Bad news for one unlucky patient is also a stark example of how dysfunctional U.S. health coverage can be.
By Sarah Kliff
John Druschitz spent five days in a Texas hospital last April with fever and shortness of breath. It was still the early days of the pandemic, and doctors puzzled over a diagnosis.
They initially suspected coronavirus and hung signs outside his door warning those entering to wear protective equipment. Mr. Druschitz had already spent two weeks at home with worsening symptoms. He recalls one doctor telling him, “This is what it does to a person.”
Ensuing lab work, however, was ambiguous: Multiple molecular tests for coronavirus came back negative, but an antibody test was positive.
Doctors found that Mr. Druschitz had an irregular heartbeat and blood clots in both his lungs. They sent him home on oxygen, and ultimately did not give a coronavirus diagnosis because of the negative tests. He didn’t think much about the decision until this fall, when he received a $22,367.81 bill that the hospital has since threatened to send to collections.
“I thought everything was good to go, and then I get the first bill in October saying I owe $20,000,” said Mr. Druschitz, 65, who retired in December.
Working with a patient advocate, he discovered that his debt stemmed in no small part from his diagnosis. Not having a coronavirus diagnosis disqualified his hospital from tapping into a federal fund to cover bills for people who do.
Mr. Druschitz ultimately fell slightly short of qualifying for multiple federal health programs that would have paid for his care if the details had been slightly different. Health policy experts see his experience as a case study in how easily patients can fall through the cracks of America’s fragmented health insurance system.
“It shows the insanity of having a health care system where literally the clinical diagnosis determines whether someone is going to get bankrupted,” said Dr. Ashish Jha, dean of the public health school at Brown University.
Most developed countries have a national system that provides health coverage to all residents. Some, like Britain, use a public health plan. Others, like Switzerland, rely on private insurers to cover all citizens with robust medical benefits.
The United States’ health coverage system is more of a patchwork: People qualify for different health programs depending on their age, employer and health status. The Affordable Care Act has increased coverage in recent years, but 29.6 million Americans still remain uninsured.
Mr. Druschitz was briefly among those uninsured millions. On the day the hospital admitted him, he was 64 years old, 23 days away from qualifying for Medicare. He had mistakenly terminated his private health plan, which he had purchased on the Obamacare marketplaces, one month early.
“My whole life I had insurance except this one month when all this happened,” he said.
If Mr. Druschitz’s hospital visit had happened 24 days later, Medicare would have covered the vast majority of the costs regardless of the diagnosis.
Because he was uninsured, the hospital did send a letter less than a week after discharge offering to “help apply for medical assistance through various government programs.” Mr. Druschitz hadn’t yet received a bill at the time. When it did arrive, six months later, he was told that offer had expired.
A third source of federal funding would have become available if the hospital had determined he had coronavirus: the Covid-19 Uninsured Program.
Created last spring, the program pays the medical bills of coronavirus patients who lack health coverage. It reimburses hospitals at the same prices that Medicare pays medical providers.
It has faced some criticism from hospitals and patients for being too narrow, and for covering bills only where coronavirus is the primary diagnosis. A patient with a primary diagnosis of respiratory failure and a secondary diagnosis of coronavirus would not qualify, for example.
The Health Resources and Services Administration, which runs the federal fund, does not have plans to change that policy. So far, it has spent $2 billion to reimburse health care providers for the bills of uninsured coronavirus patients.
“The H.R.S.A. uninsured program is a voluntary claims program, not an insurance program,” said Martin Kramer, an agency spokesman. “The scope is narrow, and its primary function is to help combat Covid-19 by removing financial barriers.”
The hospital that treated Mr. Druschitz — the Baylor, Scott and White Medical Center in Austin, Texas — did not submit his charges for reimbursement because of the negative coronavirus tests, said Julie Smith, a spokeswoman.
“The nucleic amplification Covid-19 test is the standard to diagnose or rule out Covid-19,” she said in an email. “Because the diagnosis for this admission was not Covid-19, his hospital stay is not eligible.”
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The positive antibody test, she said, “may indicate a previous infection.”
The hospital has submitted other claims to the uninsured fund, and has so far received a quarter-million dollars in reimbursement. It has applied a 40 percent uninsured discount to Mr. Druschitz’s $34,058 charge. It’s not clear from his billing codes whether the hospital is pursuing him for a larger amount than what the federal fund for uninsured people would have paid.
Multiple clinicians with expertise in Covid-19 reviewed Mr. Druschitz’s medical records for The New York Times. They said that his case was ambiguous: It wasn’t completely clear whether coronavirus had caused his symptoms.
“There is a good chance that he did have Covid-19, and I base that on the fact that his symptoms are consistent with that diagnosis,” said Dr. Alexander McAdam, an associate professor of pathology at Harvard. “The lab data, however, don’t definitively demonstrate that.”
Dr. McAdam was not surprised that a Covid test at the hospital could come back negative even when Mr. Druschitz was very ill.
“People can have persistent symptoms even after the virus is no longer detectable,” he said. “It could be the virus is now in the lower respiratory tract but not the upper,” meaning it might not show up on a test.
But he and Dr. Jha, who also reviewed the records, said they would have expected an earlier test, conducted 10 days before his hospital stay, to be positive. It would be unusual for a test to be negative at that point, as Mr. Druschitz’s was, when he was already symptomatic.
“It’s more likely than not that he did not have Covid, but it’s certainly not a zero chance,” Dr. Jha said. “The fact that it will end up making a big difference in the bill is really problematic.”
Mr. Druschitz’s primary care provider, Dr. Craig Kopecky, who saw him shortly before and after the hospital visit, says that the diagnosis is wrong and that his patient did have coronavirus.
Dr. Kopecky initially suspected bronchitis when Mr. Druschitz came to his office in mid-April with a cough and some shortness of breath. He began to suspect Covid in a follow-up telemedicine visit 10 days later.
“At that point he’d started to lose some of his sense of taste,” he said. “I couldn’t examine him because it was telemedicine, but I could clearly hear him struggling to breathe.”
Dr. Kopecky submitted his bills for Mr. Druschitz’s treatment to the federal fund for uninsured patients, and said he received reimbursement.
The patient advocate that Mr. Druschitz retained, Jan Stone of StoneWorks Healthcare Advocates, has asked the hospital to re-evaluate the diagnosis. She’s now running up against a deadline: Hospitals have one year to submit claims to the uninsured fund. This means the hospital would need to file for reimbursement within the next six weeks.
“The clock is definitely ticking,” she said.
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