergency room. The mechanism of such accidents is very concerning and typically justifies a trauma activation and CT scans to evaluate for internal injuries. Urgent care is not equipped to handle patients if they develop life-threatening complications from a severe injury.

— Dr. William Weber, Harvard Medical School / Beth Israel Deaconess, Boston

— James Conner, Kalispell, Montana

This article is missing the perspective of a medical provider. I am a retired board-certified emergency physician with 33 years in the emergency department and more than five years in urgent care and feel the need to address the medical care differences between the ED and urgent care.

I agree with the facts of your article and don’t dispute the financial issues, problems, inequities of the broken system. But there is more to the story.

The knowledge, ability, skill, and experience of the provider are key. The location of care predisposes to the abilities of the provider but doesn’t guarantee them. You may receive excellent to below-average care depending on the provider. I have seen people die from auto accidents that were sent home from urgent care after receiving an evaluation by a general practitioner not trained in trauma. Some ED physicians miss things, but the odds are better that the ED doctor will not miss critical cases.

Conversely, you might get care from an experienced ED physician at an urgent care.

Then there are the personnel and resources provided. If it is a simple “urgent” problem, no significant difference in outcome is likely to result.

There is the dilemma. What is an emergency? This has been argued in Congress: to err on the side of not missing serious problems for which a “prudent layperson” could observe symptoms. So an emergency is what a “prudent layperson” believes it is.

Some of the urgent care centers I worked in turned away “third-party” cases but most didn’t — even within the same hospital-owned urgent care chain. An option would be to offer to pay cash, asking for the cash-upfront price. Difficult to be accurate in predicting the cost ahead of time, but an estimate is not unreasonable. Instead of a low four-figure bill, the family might have turned out to have a low three-figure bill if not referred to the hospital after the urgent care evaluation.

In my experience, I’ve never seen a patient sent from urgent care (owned by or affiliated with a hospital) to the hospital for the sole reason of the hospital billing a second charge. Many patients are sent because they need a higher level of care that isn’t available, such as hospitalization, injectable medications, specialty care, imaging, and “stat” lab work not available.

Sure, the hospital uses the urgent care as a feeder site, but the patient (or the paramedic) gets to choose which hospital to go to, if they have a preference.

Please remember that not all hospitals or urgent cares are the same. Many smaller hospitals do not have some/many specialists required to back up the emergency department. Some urgent cares use primarily general practitioners, while others use only board-certified emergency physicians, nurse practitioners, or physician assistants.

Yes, the system is broken. Per a recent webinar by the California Medical Association: In the past 50 years, the increase in the number of physicians was 2%. Administrative health care personnel increased more than 3,000%. (That includes both the provider and the payer side.)

— Dr. Mickey Kolodny, Palos Verdes Peninsula, California

— Donald Farmer, Woodinville, Washington

After 40 years as a board-certified emergency medicine physician, I believe the article by Sam Whitehead is very misleading. First of all, the patient should never have gone to an urgent care. Had she called 911 as she should have, just because of the mechanism of the crash, she would have been brought to an emergency room. The ER obviously believed two CT scans were needed, which the urgent care would not have been able to provide. The reporter did not dig into the details of the acute trauma care this patient needed — other than understating her post-accident situation, which was self-defined. The author writes as if it is strictly an insurance issue or a way for the urgent care/hospital system to gain patients.

There is no indication of this happening given that the patient needed, by protocol, Advanced Trauma and Life Support (ATLS). By EMS protocol and by malpractice case law, this patient needed a visit to a trauma center emergency room. And the bill is a totally different issue. In other words, the author totally missed the medical issues to overstate and sensationalize billing issues.

— Dr. Anthony F. Graziano, Oconomowoc, Wisconsin

— Kendra Lee, Woodbridge, Virginia

I listened to your story as retold on NPR about a young woman who had a high bill for an ER visit after a car accident. I felt that the story was editorially biased, as it mentioned nothing about the requirements for care for traumatically injured patients. It seemed to recommend visiting urgent care centers instead of emergency rooms. Although less expensive, such facilities generally should not care for patients with serious injuries. Most hospitals require board-certified emergency medicine physicians and have extensive resources whereas an urgent care doctor may not have completed a residency. The “physician expert” in the story clearly had no experience in the care of traumatically injured patients. Having such insight would lend depth to what I saw as a superficial look at a nuanced issue. Clearly the public should be better informed about cost-effective care, but an evaluation after a serious car crash is inappropriate to be sent to an urgent care.

— Dr. Christopher Goltz, Flint, Michigan

A Wealth of WISDOM

Nice article (“Genetic Tests Create Treatment Opportunities and Confusion for Breast Cancer Patients,” Sept. 21). With breast cancer awareness month upon us, I would also point out the existence of the WISDOM study funded by the National Institutes of Health, which is looking at different approaches to using genetic testing to screen women for breast cancer. Check it out at www.thewisdomstudy.org.

— Dr. Daniel Halevy, New York City

— Dr. Cee A. Davis, Winchester, Virginia

On the Birth of Obstetrics Emergency Departments

I was disappointed by your article “Baby, That Bill Is High: Private Equity ‘Gambit’ Squeezes Excessive ER Charges From Routine Births” (Oct. 13). While I recognize that medical billing is often confusing and at times even alarming to patients, I would like to share a few points that I feel were downplayed or omitted:

  • The article gives the impression that the obstetrics emergency department, or OBED, is created simply by rebranding an existing process within hospitals. The author neglects to mention that before the OBED, most hospitals did not have OB-GYN hospitalists stationed in-house 24/7 to address emergencies. Prior to the implementation of the OBED, many expectant mothers, concerned that something might be wrong, were not able to see a physician when they visited a hospital emergency room. Instead, they were transferred to the labor and delivery department to be evaluated by a nurse taking instructions over the phone from a physician. If the patient and her baby were in serious distress, it became a waiting game, with the risk escalating every minute she waited for medical attention from her doctor — or any doctor. Hundreds of thousands of life-threatening emergencies are managed each year by OB-GYN hospitalists who staff obstetrics emergency departments.
  • Reporter Rae Ellen Bichell seems to have a beef with the practice of hospitals charging for an emergency evaluation when unscheduled pregnant patients arrive at the hospital with medical complaints. Whether we like it or not, that is simply the way that health care works in America. If you show up unexpectedly at a hospital for evaluation of a health concern, you will be treated as an emergency — and you will likely receive a large bill corresponding to the unscheduled care you received.
  • The author works hard to establish or imply a causal relationship between the private equity backing of medical staffing companies and the fact that hospitals are billing patients for emergency medical services. However, hospital service providers and vendors have absolutely no control over a hospital’s billing practices. This bit about private equity seems to serve no logical purpose in this article except to make the story appear as a “whodunit,” casting private equity firms in the role of immoral shadow bosses turning a profit at the expense of unwitting expectant mothers, when in fact they play no role in establishing the billing policies that Ms. Bichell incorrectly and perhaps unfairly characterizes as “moneymaking ‘emergency’ events.”

I have dedicated my career to the development and implementation of obstetrics emergency departments in hundreds of hospitals across the U.S., but I am unaware of any hospital turning routine births into moneymaking emergency events as claimed in the title and misleading argument of this article. I stand by my statement — and my sincere belief — that having trained doctors available 24/7 on the labor-and-delivery floor has significantly enhanced the quality of care available to expectant mothers at some of the most challenging and medically consequential hours of their lives.

Thank you for considering my point of view.

— Dr. Christopher C. Swain, Charleston, South Carolina

— Adam W. Gaffney, Boston

Shooting Craps?

Online stock brokerage houses have made all cellphones into “gambling devices” years ago (“Addiction Experts Fear the Fallout if California Legalizes Sports Betting,” Oct. 5). What a load of crap that California gaming would suddenly create new cases of addiction. Stop the crap reports.

— Matt McLaughlin, Carpinteria, California

— Kristina Bas Hamilton, Sacramento, California

Measuring Fat: A Gut Check

Julie Appleby provided useful information on how modern medicine misclassifies patients’ health status through the use of the body mass index (“BMI: The Mismeasure of Weight and the Mistreatment of Obesity,” Oct. 12). She included comments advocating the use of waist circumference (WC, by tape measure in the standing position) rather than body weight to indicate more specifically where the metabolic problems can be found. She’s on the right track, but her article might have gone further to explore alternative, more focused indicators of excess adiposity.

Anatomically, more than 90% of human body fat can be classified into three main depots: gluteo-femoral (hips, buttocks, and thighs) subcutaneous adipose tissue, abdominal subcutaneous adipose tissue, and visceral (inside the abdomen) adipose tissue. Of these three, only the visceral fat is clearly associated with cardiac and metabolic disorders. Increased gluteo-femoral subcutaneous fat has been shown repeatedly to be associated with improved health outcomes. Abdominal subcutaneous fat tends to have neutral, benign effects for most individuals.

What we need is a simple adiposity indicator that can estimate the burden of visceral fat. Three decades of research suggests that a simple measure of the supine sagittal abdominal diameter (SAD, sometimes called the “abdominal height”) predicts poor health better than the standing WC. When persons are in the supine position, their benign, abdominal subcutaneous fat falls to the sides of the midline. For this reason, variation in the SAD, rather than in the WC, is more strongly associated with the variation in visceral fat volume. The SAD/height ratio (SADHtR) is arguably even better than SAD alone. The SADHtR has been shown in the federal National Health and Nutrition Examination Survey (NHANES) to be significantly better than BMI for identifying major cardio-metabolic risk factors, i.e., insulin resistance or serum triglycerides.

There is a simple tool that researchers or clinicians can use to measure the SAD: a low-cost, portable, sliding-beam caliper. Various calipers are available, all of which are less expensive than a high-quality scale. And the calipers are easier to calibrate, too.

Choosing between the adiposity indicators SAD or WC could depend on the method’s simplicity and replicability. Especially among persons with large bellies, the reliability of the standing WC is challenged by conflicts between minimizing tension on the measuring tape and the tape’s tendency to droop unpredictably below the horizontal plane. For the SAD, both the examinee and the examiner can relax as the upper arm of the sliding-beam caliper descends just to the point where it touches the abdomen. No further judgment is required.

— Dr. Henry S. Kahn, Atlanta

— Morgan Harlan, Washington, D.C.

Revisiting the Homelessness Conundrum

To me, there is only one solution to helping our homeless get off the streets and into an environment that is safe, that will provide them with food, medical attention, and security, as well as provide them a means to regain the loss of self-esteem of so many of the homeless (“Sobering Lessons in Untying the Knot of a Homeless Crisis,” June 21). Our military bases could provide all the above, of course, with the permission of the Department of Defense and base commanders. I see so many efforts at trying to utilize hotels, apartment buildings, and the like, that are costing our cities, states, and federal government so much money that really is just a waste of time. We need to show our homeless that our government and all of us really care about them. We need to offer them the opportunity to settle in on a military base. They have the human resources and financial resources to really do something, and in a short period of time. These homeless could even be offered up some tasks to do on the bases. Please support this effort. Thank you for your efforts, too. I think every heart cries when we see this tragic situation on our street, and leaves us feeling helpless and hopeless for them.

— Mike Stalsby, La Jolla, California

— Arielle Kane, Washington, D.C.

A Rural Doctor Gave Her All. Then Her Heart Broke.

Physicians suffer one of the highest burnout rates among professionals. Dr. Kimberly Becher, one of two family practitioners in Clay County, West Virginia, learned the hard way.