This is Not a Bill

I’ve been following the Sunday series in the New York Times in which Ezekiel Emanuel—vice-provost and Professor of Medical Ethics at the University of Pennsylvania, and former White House advisor—has been explaining high healthcare costs.

I particularly appreciated this week’s discussion, “Billions Wasted on Billing.” My husband and I are at the age when doctor’s visits become more frequent, and I have weekly opportunities to open envelopes to read incomprehensible jumbles of medical and financial jargon under the heading “this is not a bill.”  Anyone having experience with mailings of any sort—bills, invoices, reminders—knows that it is impossible to generate and mail anything for less than $5-$7 dollars, once you account for clerical time, stationery and postage. I’ve never understood why the same not-so-informative information can’t be included when the actual bill is sent.

Emanuel’s column was not just about billing, but about all the other repetitive, duplicative paperwork that characterizes our current health care system. How many times do we fill out patient forms with the identical information? How many insurance claims must be completed in different formats by all those white-haired ladies in colorful smocks sitting behind the glass partitions in your doctor’s office?

What does all this cost, and how much of it is really necessary?

According to Harvard economist David Cutler, electronic billing and credentialing could save the system upwards of 32 billion dollars a year. Transitioning to electronic record-keeping would pay other dividends as well: it would allow medical providers to use existing anti-fraud detection methods currently used by credit card companies, and it would minimize the errors that are inevitable when data is manually entered. (No longer getting “this is not a bill” mailings would also have a salutary effect on my blood pressure.)

What Emanuel’s column did not address is the question why medical insurers and providers have been so slow to adapt to the electronic age. I think a part of the answer is the complexity of what passes for a medical system in the U.S.—a complexity that also bedevils efforts to conduct reasonable policy discussions about health care in general.

We’ve all joked about the senior citizen at the Town Hall meeting who shouted “keep government’s hands off my Medicare.”  It’s true that most Americans do know Medicare and Medicaid are government programs. We know that taxpayers fund the (much-lauded) Veteran’s Administration. But how many of us understand the extent to which government currently funds pharmaceutical and medical research? Or how much state governments contribute to the cost of medical education? To public health programs? How many of us know what local government units spend for everything from ambulance service to charity care?

I like to think of myself as informed, but I certainly don’t know the answers to those questions. I was astounded a few years ago when, serving on an academic committee dominated by healthcare professionals, I learned that government at all levels currently funds between 60% and 70% of all healthcare costs.

The real question isn’t whether we should have a government system or a private one. We haven’t had a private, market-driven system for decades, and for good reason. Markets require a willing buyer and willing seller, each of whom has the necessary relevant information and the ability to exercise choice. The real question is how to identify the measures that will reduce healthcare costs and improve patient care and access. Right now, we pay 2 ½ times what the next most expensive country pays for a system that ranks 36th in the world.

That’s a bill we shouldn’t have to pay.


  1. The most damning factoid about medical costs is the outright refusal of hospitals to post a public price list. Conservatives holler against ignorant folk making dumb and unwise healthcare choices but when the prices are deliberately hidden, how can one make informed choices?

  2. Hear, hear to the comment above mine. I had 3 ER visits earlier this year (kidney stones, which I do NOT recommend) and I kept trying to get people to tell me what various procedures, tests, etc. would cost. Even my car mechanic isn’t allowed to do work on my car until he provides a written estimate of costs. But the healthcare industry? Forget about it.

    I’ve been an empaneled service provider as well as a consumer of services. I can tell anyone who wants to know from first-hand experience that one of the major driver of excessive costs is dealing with dozens of different insurance companies, different plans, different copays, different reimbursement rates, making call after call after call to say “why did you pay me for this but not for that,” having insurers lose claims that were in the same envelope as other claims… I did all this work for myself as a therapist with a small private practice, and every insurance client took twice the time for 60% of the income of my cash pay clients. But without insurance, most people could not have afforded to access care.

    SINGLE PAYER is the only solution.

  3. Single payer–or “Medicare for All”– IS the only solution. Much as the Affordable Care Act falls short of what is needed, however, it is a first step, and a major breakthrough given the forces arrayed against any sort of reform. The task now is to amend it, incrementally if necessary, until it resembles what we actually need.

  4. “…the forces arrayed against any sort of reform.”

    would include Speaker Pelosi and the Democratic majorities in both houses that refused Republican amendments in the creation of the Affordable Care Act. Doctor in the House, a book by Texas Republican representative, Dr. Michael Burgess, details by bill number the attempts to address portability, pre-existing conditions, crossing-state-lines to obtain coverage, malpractice limitations, and other issues that were not allowed to considered in the resultant Obamacare.

    I do no understand how something unaffordable can be considered a “breakthrough” unless we’re talking about the lining of our pocket that holds the money. The late night prescription drug benefit program passed under “compassionate conservatism” under Bush was at least equally fiscally irresponsible.

    Is it any wonder why some Tea-Partiers and Occupiers share anger alike rail against the corruption of public officials who care more about reelections and feathering their own nest than the plight of the average taxpayer?

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