Tag: Bill Of The Month

It’s Called an Urgent Care Emergency Center — But Which Is It?

One evening last December, Tieqiao Zhang felt severe stomach pain.

After it subsided later that night, he thought it might be food poisoning. When the pain returned the next morning, Zhang realized the source of his pain might not be as “simple as bad food.”

He didn’t want to wait for an appointment with his regular doctor, but he also wasn’t sure if the pain warranted emergency care, he said.

Zhang, 50, opted to visit Parkland Health’s Urgent Care Emergency Center, a clinic near his home in Dallas where he’d been treated in the past. It’s on the campus of Parkland, the city’s largest public hospital, which has a separate emergency room.

He believed the clinic was an urgent care center, he said.

A CT scan revealed that Zhang had a kidney stone. A physician told him it would pass naturally within a few days, and Zhang was sent home with a prescription for painkillers, he said.

Five days later, Zhang’s stomach pain worsened. Worried and unable to get an immediate appointment with a urologist, Zhang once again visited the Urgent Care Emergency Center and again was advised to wait and see, he said.

Two weeks later, Zhang passed the kidney stone.

Then the bills came.

The Patient: Tieqiao Zhang, 50, who is insured by BlueCross and BlueShield of Texas through his employer.

Medical Services: Two diagnostic visits, including lab tests and CT scans.

Service Provider: Parkland Health & Hospital System. The hospital is part of the Dallas County Hospital District.

Total Bills: The in-network hospital charged $19,543 for the two visits. BlueCross and BlueShield of Texas paid $13,070.96. Zhang owed $1,000 to Parkland — a $500 emergency room copay for each of his two visits.

What Gives: Parkland’s Urgent Care Emergency Center is what’s called a freestanding emergency department.

The number of freestanding emergency rooms in the United States grew tenfold from 2001 to 2016, drawing attention for sending patients eye-popping bills. Most states allow them to operate, either by regulation or lack thereof. Some states, including Texas, have taken steps to regulate the centers, such as requiring posted notices identifying the facility as a freestanding emergency department.

Urgent care centers are a more familiar option for many patients. Research shows that, on average, urgent care visits can be about 10 times cheaper than a low-acuity — or less severe — visit to an ER.

But the difference between an urgent care clinic and a freestanding emergency room can be tough to discern.

Generally, to bill as an emergency department, facilities must meet specific requirements, such as maintaining certain staff, not refusing patients, and remaining open around the clock.

The freestanding emergency department at Parkland is 40 yards away from its main emergency room and operates under the same license, according to Michael Malaise, the spokesperson for Parkland Health. It is closed on nights and Sundays.

(Parkland’s president and chief executive officer, Frederick Cerise, is a member of KFF’s board of trustees. KFF Health News is an editorially independent program of KFF.) The hospital is “very transparent” about the center’s status as an emergency room, Malaise told KFF Health News in a statement.

Malaise provided photographs of posted notices stating, “This facility is a freestanding emergency medical care facility,” and warning that patients would be charged emergency room fees and could also be charged a facility fee. He said the notices were posted in the exam rooms, lobby, and halls at the time of Zhang’s visits.

Zhang’s health plan required a $500 emergency room copay for each of the two visits for his kidney stone.

When Zhang visited the center in 2021 for a different health issue, he was charged only $30, his plan’s copay for urgent care, he said. (A review of his insurance documents showed Parkland also used emergency department billing codes then. BCBS of Texas did not respond to questions about that visit.)

One reason “I went to the urgent care instead of emergency room, although they are just next door, is the copayment,” he said.

The list of services that Parkland’s freestanding emergency room offers resembles that of urgent care centers — including, for some centers, diagnosing a kidney stone, said Ateev Mehrotra, a health care policy professor at Harvard Medical School.

Having choices leaves patients on their own to decipher not only the severity of their ailment, but also what type of facility they are visiting all while dealing with a health concern. Self-triage is “a very difficult thing,” Mehrotra said.

Zhang said he did not recall seeing posted notices identifying the center as a freestanding emergency department during his visits, nor did the front desk staff mention a $500 copay. Plus, he knew Parkland also had an emergency room, and that was not the building he visited, he said.

The name is “misleading,” Zhang said. “It’s like being tricked.”

A portrait of a man sitting outside.
In severe pain and uncertain of its cause, Tieqiao Zhang of Dallas says he didn’t want to wait for an appointment with his regular doctor, but he also wasn’t sure if he needed emergency care. He visited a clinic on the campus of Dallas’ largest public hospital — and was charged 10 times what he expected.(Laura Buckman for KFF Health News)

Parkland opened the center in 2015 to reduce the number of patients in its main emergency room, which is the busiest in the country, Malaise said. He added that the Urgent Care Emergency Center, which is staffed with emergency room providers, is “an extension of our main emergency room and is clearly marked in multiple places as such.”

Malaise first told KFF Health News that the facility isn’t a freestanding ER, noting that it is located in a hospital building on the campus. Days later, he said the center is “held out to the public as a freestanding emergency medical care facility within the definition provided by Texas law.”

The Urgent Care Emergency Center name is intended to prevent first responders and others facing life-threatening emergencies from visiting the center rather than the main emergency room, Malaise said.

“If you have ideas for a better name, certainly you can send that along for us to consider,” he said.

Putting the term “urgent” in the clinic’s name while charging emergency room prices is “disingenuous,” said Benjamin Ukert, an assistant professor of health economics and policy at Texas A&M University.

When Ukert reviewed Zhang’s bills at the request of KFF Health News, he said his first reaction was, “Wow, I am glad that he only got charged $500; it could have been way worse” — for instance, if the facility had been out-of-network.

The Resolution: Zhang said he paid $400 of the $1,000 he owes in total to avoid collections while he continues to dispute the amount.

Zhang said he first reached out to his insurer, thinking his bills were wrong, before he reached out to Parkland several times by phone and email. He said customer service representatives told him that, for billing purposes, Parkland doesn’t differentiate its Urgent Care Emergency Clinic from its emergency department.

BlueCross and BlueShield of Texas did not respond to KFF Health News when asked for comment.

Zhang said he also reached out to a county commissioner’s office in Dallas, which never responded, and to the Texas Department of Health, which said it doesn’t have jurisdiction over billing matters. He said the staff for his state representative, Morgan Meyer, contacted the hospital on his behalf, but later told him the hospital would not change his bill.

As of mid-May, his balance stood at $600, or $300 for each visit.

The Takeaway: Lawmakers in Texas and around the country have tried to increase price transparency at freestanding emergency rooms, including by requiring them to hand out disclosures about billing practices.

But experts said the burden still falls disproportionately on patients to navigate the growing menu of options for care.

It’s up to the patient to walk into the right building, said Mehrotra, the Harvard professor. It doesn’t help that most providers are opaque about their billing practices, he said.

Mehrotra said that some freestanding emergency departments in Texas use confusing names like “complete care,” which mask the facilities’ capabilities and billing structure.

Ukert said states could do more to untangle the confusion patients face at such centers, like banning the use of the term “urgent care” to describe facilities that bill like emergency departments.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Emily Siner reported the audio story.

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Biden Budget Touches All the Bases

The Host

President Joe Biden’s fiscal 2024 budget proposal includes new policies and funding boosts for many of the Democratic Party’s important constituencies, including advocates for people with disabilities and reproductive rights. It also proposes ways to shore up Medicare’s dwindling Hospital Insurance Trust Fund without cutting benefits, basically daring Republicans to match him on the politically potent issue.

Meanwhile, five women in Texas who were denied abortions when their pregnancies threatened their lives or the viability of the fetuses they were carrying are suing the state. They charge that the language of Texas’ abortion ban makes it impossible for doctors to provide needed care without fear of enormous fines or prison sentences.

This week’s panelists are Julie Rovner of KHN, Shefali Luthra of The 19th, Victoria Knight of Axios, and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s episode:

  • Biden’s budget manages to toe the line between preserving Medicare and keeping the Medicare trust fund solvent while advancing progressive policies. Republicans have yet to propose a budget, but it seems likely any GOP plan would lean heavily on cuts to Medicaid and subsidies provided under the Affordable Care Act. Democrats will fight both of those.
  • Even though the president’s budget includes something of a Democratic “wish list” of social policy priorities, the proposals are less sweeping than those made last year. Rather, many — such as extending to private insurance the $35 monthly Medicare cost cap for insulin — build on achievements already realized. That puts new focus on things the president has accomplished.
  • Walgreens, the nation’s second-largest pharmacy chain, is caught up in the abortion wars. In January, the chain said it would apply for certification from the FDA to sell the abortion pill mifepristone in states where abortion is legal. However, last week, under threats from Republican attorneys general in states where abortion is still legal, the chain wavered on whether it would seek to sell the pill there or not, which caused a backlash from both abortion rights proponents and opponents.
  • The five women suing Texas after being denied abortions amid dangerous pregnancy complications are not asking for the state’s ban to be lifted. Rather, they’re seeking clarification about who qualifies for exceptions to the ban, so doctors and hospitals can provide needed care without fear of prosecution.
  • Although anti-abortion groups have for decades insisted that those who have abortions should not be prosecuted, bills introduced in several state legislatures would do exactly that. In South Carolina, those who have abortions could even be subject to the death penalty. So far none of these bills have passed, but the wave of measures could herald a major policy change.

Also this week, Rovner interviews Harris Meyer, who reported and wrote the two latest KHN-NPR “Bill of the Month” features. Both were about families facing unexpected bills after childbirth. If you have an outrageous or exorbitant medical bill you want to share with us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: KHN’s “Girls in Texas Could Get Birth Control at Federal Clinics, Until a Christian Father Objected,” by Sarah Varney

Shefali Luthra: The 19th’s “Language for Treating Childhood Obesity Carries Its Own Health Risks to Kids, Experts Say,” by Jennifer Gerson

Victoria Knight: KHN’s “After People on Medicaid Die, Some States Aggressively Seek Repayment From Their Estates,” by Tony Leys

Margot Sanger-Katz: ProPublica’s “How Obamacare Enabled a Multibillion-Dollar Christian Health Care Grab,” by J. David McSwane and Ryan Gabrielson

Also mentioned in this week’s podcast:

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Surprise-Billing Law Loophole: When ‘Out of Network’ Doesn’t Quite Mean Out of Network

It was the first day of her family’s vacation in the San Juan Islands last June when Danielle Laskey, who was 26 weeks pregnant, thought she was leaking amniotic fluid.

A registered nurse, Laskey called her OB-GYN back home in Seattle, who said to seek immediate care. Staff members at a nearby emergency department found no leakage. But her OB-GYN still wanted to see her as soon as possible.

Laskey and her husband, Jacob, made the three-hour trip to the Swedish Maternal & Fetal Specialty Center-First Hill. Laskey had sought the clinic’s specialized care for this pregnancy, her second, after a dangerous complication with her first: The placenta had become embedded in the uterine muscles.

Back in Seattle, doctors at the clinic found Laskey’s water had broken early, posing a serious risk to her and the fetus, and ordered her immediate admission to Swedish Medical Center/First Hill. She delivered her son after seven weeks in the hospital. Though she was treated for multiple postpartum complications, she was well enough to be discharged the next day. Her son, who is healthy, went home a month later.

Laskey soon developed a fever and body aches, and she was told by her OB-GYN to go to Swedish’s emergency department. She said doctors there wanted to admit her when she arrived Aug. 20 and scheduled a procedure for Aug. 26 to remove a fragment of placenta that her body had not eliminated on its own.

Laskey, who had already spent weeks away from her 3-year-old daughter, chose to go home. She returned for the procedure, which went well, and she was home the same day.

Then the bills came.

The Patient: Danielle Laskey, 31, was covered by a state-sponsored plan offered by her employer, a local school district, and administered by Regence BlueShield.

Medical Service: In-patient hospital services for 51 days, plus a one-day stay that included a second placenta removal procedure.

Service Provider: Swedish Medical Center/First Hill, part of Providence Health & Services, a large, nonprofit, Catholic health system.

Total Bill: Swedish, through Regence, billed about $120,000 in cost sharing for Laskey’s initial hospitalization and about $15,000 for her second visit and procedure.

What Gives: The specialized clinic caring for Laskey before her hospital admission was in her insurance plan’s network. The clinic’s doctors admit patients only to Swedish Medical Center, one of the Seattle area’s only specialized providers for Laskey’s condition — which, given that connection, she assumed was also in the network.

So after being urgently admitted to Swedish, Laskey believed her bills would be largely covered, with the couple expected to pay $2,000 at most for their portion of in-network care because of her plan’s out-of-pocket cost limit.

It turned out Swedish was out of network for Laskey’s plan and, at first, Regence determined that Laskey’s hospitalizations were not emergencies. In November, a Regence case manager initially told Jacob that Laskey’s lengthy hospitalization was an emergency admission and out-of-network charges would not apply. But then she called back and said the charges would apply after all, because Laskey had not come in through the emergency department.

Both Washington state and federal laws prohibit insurers and providers from billing patients for out-of-network charges in emergency situations. The couple said neither Swedish nor Regence told them before or during the two hospitalizations that Swedish was out of network, and that they never knowingly signed anything agreeing to accept out-of-network charges.

Jacob, who works as a psychiatrist at a different hospital, said he mentioned the surprise-billing laws to the case manager, but she replied that the laws did not apply to his family’s situation.

It was only after Regence was contacted by KHN that the insurer explained its reasoning to the reporter: Regence said the Swedish hospital, while out of network for Danielle, had a broader contract with the insurer as a “participating provider” and so the insurer was not in violation of surprise-billing laws by approving Swedish’s out-of-network coinsurance charges.

The broader contract allowed Swedish to bill members of any Regence plan who receive out-of-network services there 50% coinsurance — the patient’s portion of the overall cost the insurer allows the provider to charge — with no out-of-pocket maximum for the patient.

What’s the difference between a hospital that’s “in network” and one that’s a “participating provider”? In this case, by contracting with Regence as an out-of-network but also participating provider, Swedish straddled the line between being in and out of network — designations that traditionally indicate whether a provider has a contract with an insurer or not.

Setting the terms with an insurer for providing its members emergency or other care appears to allow hospitals to sidestep new surprise-billing laws that prevent out-of-network providers from charging high, unpredictable rates in emergencies, according to government and private-sector medical billing experts.

Experts said they had not heard of out-of-network providers evading surprise-billing laws by being contracted as “participating providers” until KHN asked about Laskey’s case.

Ellen Montz, director of the Center for Consumer Information and Insurance Oversight at the Centers for Medicare & Medicaid Services, said that under the federal No Surprises Act the definition of a “participating” emergency facility that’s subject to the law’s surprise billing protections depends on whether the facility has a contract with the insurer specifying the terms and conditions under which an emergency service is provided to a plan member.

Matthew Fiedler, a senior fellow at the University of Southern California-Brookings Schaeffer Initiative for Health Policy who studies out-of-network billing, said Laskey’s case seems to fall into a “weird” gray area of the state and federal laws protecting patients from out-of-network charges in emergency situations.

If there had been no contract between Regence and Swedish, the laws clearly would have prohibited those charges. But since there was a contract specifying a 50% coinsurance rate when Swedish was out of network for a particular Regence plan, those laws legally may not apply, Fiedler said.

After he declined to apply for the hospital’s financial assistance program, Jacob said Swedish also notified the couple in November that they had two months to pay or be sent to collections.

Natalie Kozimor, a spokesperson for Providence Swedish, said the hospital disagreed with “some of the details and characterizations of events” presented by the Laskeys, though she did not specify what those were. She said Swedish assisted Danielle with her appeal to Regence.

“We had no luck with Swedish taking any role or responsibility with regard to our billing or advocating on our behalf,” Jacob said. “They basically just referred us to their financial department to put us on a payment plan.”

A photo shows a woman taking care of an infant baby lying on a padded floor mat.
Danielle Laskey at her home just outside Seattle, with her infant son.(Ryan Henriksen for KHN)

The Resolution: In December, the couple appealed Regence’s approval of Swedish’s out-of-network charges for the 51-day hospitalization, claiming it was an emergency and that there was no in-network hospital with the expertise to treat her condition. They also filed a complaint with the state insurance commissioner’s office.

The office told KHN that the “participating provider” contract does not override the laws barring out-of-network charges in emergency situations. “Danielle had an emergency and Regence acknowledges it was an emergency, so she cannot be balance-billed,” said Stephanie Marquis, public affairs director for the Washington state Office of the Insurance Commissioner.

On Jan. 13, Regence said it would grant the Laskeys’ appeal to cover the first hospitalization as an in-network service, erasing the biggest part of Swedish’s bill but still leaving the family on the hook for the $15,000 bill for Danielle’s second visit and procedure.

On Jan. 27, two days after KHN contacted Regence and Swedish about Danielle Laskey’s case, a Regence representative called and informed her that her second hospitalization also would be reclassified as an in-network service.

Ashley Bach, a Regence spokesperson, confirmed to KHN that both stays now will be covered as emergency, in-network services, eliminating Swedish’s coinsurance charges. But in what appears to be contrary to the insurance commissioner’s stance, he said the bills had not violated state or federal laws prohibiting out-of-network charges in emergency situations because of the contract with Swedish covering all its plans.

“Under the Washington state and federal balance-billing laws, the definitions of whether a provider is considered in network hinges on whether there is a contract with a specific provider,” Bach said.

The Takeaway: More than a year after the federal surprise-billing law took effect, patients can still get hammered by surprise bills resulting from health plans’ limited provider networks and ambiguities about what is considered emergency medical care. The loopholes are out there, and patients like Laskey are just discovering them.

Washington state Rep. Marcus Riccelli, chair of the House Health Care and Wellness Committee, said he will ask the state’s public and private insurers what steps they could take to avoid provider network gaps and out-of-network billing surprises like this. He said he will also review whether there is a loophole in state law that needs to be closed by the legislature.

Fiedler said policymakers need to consider addressing what looks like a major gap in the new laws protecting consumers from surprise bills, since it’s possible that other insurers across the country have similar contracts with hospitals. “Potentially this is a significant loophole, and it’s not what lawmakers were aiming for,” he said.

Congress might have to fix the problem, since the federal agencies that administer the No Surprises Act may not have authority to do anything about it, he added.

Bruce Alexander, a CMS spokesperson, said the Departments of Health & Human Services, Labor, and Treasury are looking into this issue. While the agencies can’t predict whether a new rule or guidance will be needed to address it, he said, “they remain committed to protecting consumers from surprise medical bills.”

In the meantime, patients, even in emergencies, should ask their doctors before a hospital admission whether the hospital is in their plan network, out of network, or (watch for these words) a “participating provider.”

As the Laskeys discovered, hospital billing departments may offer little help in resolving surprise billing. So, while it is worth contesting questionable charges to the provider, it’s also usually an option to quickly appeal to your state insurance department or commissioner.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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KHN’s ‘What the Health?’: Medicaid Machinations

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The lame-duck Congress is back in Washington with a long list of bills it would like to pass and a short time to do it before Republicans take over the House majority in January. How many health-related items can be accomplished depends largely on how much money Congress agrees to spend overall, as it hashes out the annual federal spending bills.

Meanwhile, some of the remaining states that have not yet expanded the Medicaid program may be warming up to the idea, particularly North Carolina and Kansas, which have Democratic governors and Republican legislatures.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s episode:

  • How much the lame-duck Congress manages to accomplish will partly hinge on whether congressional leaders opt for an omnibus spending bill — which would complete the unfinished spending bills through September 2023 — versus a continuing resolution, which would simply extend what’s already on the books into sometime in the new year. Bottom line: Health priorities are competing for a pot of money, but it’s unclear how large that pot will be. Some insiders describe it as a traffic jam.
  • At the top of that list are FDA reforms that didn’t make it into the prescription drug user-fee reauthorization bill that passed this year. Lawmakers fought to keep that measure “clean,” leaving the door open to tackle some leftover issues. What, if anything, will make the final cut is yet to be seen.
  • Other things on the lame-duck list include reversing a 4% scheduled cut to Medicare providers’ reimbursements; weighing proposals related to pandemic preparedness; addressing Medicaid funding for U.S. territories; addressing the end of the public health emergency; and scrutinizing telehealth policy.
  • Among the states that have yet to expand Medicaid under the Affordable Care Act, action is possible by those with a Democratic governor and Republican legislature — Kansas and North Carolina, in particular. Advocates are targeting such places because coverage for hundreds of thousands of people could be at risk, especially as the official end of the public health emergency looms. The financial well-being of some rural and safety-net hospitals also is in jeopardy.
  • Georgia is poised to expand Medicaid eligibility somewhat, but only to people who can prove they worked or did community service for 80 hours per month. This comes after a federal judge ruled that the Biden administration’s move to cancel a Trump administration-approved waiver was “arbitrary and capricious.” The only other Medicaid work requirement that has taken effect, in Arkansas, ended up taking coverage away from thousands of people who were eligible and working, due to its complicated reporting system.
  • Anti-abortion groups seem keen on finding creative ways to take aim at the so-called abortion pill, which recently became the most common method of ending pregnancy in the United States. Medication abortions are much more difficult for anti-abortion groups to target, because women do not have to go to a clinic to receive the drugs.
  • One lawsuit sought to force the FDA to rescind its approval of mifepristone, dating to 2000. Anti-abortion groups say the agency didn’t have the authority to approve the drug through the “expedited” pathway it chose.
  • Another strategy from anti-abortion groups claims that the use of abortion pills is contaminating wastewater and groundwater; they seek to deploy environmental laws to block the use of the drugs.
  • Despite Americans’ desire to put the covid-19 pandemic in the rearview mirror, the virus may have other plans. The Biden administration wants another $10 billion before the end of the year to pay for its anti-covid campaign, although even Democrats in Congress are not pushing hard for that funding. Meanwhile, governments and social media platforms are still struggling to address covid misinformation and disinformation.

Also this week, Rovner interviews KHN’s Fred Clasen-Kelly, who reported and wrote the latest KHN-NPR “Bill of the Month,” about a mysterious mishap during minor surgery. If you have an enormous or mystifying medical bill you’d like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Stat’s “Resistance to FDA’s Opioid-Disposal Plan Raises Concerns About CADCA, a Powerful Advocacy Group,” by Lev Facher

Alice Miranda Ollstein: ProPublica and The New York Times’ “She Wanted an Abortion. A Judge Said She Wasn’t Mature Enough to Decide,” by Lizzie Presser

Rachel Cohrs: The New Yorker’s “How Hospice Became a For-Profit Hustle,” by Ava Kofman

Sarah Karlin-Smith: The New York Times’ “Jail Is a Death Sentence for a Growing Number of Americans,” by Shaila Dewan

Also mentioned in this week’s episode:

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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.

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Listen: Grieving Families Face the Cruelest Bills

NPR’s “Consider This” podcast tells the stories of the Markow, Shickel, and Raspe familes. All had very sick infants who died after needing highly technical, very expensive treatment in neonatal intensive care units. Medical bills lived on for each family even after their babies died. “All Things Considered” host Juana Summers spoke to KHN Midwest correspondent Lauren Weber about her reporting on The Cruelest Bills.

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Shattered Dreams and Bills in the Millions: Losing a Baby in America

The day after his 8-month-old baby died, Kingsley Raspe opened the mail and found he had been sent to collections for her care.

That notice involved a paltry sum, $26.50 — absurd really, given he’d previously been told he owed $2.5 million for treatment of his newborn’s congenital heart defect and other disorders.

Raspe and his wife, Maddie, had endured watching doctors crack open the chest of their pigtailed daughter, Sterling, whom they called “sweet Sterly gurl.” The health team performed so many other procedures. But it couldn’t keep her — or her parents’ dreams for her — alive.

The bills lived on for them, as they do for many other families of premature and very sick infants who don’t survive.

“What a lasting tribute to the entire experience,” Kingsley said angrily. “The process was just so heartless.”

More than 300,000 U.S. families have infants who require advanced medical attention in newborn intensive care units every year. Some babies stay for months, quickly generating astronomical fees for highly specialized surgeries and round-the-clock care. The services are delivered, and in U.S. health care, billing follows. But for the smaller fraction of families whose children die, the burden can be too much to bear.

A patchwork of convoluted Medicaid-qualification rules seek to defray these kinds of bills for very sick children. But policies differ in each state, and many parents — especially those, like the Raspes, who have commercial insurance — don’t know to apply or think they won’t qualify.

Also, because many crises that befall premature or very sick babies are in-the-moment emergencies, there may not be time for the preapprovals that insurers often require for expensive interventions. That leaves parents in crisis — or in mourning — tasked with fighting with insurers to have treatment covered.

Three families detailed for KHN how medical bills compounded their suffering during a time when they were just trying to process their loss.

Bennett Markow

As the hospital in Reno, Nevada, was converting a parking garage into a covid-19 unit in November 2020, Bennett Markow came into the world four months early. He weighed less than a pound. His care team loved to sing “Bennie and the Jets” to him as a nod to the jet ventilator keeping his tiny lungs working.

On Jan. 20, 2021, when Bennett was 2 months old, his parents were told he needed to go to UC Davis Children’s Hospital in Sacramento, California, for specialized care that could keep him from going blind. The transfer team would be there in an hour. And the Nevada care team said that because it was an emergency, the family needn’t worry about their insurance or the method of transportation.

Bennett’s eye problem ended up being less severe than the doctors had feared. And Crissa Markow and her husband, A.J., were billed for the plane ride from REACH Air Medical Services, which turned out to be out of network. Jason Sorrick, vice president of government relations for REACH’s parent company, Global Medical Response, said the ride happened during a “lapse” in Bennett’s Medicaid coverage.

The Markows said there was no lapse. They hadn’t applied yet because they thought they wouldn’t qualify — the family is middle-class, and Bennett was on Crissa’s insurance. They did not know they should until a social worker at UC Davis gave them more information — after the flight.

Crissa Markow said her heart dropped to her toes when she realized she was being billed over $71,000, more than she makes in a year as a social worker. (The No Surprises Act, which aims to eliminate surprise billing, could have prevented some of the family’s headaches — but Bennett was born before it went into effect this year.)

Bennett Markow with his mother, Crissa, during a family visit at UC Davis Children’s Hospital in Sacramento, California. (Crissa Markow)
Bennett Markow came into the world four months early. He weighed less than a pound. His care team loved to sing “Bennie and the Jets” to him as a nod to the jet ventilator keeping his tiny lungs working. (Crissa Markow)

Although Crissa was used to working toward solutions, the billing quagmires she found herself in while juggling Bennett’s care, her job, her other son, and the travel logistics to stay with Bennett about 2½ hours away from her home were overwhelming. Crissa estimates she spent six to eight hours a week dealing with medical bills to keep them from being sent to collections — which still happened.

Bennett died last July after doctors said his lungs could not fight anymore. The Markows spent their bereavement leave battling with insurers and other billing agencies.

Finally, Crissa called REACH, the air transport company, and said: “Look, my son died. I just want to be able to grieve, I want to focus on that. Dealing with this bill is traumatic. It’s a reminder every day I shouldn’t have to be fighting this.”

By October, the Markows had settled the bill with REACH on the condition that they not disclose the terms. Sorrick said that the company reaches agreements based on the financial and personal situations of each patient and their family and that the company’s patient advocates had talked to Crissa Markow 17 times.

“If every settlement amount was disclosed publicly, then those rates become the expectation of all patients and insurance providers,” Sorrick said. “Ultimately, that would lead to all patients wanting to pay below cost, making our services unsustainable.”

Crissa Markow’s employer-provided insurance paid $6.5 million for Bennett’s care, not including what was covered by Medicaid. The Markows paid roughly $6,500 out-of-pocket to hospitals and doctors on top of their REACH settlement. But it was not those amounts — which the couple would have happily paid to save their son — but the endless harassment and the hours spent on the phone that haunt them.

“I just wanted to be with Bennett; that’s all I wanted to do,” Crissa Markow said. “And I just spent hours on these phone calls.”

[embedded content]
(Hannah Norman/KHN)

Jack Shickel

Jack Shickel was born with stunning silver hair and hypoplastic left heart syndrome. Even though he was surrounded by wires and tubes, the nurses at UVA Children’s Hospital would whisper to Jessica and her husband, Isaac, that they had a truly “cute” baby.

But his congenital disorder meant the left side of his heart never fully developed. Each year in the U.S., over a thousand babies are born with the syndrome.

After two surgeries, Jack’s heart could not pump enough blood on its own. He made it 35 days.

Weeks after his death, when the Shickels were trying to muddle through life without him in Harrisonburg, Virginia, they called the hospital billing department about two confusing bills. They were then told the full cost of his care was $3.4 million.

“I laughed and then cried,” Jessica said. “He was worth every penny to us, but that’s basically $100,000 a day.”

The Shickels with baby Jack at UVA Children’s Hospital. Jack was born with hypoplastic left heart syndrome — which means the left side of his heart never fully developed. (Jessica Shickel)

Bills from out-of-network labs and other prior approval notifications continued to overwhelm their mailbox. Eventually, they figured out how to get Medicaid. The Shickels ended up paying only $470.26.

Jessica got the final bills in March, seven months after Jack’s death.

She noted that all of this was happening as the University of Virginia Health System said it was rolling back its aggressive billing practices after a KHN investigation found the prestigious university hospital was putting liens on people’s homes to recoup medical debt.

UVA Health spokesperson Eric Swensen expressed condolences to the Shickel family and added that the health system works to help patients navigate the “complex process” of evaluating financial assistance, including Medicaid coverage.

After KHN reached out for comment, the Shickels got a call from UVA saying that the hospital was refunding their payment.

The hospital care team had given the family a pamphlet about what to do when grieving, but a more useful one, Jessica said, would have been titled “How Do You Deal With Medical Bills After Your Child Has Died?”

Sterling Raspe

Kingsley Raspe likes to say Sterling was “one special little lady” — not only did she have the same congenital heart defect as Jack Shickel, but she was also diagnosed with Kabuki syndrome, a rare disorder that can severely affect development. Sterling also had hearing loss, spinal cord issues, and a compromised immune system.

An explanation of benefits from the Raspes’ commercial insurance indicated the couple would need to pay $2.5 million for Sterling’s care — an amount so large the numbers didn’t all fit in the column. Even Kingsley’s suspicion that the $2.5 million charge was likely erroneous — in large part or in whole — didn’t erase the sheer panic he felt when he saw the number.

A computer programmer making $90,000 a year, Kingsley had decent insurance. He frantically Googled “medical bankruptcy.”

Sterling had been denied Medicaid, which is available to children with complex medical problems in some states. Kingsley had filed an application for the government insurance, which had to be submitted by mail from the family home in Gary, Indiana. In doing so, he broke the strict protocols on covid exposure set early in the pandemic at the Ronald McDonald charity house near the Illinois hospital where Sterling was being treated and jeopardized his ability to stay there.

In rejecting the application, Indiana cited an income threshold and other technical reasons.

Everyone kept telling Kingsley and Maddie to get divorced so Sterling would qualify for Medicaid. But that wasn’t an option for Kingsley, a British citizen who is in the U.S. on a green card after meeting Maddie on Tinder.

The Raspes, who lost their daughter, Sterling, were advised to get divorced to qualify her for Medicaid, which would help fend off possible medical debt. (Kingsley Raspe)
Despite myriad medical issues that left her with severe hearing loss, spinal cord issues, and a compromised immune system, Sterling Raspe was denied Medicaid in Indiana. (Kingsley Raspe)

Ultimately, Kingsley’s insurer revised the faulty notice that he owed $2.5 million. The family was told the mistake had occurred because Sterling’s initial hospital stay and surgeries had not been preapproved, although Kingsley said the heart defect was discovered halfway through the pregnancy, making surgery inevitable.

Throughout Sterling’s life, Kingsley did his programming job at his daughter’s bedside, in her hospital room. As a web developer, he created visualizations that break down Sterling’s expensive care — it helped him make sense of it all. But he cries when he remembers those days.

He hates that Sterling’s life can be reduced to a 2-inch stack of printed-out medical bills and the phone calls he still must endure from errant billers.

Despite receiving a plethora of other bills in the tens of thousands, he and his wife eventually paid their $4,000 deductible, along with a smattering of smaller charges and fees for equipment rentals that weren’t covered. In April, Maddie gave birth to a son, Wren, and Kingsley said he knows Sterling served as her brother’s guardian angel.

“My daughter passed away. I’m not unscathed, but I’m not in financial ruin. The same can’t be said for every family,” he said. “How lucky am I? I went through the worst thing imaginable, and I consider myself lucky — what kind of weird, messed-up logic is that?”

Navigating the NICU

Contact your insurance company to talk through your NICU stay costs, including what is covered and what is not. If your baby’s not already on your plan, make sure to add them.

Speak to a social worker immediately about applying for Medicaid or the Supplemental Security Income program, known as SSI. If your child qualifies, it can dramatically reduce your personal cost for a child with extensive medical bills.

The March of Dimes offers a “My NICU Baby” app designed to help you wade through the overwhelming experience. The nonprofit says the app can help you learn about caring for your baby in the NICU and at home, as well as monitor your baby’s progress, manage your own health, and keep track of your to-do list and questions.

If particular insurers or bills are confusing, reach out to your state insurance office. All states offer consumer support, and some states have dedicated advocates who can help you.

Kingsley Raspe also compiled advice for other families navigating neonatal intensive care unit stays for their babies.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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KHN’s ‘What the Health?’: Judge Takes Aim at the Affordable Care Act’s Preventive Care Benefits

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

The same federal judge in Texas who tried — unsuccessfully — to strike down the entire Affordable Care Act in 2018 has ruled that portions of the health law’s preventive care benefit package are unconstitutional. But it will be a long time, with many more court actions, before it becomes clear whether the decision will change how the law works.

Meanwhile, the U.S. Department of Veterans Affairs, after several weeks of deliberations, has decided to make abortions available to patients and some dependents in some circumstances. And in Michigan, a closely watched ballot measure on abortion scheduled for this fall may not get a vote after all because of a printing problem.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Among the takeaways from this week’s episode:

  • A decision announced this week by a federal judge in Texas could have a major impact on a popular provision of the Affordable Care Act that gives consumers no-cost access to a host of preventive care tests and treatments. Judge Reed O’Connor said the group that determines which services are eligible for that coverage does not have proper authorization from Congress.
  • O’Connor also ruled that employers with deep religious beliefs should not have to provide HIV prevention medications to workers if the employers believe those drugs encourage improper sexual behavior. The judge has not yet announced how he will suggest both these issues be remedied.
  • The Biden administration announced Thursday that it is overturning a rule implemented by the Trump administration that restricted immigrants’ ability to apply for permanent status in the U.S. if they had received government subsidies.
  • The U.S. Department of Veterans Affairs said it will now provide limited abortions for veterans and their eligible dependents at VA facilities in states that have restricted access to the procedure. The care will be available to veterans and dependents if the pregnancy is a result of rape or incest or is jeopardizing the life of the woman.
  • In Michigan, a state judge ruled that a 1931 ban on abortions is unconstitutional, but that is expected to be appealed. In the meantime, abortion-rights supporters are seeking to get a ballot measure that would guarantee access approved for consideration in the November election. The supporters have enough signatures, but the measure was drafted with a typographical error that could invalidate it. A court is expected to rule on the issue soon.
  • New covid-19 booster immunizations are rolling out to health centers and pharmacies across the country. The administration is encouraging anyone 12 or older (who hasn’t had a vaccination in the past two months) to get the shot. Administration health experts suggest this is the beginning of an effort to simplify the vaccination schedule and hope that most people will need only one shot a year after this. But that goal will depend on how the virus continues to mutate.
  • The Senate is back at work on Capitol Hill, and the House will return next week. The lawmakers still must come up with funding for the fiscal year that begins Oct. 1. Most people expect that they will turn to a temporary funding measure for the short term.
  • Three senators are out with covid, and one key Republican, Sen. Richard Burr of North Carolina, is absent because of a hip replacement. His absence comes at an inopportune time because he has worked with Democrats to try to push through a bill that extends the FDA’s ability to charge user fees to drugmakers to help pay for the agency’s assessments of drugs. He has also helped pull together a bill with Sen. Patty Murray (D-Wash.) to fund more efforts for public health preparedness.

Also this week, Rovner interviews KHN’s Lauren Sausser, who reported and wrote the latest KHN-NPR “Bill of the Month” installment, about a patient in need of a biopsy who did all the right things in advance and still got stuck with a giant bill. If you have an enormous or outrageous medical bill you’d like to send us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: KHN’s “When Does Life Begin? As State Laws Define It, Science, Politics, and Religion Clash,” by Sarah Varney

Alice Miranda Ollstein: The New Yorker’s “When Private Equity Takes Over a Nursing Home,” by Yasmin Rafiei

Joanne Kenen: ProPublica’s “‘The Human Psyche Was Not Built for This,’” by Marilyn W. Thompson and Jenny Deam

Sarah Karlin-Smith: Stat’s “Study Raises Concerns About the Effectiveness of the Monkeypox Vaccine,” by Helen Branswell

Also mentioned in this week’s episode:

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

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Bye-Bye to Health Insurance ‘Birthday Rule’? Kansas Lawmaker Floats Fix

When Kayla Kjelshus gave birth to her first child, the infant spent seven days in the neonatal intensive care unit, known as the NICU. This stressful medical experience was followed by an equally stressful financial one. Because of an obscure health insurance policy called the “birthday rule,” Kjelshus and her husband, Mikkel, were hit with an unexpected charge of more than $200,000 for the NICU stay.

Now, seven months after KHN and NPR published a story about the Kjelshus family’s experience, new parents may be spared this kind of financial uncertainty if lawmakers pass a bill that would give parents more control when it’s time to pick a health insurance policy for their child.

The new proposed law would eliminate the birthday rule. That rule dictates how insurance companies pick the primary insurer for a child when both parents have coverage: The parent whose birthday comes first in the calendar year covers the new baby with their plan first. For the Kjelshuses of Olathe, Kansas, that meant the insurance held by Mikkel, whose birthday is two weeks before his wife’s, was primary, even though his policy was much less generous and based in a different state.

“It’s an outdated policy,” Mikkel Kjelshus said. “Nowadays both parents typically have to work just to make ends meet.” Two jobs often means two offers of health insurance — and while double coverage should be a good thing, in practice, it can lead to a bureaucratic nightmare like the one the Kjelshuses faced.

U.S. Rep. Sharice Davids (D-Kansas) introduced “Empowering Parents’ Healthcare Choices Act,” a bill that would do away with “the birthday rule” and a “coordination of benefits policy” that trips up first-time parents up when it’s time to sign up a new baby for insurance.

“When I heard about the Kjelshus family’s story, I knew there had to be a way to help,” Davids said. “Parents should have the power when it comes to their new baby’s health care coverage.”

For Charlie Kjelshus, the birthday rule meant her dad’s plan — with a $12,000 deductible, a high coinsurance obligation and a network focused in a different state — was deemed her primary coverage. Her mom’s more generous plan was secondary. Confusion over the two plans caused a tangle of red tape for the family that took almost two years and national media attention to resolve.

This model regulation was set by the National Association of Insurance Commissioners and adopted by most states, including Kansas, said Lee Modesitt, director of public affairs with the Kansas Insurance Department. It is a somewhat arbitrary rule that could be fair if all jobs offered health plans with similar coverage. But for many families, one partner’s plan is much more generous.

“It feels awesome,” Mikkel Kjelshus said of the news that a change has been proposed. “We really didn’t want this to happen to anyone else.”

To be enacted, the bill would need to pass the House and Senate before receiving the president’s signature. Davids was elected to Congress in 2018, flipping a seat in Overland Park, Kansas, that had been held by a Republican for a decade. She was reelected in 2020 and is the only Democrat in Kansas’ House delegation.

Ellie Turner, a spokesperson for the congresswoman, said Davids is talking with colleagues in the House to garner additional support.

“It’s becoming clear that the Kjelshus family is not alone in this experience,” Turner wrote in an email. “We are going to continue working to raise awareness and gain momentum for a birthday rule fix, because every family deserves a choice when it comes to their child’s health.”

As they await the arrival of their second child, this time around the Kjelshus family has a better idea of how the health insurance will work. And, much like the first time, they feel prepared.

“We’ve got the crib. We’ve got the baby stuff. It’s a lot less stress this time around,” Mikkel Kjelshus said. “We kind of know what we’re doing.”

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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