He visited the U.S. for his daughter's wedding ceremony — and left with a $42,000 medical invoice


After emergency surgical procedure, an American expatriate with Swiss insurance coverage now carries the bags of a five-figure invoice.

Aria Konishi/KFF Health News

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Aria Konishi/KFF Health News

After emergency surgical procedure, an American expatriate with Swiss insurance coverage now carries the bags of a five-figure invoice.

Aria Konishi/KFF Health News

Last June, Jay Comfort flew to the United States from his residence in Switzerland to attend his solely daughter’s wedding ceremony. But the week earlier than the ceremony — on a Friday night — Comfort stated he discovered himself in “excruciating pain.”

“I tried to gut it out for three hours because of the insurance situation,” stated Comfort, a retired trainer and American citizen who has Swiss insurance coverage.

When the ache turned insufferable, Comfort referred to as his brother, who drove him and his spouse, Nazuna, just a few miles to the closest emergency division, on the University of Pittsburgh Medical Center’s hospital in Williamsport, Pennsylvania.

Every bump of the drive was “like someone taking something and just jabbing it into my abdomen,” he stated.

At the hospital, Nazuna Konishi Comfort handed over her husband’s Swiss insurance coverage card, which confirmed protection by Groupe Mutuel. Jay recalled the employees making copies of his insurance coverage card after which treating his acute appendicitis. Doctors carried out emergency surgical procedure to take away the infected appendix.

Diagnostic checks confirmed he had a uncommon most cancers, which docs in Switzerland later eliminated with one other surgical procedure after he returned residence. “It was a miracle,” Comfort stated, including that the most cancers was fully eliminated.

After his appendectomy, Comfort recalled vomiting after which ready in a restoration room. In all, he spent about 14 hours at UPMC Williamsport earlier than being launched. He attended his daughter’s wedding ceremony and, ultimately, traveled again to Switzerland.

Then the invoice got here.

The affected person: Leslie “Jay” Comfort, 66, a retired educator who labored in Japan and Switzerland. Comfort pays a month-to-month charge and deductible for Switzerland’s obligatory fundamental medical insurance, which he has with the Swiss-based Groupe Mutuel. His advantages — and the costs for procedures — are outlined by the Swiss authorities.

Medical service: Emergency laparoscopic appendectomy and diagnostic checks, which confirmed Comfort had a uncommon subtype of most cancers referred to as goblet cell adenocarcinoma.

Service supplier: University of Pittsburgh Medical Center Williamsport, which is about 3½ hours northeast of Pittsburgh. The UPMC well being system is among the state’s largest employers, with 40 hospitals.

Total invoice: $42,156.50, protecting emergency surgical procedure, scans, laboratory testing, and three hours in a restoration room. His insurer has stated it is going to pay him about $8,184 (7,260.40 in Swiss francs), which is double the process’s value in Switzerland. This left him to cowl the remaining roughly $34,000.

What offers: Although Comfort has well being protection, his Swiss insurance coverage had no contract with the U.S. hospital the place he underwent emergency surgical procedure — or with every other supplier outdoors Switzerland.

With what is taken into account a wonderful well being system, Switzerland has the very best costs for medical care in Europe. As within the U.S., the nation depends on non-public insurers and hospitals. But the price of care in Switzerland is considerably decrease than what’s charged within the U.S., so the reimbursement his insurer supplied is a fraction of what Comfort owes the U.S. hospital.

“I’m trying to do the right thing and say I’m willing to pay my responsibility,” he stated.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical payments. Do you’ve gotten an attention-grabbing medical invoice you need to share with us? Tell us about it!

Groupe Mutuel doesn’t have agreements with international suppliers, reminiscent of UPMC, and doesn’t cope with them instantly, stated Lisa Flückiger, a spokesperson for Groupe Mutuel. The insurer initially agreed to reimburse Comfort what would have been paid in Switzerland for a similar therapy in a public hospital after which double that as a result of it was an emergency abroad — a complete of 4,838 in Swiss francs, or about $5,460.

While useful, Comfort stated, that quantity would not repay the $42,156.50 he owes UPMC.

UPMC has expanded its attain all through Pennsylvania and is now the most important supplier of care in lots of elements of the state. In 2016, it bought a smaller well being system and now runs two majors hospitals, UPMC Williamsport and UPMC Williamsport Divine Providence Campus.

Studies present that in areas the place hospital consolidation is excessive, costs go up. Because there may be much less competitors, hospitals have extra energy to cost what they need when sufferers have non-public insurance coverage or are paying out-of-pocket.

In the U.S. the quantities charged for medical care are “all over the map,” stated Johnathan Clarke, vice chairman of technique and enterprise growth at Penfield Care, a medical cost-containment firm in Canada. The firm negotiates medical payments on behalf of people, together with worldwide guests to the U.S., however isn’t concerned in Comfort’s case.

Clarke stated he would count on an appendectomy to be priced between $6,500 to $18,800, primarily based on his evaluation of Medicare funds within the Pittsburgh space. Healthcare Bluebook — which evaluates insurers’ claims knowledge to offer value estimates primarily based on what insurers have paid, quite than what suppliers cost — says a good value for a laparoscopic appendectomy in Williamsport is about $14,554.

Comfort stated a “reasonable price estimate” primarily based on his personal web analysis could be between $7,500 and $12,000.

Comfort’s care included an X-ray and an EKG, or electrocardiogram for his coronary heart, as a result of “there was no information relating to past medical/surgical history for this patient,” wrote Susan Manko, vice chairman of public relations at UPMC. The employees additionally performed pathology work that recognized most cancers.

But these extra companies didn’t absolutely clarify the hole between value estimates and what the hospital charged. For occasion, UPMC charged $8,357 for Comfort’s three-hour keep within the restoration room.

Manko stated Comfort’s whole invoice aligns with UPMC’s normal prices.

The value disparities spotlight the stark distinction in worldwide pricing. Cost estimates final 12 months confirmed the common quantity paid for an appendectomy within the U.S. was “nearly exactly double” that paid in Switzerland, stated Christopher Watney, chief government of the International Federation of Health Plans, an trade affiliation whose members embrace well being insurers on six continents.

Health care in Switzerland, although, is usually costly in contrast with different European international locations, Watney stated. The Swiss pay double for an appendectomy in contrast with Germans, and greater than thrice that of these in Spain, he stated. Across the globe, Watney stated, many international locations embrace an in a single day keep in the price of an uncomplicated appendectomy in distinction to Comfort’s expertise, which was billed as outpatient care.

Comfort, who has twin residency in Switzerland and Japan after practically three a long time working overseas, stated he labored within the U.S. lengthy sufficient to qualify for Social Security advantages and Medicare. He stated he had beforehand tried to realize Medicare protection at one level however nonetheless isn’t enrolled, after being transferred to a few workplaces and “playing phone tag.”

Still, not like many sufferers coping with a five-figure medical invoice, Comfort stated he isn’t involved about UPMC harming his monetary fame. The well being system would not “seem to put bad marks against people’s credit record — and I don’t have credit in the United States. I’ve been out for 30 years.”

Manko confirmed that, saying UPMC reviewed and up to date its assortment coverage final 12 months; it states the well being system is not going to interact in “extraordinary collection actions” reminiscent of lawsuits, liens on houses, arrests, or reporting to credit score businesses.

She stated the well being system — which, as a nonprofit system, is tax-exempt — maintains a “robust financial assistance program” for sufferers unable to pay. But “to our knowledge” Comfort has not utilized for monetary help, Manko informed KFF Health News.

The decision: Comfort stated he spent months ready for a invoice and eventually reached out to UPMC as a result of, if the invoice had arrived this 12 months, he would have needed to pay his insurance coverage deductible once more on high of the fees.

Comfort obtained a full UPMC invoice six months after his surgical procedure. Manko stated there was “confusion” on the time of Comfort’s ER registration. Comfort’s spouse offered the insurance coverage data, she stated, “but there was no documentation in the patients record for address, policy number or policy holder information.”

Once Comfort obtained his invoice, he realized it was a lot larger than his Swiss insurance coverage reimbursement and, annoyed, contacted KFF Health News.

Flückiger stated the unique cost quantity Comfort’s insurer calculated was particularly for the appendectomy and didn’t embrace the scan or laboratory prices. After receiving questions from a KFF Health News reporter, Groupe Mutuel “realized that we have not included the laboratory analysis and the CT scan,” which aren’t routinely a part of an appendectomy, Flückiger wrote.

After KFF Health News offered an in depth abstract of the UPMC invoice, the insurer elevated the quantity it could pay Comfort. In all, the insurer stated, Comfort ought to obtain 7,260.40 in Swiss francs, or about $8,184.

Comfort nonetheless hopes to barter instantly with UPMC to cut back what he owes.

“I don’t want to try to walk away, saying I don’t owe you anything,” Comfort stated. “That’s not right. We’re moral people, you know. But if you’re going to try to gouge me and play the power trip and think you’re going to try to get everything you can out of me, I won’t play that game.”

The takeaway: Though the Affordable Care Act was meant to offer insurance coverage to extra Americans and convey down the price of care, hospital payments stay terribly excessive and extremely variable.

For a nonemergency, Comfort might have tried to match costs at different hospitals. But most hospitals within the space the place he fell in poor health are owned by UPMC. And an infected appendix cannot look forward to comparability buying.

Clarke, the cost-containment skilled, stated the “only thing” Comfort might have executed otherwise was to buy a journey medical insurance coverage earlier than leaving Switzerland. While costs for well being care in continental Europe are similar to Switzerland, the excessive value of care within the U.S. means Groupe Mutuel insurance coverage is “insufficient.”

That is particularly necessary for guests to the U.S. since, as Robin Ingle, CEO of journey insurance coverage firm Ingle International, stated: U.S. costs are “kind of crazy numbers.”

KFF Health News, previously generally known as Kaiser Health News (KHN), is a nationwide newsroom that produces in-depth journalism about well being points and is among the core working applications at KFF — the impartial supply for well being coverage analysis, polling, and journalism.

Emmarie Huetteman of KFF Health News edited the digital story, and Taunya English of KFF Health News edited the audio story. NPR’s Will Stone edited the audio and digital story.

Source: www.npr.org