In states such as Illinois, hospitals commonly give insurance companies 40 percent to 50 percent breaks too, according to the Hospital Accountability Project. West Virginia's insurance companies and HMOs represent fewer people, so they don't have the clout to demand big discounts.
Fewer insured West Virginians have discounts. More pay top dollar.
Discounts make hospital billing even more unpredictable: If Carolyn Davis had gone to St. Francis or Thomas Memorial Hospital, her bill would have been thousands less. Both those hospitals gave Aetna a 25 percent discount at the time she broke her leg. CAMC did not give Aetna a discount at all.
If Davis had been insured by Carelink, CAMC would have knocked 37 percent off her bill. Thomas gives Carelink a 15 percent discount.
Still, the Davises did get some breaks. Their surgeon reduced his fee by 30 percent because he is part of the Aetna "network." They also got discounts on physical therapy and X-rays.
Without those discounts, their total medical bill would have been $30,426 instead of $28,555.
This brings us to a brutal paradox of this incompressible billing system: Those least able to pay are charged most.
An uninsured person would have owed every penny of that $30,426. For the hospital bill alone, he or she would have been billed more than twice what Medicaid pays: 158 percent more.
"When the books of the hospitals are balanced on the backs of the poor and the uninsured, something is really wrong with our system," said Joseph Geevarghese, who directs Chicago's Hospital Accountability Project, run by the Service Employees International Union.
Bad debts, charity care
In yet another paradox, the care the hospital gives some poor people increases the burden on others.
Last year, CAMC provided $45.4 million in care it didn't get paid for, said Hudson, CAMC's finance chief. "Charity care is our community mission," he said, "so we don't question that." The $45.4 million (undiscounted prices) also includes bad debt, subject to collection, which includes bills of uninsured people who were charged full sticker. Hudson said it is nearly impossible to separate the two. Nationally, 80 percent of uncompensated care is bad debt, according to the Hospital Accountability Project.
CAMC does give millions in services, support and subsidies to West Virginia Health Right, the Charleston area free clinic. "They are far and away the most generous area hospital in support of what we do," said Health Right Administrator Pat White.
People who make below 150 percent of the federal poverty level and have less than $50,000 in assets (not counting home and car) can get free care at all three hospitals. St. Francis Hospital offers free care to 200 percent of poverty and a sliding scale for people who make below 400 percent of poverty. The federal government gives hospitals financial breaks in return.
Ironically, uncompensated care adds to the pressure to hike prices. "Ain't it fun?" White sighed. "If you solve a problem in one place, you create one in another."
Nationwide, medical bills are now the leading cause of bankruptcy.
"Poor people are often afraid to question their bills, no matter how weird the bill looks," White said, "because they could lose their houses, their credit rating, job opportunities, ability to borrow money. They are truly intimidated."
The Davises are not immune. "My wife asked the other day why we didn't just pay it, even if it isn't right," Roy Davis said, "because we've never had a mark on our credit, and she's scared CAMC is going to ruin our credit."
Defibrillators and bus ads
The list goes on. Hudson ticks off yet other factors he says force CAMC to hike bills they're allowed to hike:
CAMC is also a teaching hospital ($10 million a year), and its staff handles more complicated, expensive cases than other area hospitals do.
Then there's the cost of advertising. Charleston-area hospitals are engaged in an advertising war on TV, buses, billboards and radio — each trying to capture non-government customers.
Then there is the fact that, last summer, the state gave a Parkersburg hospital permission to start a heart surgery unit. Bluefield may not be far behind. Heart surgery is CAMC's bread and butter. CAMC quickly made deals with both facilities to supply doctors to their new heart units. But CAMC's bottom line will still shrink.
Bad news for the uninsured. Bad news for the Roy Davises who get itemized bills. Solve a problem in one place, create one in another.
Back to Roy Davis (or What about those DRILs?)
"Why didn't they explain any of this to me?" Davis wonders. In all his conversations with the CAMC billing people since June, nobody mentioned any of this, he said.
Instead, CAMC staff told him (1) that they didn't know what various items on his wife's bill were and they would get back to him, and (2) that the state of West Virginia sets the prices for the walker and other items on his bill.
"CAMC should be concerned that I've been stonewalled and patronized and given incorrect information," Davis said. "They should also realize that there are going to be a lot more people like me to contend with."
Hudson said CAMC has hired a firm to help them improve their customer relations in relation to billing. "It may be that we should provide fuller explanations," he said.
On Oct. 6, a month after promising to get back to Davis, a CAMC auditor wrote that, among other things, "The charges for the walker are based on the type of equipment the physical therapist knew was appropriate for the patient. The price for all these services, as I discussed with Mr. Davis, is controlled by an agency within the state of West Virginia."
"The state of West Virginia does not tell CAMC what to charge for a walker," Davis said. "They must think we're stupid."
No, the state does not set the price of any item, said Sonia Chambers, chair of the state Health Care Authority, charged with regulating hospital costs. "We do not get into setting individual prices for individual things. The fact that a hospital submits its charge master to us does not mean we approved it. We use it for informational purposes."
The HCA does not limit anyone's bill either, Chambers said. The HCA regulates the overall average of a hospital's bills. If you average all of CAMC's half-million inpatient bills for 2003, for instance, the final average has to fall within the range the HCA allows. An individual bill can land wildly outside that range, as long as the average comes out right.
In their Oct. 6 letter, CAMC staff also told Davis that the two $816 DRILs on his bill were not really drills, but were drill bits. So he could not have them.
Drills are reusable equipment, so CAMC cannot charge for them, but drill bits get blood on them, so are considered hazardous waste. The letter said CAMC had determined that DRILs were drill bits "through the orthopedic surgery area using the code(s) supplied in the bill." According to the charge master, that code is "miscellaneous."
Davis wrote back and pointed out that the fact that there is already a BIT DRIL 2.5 listed on the bill for $274.95.
In their letter and a later phone call, CAMC staff promised him a revised bill. "I'm still waiting," Davis said.
Monday in the Gazette: Defend yourself against hospital billing errors
To contact staff writer Kate Long, use e-mail or call 348-1798.