Eamon Queeney for KHN
When Jerry Bilinski, a 67-year-old retired social worker, scheduled cataract surgery with Carolina Eye Associates near his home in Fayetteville, North Carolina, he expected no drama, just a future. with better vision.
Cataract procedures are among the most common surgeries in the United States – nearly 4 million take place every year – and usually take about 30 minutes under light sedation. At the same time, the surgeon scheduled the placement of a small stent inside his eye to relieve pressure from his diabetes-related glaucoma, also a routine procedure to preserve his sight.
Bilinski remembers being sedated during the operation in May and hearing a nurse anesthetist ask him if he was in pain. Bilinski said no, just some pressure on the right side of his head. He said the nurse anesthetist replied that he would increase the sedation. Although he was under anesthesia, Bilinski knew something was wrong.
“The next thing I know is there’s kind of a commotion, and I hear the doctor yelling at me, ‘Don’t move! Stay still!’ — screaming in my ear,” Bilinski said. “And then I hear the doctor say, ‘What’s that cut on your head?’
It was a small scrape — nothing serious, Bilinski said — but it wasn’t mentioned by staff when he was discharged from surgery. At home, after a nap, he woke up with blood on his pillow, and memories of the incident came flooding back.
His doctor didn’t mention anything about the incident during his post-op appointment, so Bilinski spoke about it.
“I said, ‘You know, doctor, I just have a few questions for you because I have memories of some things that happened there,'” he said. At that point, I think she probably knew the jig was up and said, “Yeah, we had a little incident. You had a little negative impact from the anesthesia.”
The operation was successful and the cut on his forehead healed. But Bilinski still wanted to know more about his reaction to the sedation. Later, when he got his medical records, he said the operation had “no complications”.
“They hid it,” Bilinski said.
Then the bill came.
The patient: Jerry Bilinski, 67, a retiree who receives traditional health insurance and a supplemental health insurance plan through UnitedHealthcare.
Medical service: Cataract removal and lens replacement, plus insertion of a Hydrus Microstent device to treat glaucoma.
Service provider: The Bilinski procedure was performed at Fayetteville Ambulatory Surgical Center by Dr. Tarra Millender of Carolina Eye Associates, a chain of medical and surgical eye care centers headquartered in Southern Pines, North Carolina
Total bill: $1,805 for physician fees for cataract surgery and stent insertion. Bilinski’s share of that bill was $54. Additionally, Fayetteville Ambulatory billed Medicare $10,745 for the operation. Medicare paid the surgery center $2,377, and Bilinski’s supplemental health insurance plan paid an additional $550. Bilinski owed the surgery center $50.
Which give: Professional standards of care dictate that healthcare providers inform patients about injuries that occur during surgery. But what should happen next — whether it’s an apology or an offer to waive part of the bill — is an open question in the US healthcare system. Another question: if the injury requires treatment (if, for example, Bilinski’s cut needed stitches – it didn’t), who should foot the bill?
TJ McCaskill, chief operating officer of Carolina Eye Associates, declined a request for an interview, citing federal and state patient privacy laws, even though Bilinski allowed details of his medical case to be released to a reporter. Millender, the doctor, did not return messages from a reporter.
When patients experience adverse effects during treatment, they are generally expected to pay the price for a return to health. It might make sense if the reaction — like an allergic reaction to a new antibiotic — couldn’t have been anticipated. But what if the injuries were the result of negligence, carelessness, or a medical accident (after all, providers are human and accidents happen)?
After reviewing the details of Bilinski’s case, Arthur Caplan, professor of bioethics at New York University’s Grossman School of Medicine in New York, said he found the injury bizarre. He said he couldn’t understand why an adverse reaction to anesthesia would lead to a bloody forehead.
“That gash is pretty weird,” Caplan said. “If someone had asked me to pay a bill about this, I would have said ‘No, until we fix this’.”
Caplan said a case like Bilinski’s probably wouldn’t pose a legal risk to the supplier; most attorneys will not accept a case where the damages are likely to be low. In some cases, doctors and medical practices voluntarily give discounts to patients injured during treatment, Caplan said. A patient who suffered an infection at the site of an IV, for example, and needed a few extra days in the hospital for antibiotics might not be billed for the extra days.
“There is no standard policy,” he said. “It’s the decision of the doctor or the doctor’s office.”
Resolution: The cut on his forehead healed, but Bilinski – who has spent his career working in healthcare – felt he deserved to know what caused the injury.
“If you do medical records that aren’t accurate, it puts people at risk,” he said. “In my case, it indicates that I had a certain anesthetic at a certain dosage, which actually produced an undesirable and potentially dangerous side effect and it’s not there. And instead it says that everything is fine. went well and [I] tolerated the procedure well.”
Bilinski said he spoke with McCaskill, the head of Carolina Eye Associates, but did not receive an apology or a satisfactory explanation.
Medicare, a government insurance program that typically serves the elderly and disabled, and a secondary insurance plan that Bilinski runs at UnitedHealthcare covered most of the costs of Medicare’s negotiated rates for the surgery.
Bilinski owed his modest and predictable Medicare copayments — as most enrollees do after surgeries. But Bilinski said he believes taxpayers were misled because the management of his injury was unprofessional and Medicare paid his full costs for a procedure in which something went wrong.
He filed a complaint with the North Carolina Medical Board, which licenses doctors and investigates allegations of medical error and wrongdoing. He also filed an affidavit with the Fayetteville Police Department. (A police representative told Bilinski that this was a civil matter, not a criminal one, so outside the purview of the police department.)
A spokesperson for the medical board, Jean Fisher Brinkley, declined a request for an interview, saying the agency was not publicly discussing ongoing investigations.
“How many other people has this kind of thing happened to?” said Bilinsky.
The takeaway: If you have questions about an unexpected event that occurs during medical treatment, ask for a copy of your complete file. In Bilinski’s case, her records said there were “no complications” with the procedure. That clearly wasn’t entirely true, Bilinski said.
Patients injured during a procedure can seek reimbursement or request a waiver from insurance copays, Caplan said. They can also file a complaint with a state medical board to try to find out what happened and whether professional standards were violated.
Medical care is often unpredictable, but if a preventable injury occurs, the patient shouldn’t necessarily have to pay to fix it, Caplan said.
Patients often have to hold the bag for extended hospital stays and restorative treatments for events that are not their fault. They might have to stay in hospital for three extra nights, over a weekend, for example, because a social worker was not available to schedule discharge on Friday. If a defective joint implant is placed in a knee, replacement costs are often borne by the patient and the insurer. (Although legal action may eventually lead to a full or partial refund from the manufacturer, such cases typically take years to reach a judgment.)
Patients should fight back and refuse to pay such bills, advises Caplan. Likewise, doctors in such situations should be fully transparent about what happened and why. Although some physicians may be concerned about the risk of a malpractice lawsuit, studies have shown that a simple admission, combined with an apology, often extinguishes a patient’s anger. Such apologies are required by professional ethics, and in some states are also required by law.
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