Letters to the Editor聽is a periodic feature. We聽聽and will publish a selection. We edit for length and clarity and require full names.
鈥 Laurie Garrett, New York City
Medical Debt as the Ultimate Medical Mystery
I read your investigation about health care and debt on NPR鈥檚 site (鈥Diagnosis: Debt: 100 Million People in America Are Saddled With Health Care Debt,鈥 June 16). However, it seems the story鈥檚 focus is wrong. It shouldn鈥檛 be about how we pay for these astronomical medical bills but why are they so high to begin with? How do hospitals get away with their fees? For example, my daughter, who is 7, has been to the hospital/emergency room five times in her life. Each bill has been completely different with no rhyme or reason. The latest one was $7,000 for about a three-hour ER visit and for two IVs! It鈥檚 the highest bill we have ever seen, and that includes a two-night stay at a hospital. In addition to this bill, collections called us 鈥 and it hadn鈥檛 even been 60 days since our visit and had been only a few weeks since the hospital visit. So now our credit score could be affected, and we haven鈥檛 even had a chance to review or figure out how to pay this bill. Would love all this explained.
鈥 Ilyssa Block, Kansas City, Missouri
A Hard-Learned History Lesson
Although I liked the article by Noam N. Levey and Aneri Pattani on people burdened by medical debt (鈥Diagnosis: Debt: Upended: How Medical Debt Changed Their Lives,鈥 June 16), it uses the term 鈥済randfathered in.鈥 This term was used as a rule to prevent Black people from voting after the Civil War. Please make an effort to refrain from using this offensive term.
鈥 MB Piccirilli, Portland, Oregon
鈥 Andrew Gallan, Boca Raton, Florida
Steering Clear of Predatory Billing
Every month I see and hear these 鈥淏ill of the Month鈥 stories on NPR鈥檚 webpage or broadcast on the NPR affiliate station in my area (鈥Her First Colonoscopy Cost Her $0. Her Second Cost $2,185. Why?鈥 May 31). Every month I pat myself on the back for having decided that there is no way I am ever going to put myself through so-called screenings, which are just one more avenue for the U.S. health delivery system to screw people over as that health delivery system is well aware that there is no oversight for this type of predatory billing. I can tell you at my age and with only Social Security retirement as sole income, I couldn鈥檛 ever hope to hire legal help to dispute a bill like those featured in 鈥Bill of the Month鈥 鈥 a bill like that would either cause me to have an immediate heart attack or file bankruptcy or both. Nope. No screenings. I actually have decided that, if I have any choice in the matter, I will simply forgo any so-called medical care. Obviously, if I keel over and pass out and someone hauls my sorry self into the emergency room, I won鈥檛 have the choice (except to walk out once 鈥渞evived鈥). Given the state of health care and the predatory behaviors of the bottom-lining money-hungry hospitals, clinics, and even just doctors, my choice is simply to opt out. KHN needs to use its voice to tell the U.S. medical community that people are so tired of the garbage that they simply refuse care.
鈥 Jan Baldwin, Coburg, Oregon
鈥 Terry Wilcox, Vienna, Virginia
In Michelle Andrews鈥 story about unexpected costs after a polyp removal during a colonoscopy, she states the anesthesiologist 鈥渕erely administers a sedative.鈥 This is an understatement. Anesthesiologists perform a review of the patient鈥檚 chart, see the patient pre-procedure, monitor their vitals during the procedure, and assess them post-procedurally. Furthermore, anesthesiologists are prepared to manage unexpected emergencies, including unexpected aspiration, allergic reactions, cardiac arrest, etc. This is more than 鈥渕erely administering a sedative.鈥
We keep folks from dying or having complications and train a long time to do so. The flippant manner in which our actions are framed in the article is unfortunate.
鈥 Dr. Elizabeth Leweling, Chicago
鈥 Dr. Ian Weissman, Milwaukee
As president of the American Society for Gastrointestinal Endoscopy, I listened with interest to regarding patient cost sharing for a screening colonoscopy. The segment featured patient Elizabeth Melville, who received a bill for her screening colonoscopy that involved a removal of a polyp.
I was dismayed by the segment, which included several factually incorrect and misleading statements by Dr. Elisabeth Rosenthal, and which were incredibly damaging to efforts to eliminate impediments and misinformation about screening colonoscopy. ASGE has been at the forefront of policy efforts to eliminate patient out-of-pocket costs for screening colonoscopy, including those screenings that involve the removal of a polyp or other tissue. As the segment correctly noted, the Affordable Care Act provides for coverage without patient cost sharing of preventive services that have an 鈥淎鈥 or 鈥淏鈥 rating from the U.S. Preventive Services Task Force, which includes colorectal cancer screening. Recognizing that colonoscopy is the only cancer screening modality that also allows for actual removal of precancerous lesions in real time (and thus preventing the cancer), it is particularly important that patients and consumers understand the facts.
Following passage of the ACA, legislative and regulatory corrective actions have been necessary to ensure that patients who undergo a screening colonoscopy that includes a polyp removal are not stuck with a surprise bill. As noted, screening colonoscopy is a unique preventive service in that it not only detects cancer, but it can prevent it through removal of suspicious or potentially precancerous polyps or lesions. In 2020, Congress passed legislation that would phase out by 2030 cost sharing for Medicare beneficiaries when a screening colonoscopy turns diagnostic during the screening encounter. That means, if a Medicare beneficiary has a screening colonoscopy today and a polyp is removed, that patient is likely to have an out-of-pocket payment obligation.
The difference in cost-sharing rules for commercially insured patients and Medicare beneficiaries has created confusion for patients, and the changes in regulation have created complex billing scenarios. Dr. Rosenthal referred to billing for colonoscopy as a 鈥済ray area.鈥 This is not a gray area to ASGE, as coding rules are clear. But there are scenarios that could impact whether a patient has an out-of-pocket obligation for a colonoscopy. For example, often insurers will not cover a screening colonoscopy without cost sharing if the screening occurs less than 10 years after the patient鈥檚 previous colonoscopy. These shorter screening intervals typically occur when a patient is considered high-risk, or if there was a finding during the previous colonoscopy, such as a polyp, as used in your illustration. Many insurers regard these colonoscopies as 鈥渟urveillance鈥 or 鈥渉igh-risk鈥 colonoscopies and will not cover them as a preventive screening without cost sharing. This is not the decision of the physician or hospital; this is a decision made by the insurance company.
I was particularly struck by Dr. Rosenthal鈥檚 comment that 鈥渋t is not OK to change the game in the middle of the test,鈥 which leads to a patient getting a bill. I want to be very clear that when a patient is scheduled for a screening colonoscopy, the physician performing the colonoscopy has no idea whether a polyp or tissue will be found and will need to be removed. This is not a 鈥済otcha鈥 game that physicians are playing with patients, as insinuated by Dr. Rosenthal鈥檚 remarks; there are coding and billing rules that must be followed when facilities and physicians are submitting claims to insurance companies. ASGE continually works to ensure that we educate and promulgate coding rules and updated guidance for our 15,000 members worldwide.
The cost-sharing policy for colorectal cancer screening, and screening colonoscopy specifically, is complex and confusing. We are disappointed that NPR did not use the segment as an opportunity to work through the complexity to provide consumers with a better guide of questions to ask their insurance company before scheduling a colonoscopy, including whether a screening colonoscopy performed at an interval of less than 10 years will be covered under their health plan without cost sharing.
鈥 Dr. Bret T. Petersen, ASGE president, Rochester, Minnesota
鈥 Ryan Holeywell, Washington, D.C.
Taking the Doctor鈥檚 Advice
Dr. Taison Bell was wonderful to listen to (鈥Watch: UVA Doctor Talks About the State of the Pandemic and Health Equity,鈥 May 26). I really appreciated his presentation and the valuable things he had to say. Thanks for including it in your KHN mailing!
鈥 Jan McDermott, San Francisco
鈥 Dr. Taison Bell, Charlottesville, Virginia
Mad Over 鈥楴ew MADD鈥 Coverage
This article is grossly inaccurate and insulting (鈥The New MADD Movement: Parents Rise Up Against Drug Deaths,鈥 May 23). Most fentanyl users are not all-star athletes or honor students. Their parents are not more educated than the parents of addicts. And the parents of addicts have been mobilized for years, with many feeling that the fentanyl movement has distracted attention away from needed health care. The article says that the drugs are being introduced by Mexican cartels that seek vengeance against low-level dealers, many of whom are just friends getting things for one another. The article distinguishes between drug users and fentanyl 鈥渧ictims,鈥 creating and reinforcing the stigma these groups claim to be trying to eliminate. It does a great disservice to those of us who lost children to addiction and overdose, and is insulting to our children and to us as parents. Thank you.
鈥 Susan Elamri, Detroit
鈥 Paco Balderrama, chief of police, Fresno, California
When 鈥極verweight鈥 Is 鈥楴ormal鈥
Quoting from the article 鈥鈥楢lmost Like Malpractice鈥: To Shed Bias, Doctors Get Schooled to Look Beyond Obesity鈥 (May 24): 鈥淩esearch has long shown that doctors are patients who are overweight or obese, even as nearly three-quarters of adults in the U.S. now fall into one of those categories.鈥
Perhaps the answer is to change the scale of weight. Why do 25% of adults get to be called 鈥渘ormal鈥 and 75% of adults are 鈥渙verweight鈥? Let鈥檚 base the decision on reality-based observation!
鈥 Leslie Rigg, Lake Worth Beach, Florida
鈥 Dr. Stewart Lonky, Los Angeles
Innocent Until Proven Otherwise
I wanted to raise a concern about the story 鈥鈥楧esperate Situation鈥: States Are Housing High-Needs Foster Kids in Offices and Hotels鈥 (June 1) 鈥 and it鈥檚 certainly not unique to your story. It says:
鈥淭hese children already face tremendous challenges, having been given up by their parents voluntarily or removed from their homes due to abuse, neglect, or abandonment.鈥
Sometimes, of course, that鈥檚 true. But no reporter would write that every person in jail is a criminal. Many are awaiting trial and can鈥檛 make bail. Similarly, children can be in foster care for weeks, even months before any court ever determines if they have been 鈥渁bused鈥 or 鈥渘eglected.鈥 Until then, they are in foster care because their parents have been *accused* of abuse or neglect.
(Also, by the way, neglect laws are so broad and vague that often what the parent really is guilty of is poverty 鈥 but that鈥檚 another issue.)
鈥 Richard Wexler, executive director of the National Coalition for Child Protection Reform, Alexandria, Virginia
[Editor鈥檚 note: Thanks so much for your insight. The article has been updated to reflect that the parents are absent 鈥渄ue to accusations of abuse, neglect, or abandonment.鈥漖
鈥 Jeff Amy, Atlanta
Key to Harm Reduction: Buy-In From People With Addiction
With overdose deaths skyrocketing to never-before-seen levels, the United States needs harm reduction strategies to protect the health and wellness of Americans. In 2020, 41 million Americans needed substance use treatment within the previous year; however, of those who needed such treatment but did not receive it at a specialty facility, did not feel they needed it. Although America has a troubling treatment gap exacerbated by systemic legal and regulatory barriers to evidence-based addiction care, most people who need substance use treatment don鈥檛 want this treatment as it is currently being offered.
To support our friends and family members living with addiction, our system must also embrace harm reduction approaches that engage people who use drugs (PWUD) before they are ready for abstinence-based treatment (鈥As Biden Fights Overdoses, Harm Reduction Groups Face Local Opposition,鈥 June 14).
Harm reduction saves lives. Drug checking services and naloxone distribution prevent overdose deaths, while syringe and related service programs help stop the spread of infectious diseases such as HIV/AIDS and hepatitis. These are all worthy ends in themselves, but harm reduction has the further benefit of building a meaningful alliance between health care professionals and PWUD. With this therapeutic relationship, PWUD have facilitated access to high-quality, evidence-based treatment and services when they become ready for this help. It鈥檚 an obvious point, but too many people overlook the fact that a person can鈥檛 receive treatment or enter recovery if they鈥檙e dead.
As a physician, I swore an oath to do no harm 鈥 not to do nothing. Failing to embrace and expand harm reduction efforts, by definition, leaves too many of our friends, family members, and loved ones at an unacceptable risk of dying. The dichotomy between offering more addiction treatment and providing PWUD with the tools they need to live healthier lives is a false choice. The United States must simultaneously invest in treatment expansion and increase the availability of low-threshold harm reduction services; otherwise, I fear the country鈥檚 addiction and drug overdose crisis will continue to get worse.
鈥 Dr. Brian Hurley, president-elect of the American Society of Addiction Medicine鈥檚 Board of Directors, Los Angeles
鈥 Deni Carise, Philadelphia
How to Beat the Opioid Epidemic
Do you want to control the scourge of fentanyl in America (鈥The Blackfeet Nation鈥檚 Plight Underscores the Fentanyl Crisis on Reservations,鈥 May 25)? There are two options:
1. Distribute the drug solely by the government, ensuring its purity, proper dosage, and safe setting for the user, providing real-time overdose care and optional consulting for anyone who wants to quit, all for free.
2. Make some nonaddictive antidepressants (generally SSRIs, or selective serotonin reuptake inhibitors) less restrictive. You know, how health care in your country is expensive, visiting a psychiatrist or psychologist, refilling, blah-blah. I know, the nation who can鈥檛 agree on banning AR-15s from being sold to 18-year-olds won鈥檛 agree on this.
What if you let people have some SSRIs over the counter? These are not recreational, are generally safe (way safer than opioids), and do help with anxiety. Hey, what drives people to opioids? Aren鈥檛 anxiety levels at their highest all across the globe?
Also, the drugmaker mafia will support it.
Just as we have embraced over-the-counter drugs for widespread diseases like colds, we might adopt the same concept in mental health care as well. Anxiety is becoming more widespread compared with colds (my gut says).
鈥 Alireza Mohamadi, Tehran, Iran
鈥 Keith Humphreys, Stanford, California
Dust-Up Over Pollution Coverage
This article appears written from a lopsided viewpoint (鈥Some People in This Montana Mining Town Worry About the Dust Next Door,鈥 June 8).
Very few cities pass the World Health Organization鈥檚 unrealistic threshold of 5 micrograms per cubic meter, and why would you get a mechanical engineer to provide input on environmental issues? Why, because the real environmental specialist said this was not an issue? As for dust on a picnic table, that is a horrible example. We get dust on our picnic table anytime the wind blows, and we don鈥檛 live by a mine. Maybe WHO should recommend that the wind stop blowing because it causes dust.
From the : 鈥淚n 2019, 99% of the world population was living in places where the WHO air quality guidelines levels were not met.鈥 This is not a reasonable standard and was selected by bureaucrats that are out of touch with life and the real world. All of the real information and statistics say there is not a problem, but your article makes a problem where one does not exist and people who are not willing to fact-check you will think聽there聽is a problem. All these people with health issues are unfortunate and that鈥檚 very sad, but people everywhere have sad health issues. Stick to the scientific facts and real monitoring numbers, and don鈥檛 drag 鈥淭he Sky Is Falling鈥 people into news articles. Facts matter!
鈥 John Utaz, Salt Lake City
鈥 Cat Rushmore, Glasgow, Scotland