I didn’t expect to be billed. I thought emergency care in the Britain’s National Health Service was free, particularly for a British citizen like me.
But after falling off a horse when I was on vacation there last September and landing in the hospital under the care of a “polytrauma” team, I got a call. It was from Jacqueline Bishop, the hospital’s overseas visitors coordinator. She told me the NHS is a residence- not citizenship-based system, and since I live in the United States, I’d be treated like any other foreign visitor: I would have to pay full freight.
With visions of U.S. health-care dollars dancing in my head, I lost a little sleep that night. I thought about the bills from the orthopedic surgeon (for my broken pelvis and ribs) and the charges from the general surgeon (for my punctured lung); I imagined the costs of the CT scans and bedpans, of the blood thinners and painkillers. And I felt a wave of relief the team had decided to treat my injuries “conservatively.” I would be spared the expense (and pain) of surgery.
When the bill arrived, I was in for another surprise. It was a “package” deal comprising just six items, and it didn’t separate the hospital from the physician fees. There were no charges for the army of attentive doctors and nurses who met me in the ER, nor for the monitoring, blood tests and drips there. From the moment I was admitted on a Wednesday morning until the following Saturday, when I was discharged to recuperate, the bill came to 3,464 pounds.
Talk about sticker shock. That would have covered little more than one day’s stay in a U.S. hospital, which a 2012 report by the International Federation of Health Plans, the global network of health insurers, put at $4,287. That allows for an array of hospital charges such as labs and imaging but not, of course, physician fees. (The IFHP based its number on the average negotiated amount actually paid by U.S. insurers, not the far higher prices providers typically charge.)
Britain, like other industrialized countries, spends far less on health care than the United States. A 2012 analysis of care in 13 countries showed “health care spending in the U.S. dwarfs that found in any other industrialized country.”
“Higher prices” and “greater use of more expensive medical technology” are key factors in that spending, according to the analysis, which was authored by David Squires of the Commonwealth Fund, a New York-based group that supports independent health-care research.
Underlying it all is a philosophical difference, explains Uwe Reinhardt, an expert on health-care economics at Princeton University.
“Unlike England, that has a budget, we don’t have any of that” in the United States, he said. “It’s absolutely honorable here for everyone in the chain to try to extract as much money as they can from the economy, and that adds up – the drug companies and the medical device makers and then the hospital, which makes the biggest markup it can. Rehab, home health care, you name it.”
Take my CT scans. Tom Sackville, chief executive of the IFHP, views scanning as a good illustration of pricing differences.
“For the same machinery in a similar facility with the same level of staffing – assistants, nurses and so on – there are very different costs,” he said.
According to IFHP data, a pelvic CT scan costs $175 in Britain’s NHS, while the average price paid to a U.S. hospital is $567 – and many insurers shell out far more.
Not that Sackville, a former Conservative government health minister, is a fan of Britain’s taxpayer-funded system. “It’s a classic rationed system,” he said, “with delays and waiting lists.” Those are well-publicized criticisms of the cash-strapped NHS, which prioritizes care according to medical urgency and sometimes fails to meet guidelines for acceptable waiting times for non-urgent care.
As a patient with potentially life-threatening injuries, I experienced none of those problems. But I did wonder where the NHS was saving money that might have been spent on me if a horse had bucked me off in rural Virginia rather than in rural England – and what effect that had on my treatment.
In the Royal Sussex County Hospital, I shared a bay in the trauma ward with four other women. One night, when beds in the men’s bay were in short supply, a nurse asked if a man could join us. Nobody objected, so he was wheeled in behind a heavy screen to give us (and him) some privacy.
Would that have happened in America? I doubt it. Did it affect my care? I don’t think so. The other patients were a more or less welcome distraction, though the nights were noisy.
More important, I didn’t really understand who was in charge of my care. On the few occasions I had a question, the nurses seemed to turn to a different doctor every time. My discharge papers were signed by a physician I don’t even remember having met. The whole approach left me unclear about who the point person was if anything went wrong.
But when I returned to the States, I heard similar concerns.
And despite my initial relief at having avoided surgery, I continue to wonder whether anything more should have been done. Six months on, one bone in my pelvis hasn’t fully healed. It still hurts.
Several British doctors suggested if my accident had happened in America I would likely have had surgery to insert screws and plates and fix my fractures. In the U.S. fee-for-service system, the argument goes, doctors have an incentive to treat what their salaried British counterparts believed would heal with time (and without the risks of cutting me open).
One British friend, a surgeon, thought I could find a range of legitimate opinions, which is pretty much what I learned from Greg M. Osgood, who took over my care when I returned to this country. He’s an orthopedic trauma surgeon at Johns Hopkins Hospital (where, incidentally, technicians have taken three X-rays of my pelvis on each outpatient visit, as opposed to the single X-ray taken at each follow-up visit in Britain).
My case lay in a “gray area,” Osgood said. “Pelvises like to heal,” he told me. “They have a good blood supply.” And for the one bone that continued to cause discomfort, he recommended ultrasound to hasten healing rather than a trip to the OR.
And the multiple X-rays? Higher cost, more radiation, yes. But they offer a more complete view of the pelvic ring, and doctors here don’t want to risk missing a thing. “A large part of what U.S. doctors do is medical-legal,” said Hopkins chief orthopedic resident Savyasachi Thakkar, alluding to the costs of medical liability, which are far higher here than in Britain.
Both doctors exemplify the sort of individualized attention a place such as Hopkins stakes its reputation on. As Sackville put it, “About half the population in America get the best treatment in the world.”
As it turned out, I needn’t have wasted a minute worrying about the bills I was running up in Britain. My husband confirmed very quickly with our U.S. health insurance company that it covered treatment overseas.
But the possibility of foreigners’ freeloading on the NHS has become politically contentious. “What we have is a free National Health Service,” Prime Minister David Cameron said last year, “not a free international health service.”
Once back in the States, I got another surprise: a letter from the Royal Sussex County Hospital saying my bill hadn’t been paid, along with a note saying failure to pay could result in “a future immigration application to enter or remain in the UK being denied.”
What followed was the flurry of phone calls and emails familiar to any American who has haggled with a health insurance company.
In mid-March, payment finally came through – and I contacted Bishop, who handles overseas visitor billing for the Royal Sussex County and five other sites, to let her know.
In the United States, billing is a business unto itself. “A typical academic health center will have 300 to 400 billing clerks,” Reinhardt said. “And each will have his counterpart in the insurance industry. To handle the billing of one hospital, you need 800 people. That would be unthinkable in England.”
My $5,572.54 British bill might have ballooned here, not only because of “higher prices” and “greater use of more expensive medical technology,” but also because of the administrative quagmire of U.S. billing – costs Reinhardt estimates account for a quarter of U.S. health spending.
As visions of those U.S. health-care dollars spiraled upward in my head, I realized how fortunate I was to have received the care Britain provides for all its people and how lucky I am to be in what Sackville described as the half of the American population that gets the best treatment in the world.
Because ultimately there’s the rub.
What about the other half?