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Trip to the emergency room for a toothache costs man more than $1,300

ST. PETERSBURG — Kalyan Sircar took his throbbing toothache to the emergency room and left with two prescriptions and bills for $1,367.30.

He spent 10 minutes with a doctor.

"I learned my lesson — never enter the emergency room alive,'' he said.

A walk-in clinic might have cost a few hundred dollars. So how did Sircar wind up with bills three or four times that?

The answer offers an instructive glimpse into a persistent anomaly in America's health care system: Fragmented payment systems, plus haphazard decisions by patients, can create odd results.

For Sircar, it started with a cavity.

• • •

Sircar, 54, is a software developer with Serve Enterprise in downtown St. Petersburg. He is married with two daughters. In February, he went to the South Pasadena office of Coast Dental, a chain of clinics in Florida and Georgia, which told him he needed two fillings, two extractions and gum therapy.

He returned for gum therapy, but not the rest. The projected cost, he says, was about $3,500. "I don't have that much money,'' he said, and no dental insurance.

On July 6, the right side of his face began to swell. Pain set in. It turned out he had an infected cavity. But at that point, all he knew was that he had one heck of a toothache.

His dentist was off, so an assistant referred him to two other Coast Dental locations. Both were stacked up with patients.

So a Coast Dental employee told him to head for the ER.

"His symptoms could be life-threatening,'' explained Chris Duffy, Coast Dental's spokeswoman. Extreme dental infections can close a windpipe.

"With swelling and the level of pain he described and what we knew about his dental history, we knew he had to be seen immediately," Duffy said.

Neither Coast Dental nor Sircar considered dental walk-in clinics, which could treat him for a few hundred dollars.

Sircar of St. Petersburg says he didn't know much about them and Coast Dental couldn't vouch for them.

"We wouldn't have any way of knowing … if he could get the help he needed,'' Duffy said.

Sircar waited for about an hour at Bayfront Medical Center's emergency room before he was examined for about 10 minutes and sent on his way. He needed none of the expensive tests that emergency rooms can provide. Dr. Krista Gillis prescribed a painkiller and antibiotic.

A week later, the swelling had subsided enough that his dentist, now back in the office, could extract the troublesome molar.

By law, every ER must treat anybody who asks for care, no matter how mild or serious the symptoms. And bacterial dental infections should not be taken lightly, said Bob Thornton, Bayfront's chief financial officer.

"Our physicians did a thorough review and ruled out that it wasn't something more serious,'' Thornton said.

Like many Americans, Sircar is under-insured. His Benefit Alliance insurance policy pays $250 toward emergency room charges. That did not cover Gillis' $298 doctor bill, much less Bayfront's $1,069.30 charge.

Sircar said he plans to make payments because he doesn't want a black mark on his credit. But he thinks the ER charge was way too high.

"If I go to an ordinary doctor, maybe it will cost me $100 or $150. I'm willing to pay $300, but $1,400 is too much.''

Bayfront is a trauma center, which means it handles complex cases with expensive equipment. But even accounting for that, Sircar's charge exceeds Bayfront's actual cost by several times over, said Thornton.

There's a reason for that.

Lots of poor people use the ER — both for true emergencies and for minor ailments like cuts and scrapes. Many lack primary care doctors and, for whatever reason, don't use walk-in clinics that could help them quicker and cheaper.

Some patients have Medicaid, but Bayfront usually loses money on them because the rates are too low, Thornton says.

Medicare usually covers the hospital's costs, but not much more. And some patients don't make the copayments that Medicare calls for.

Most private insurance companies negotiate rates in advance. No matter what Bayfront charges, the hospital collects only the negotiated rate.

But a few insurance companies handle reimbursement differently. Instead of negotiating rates in advance, they pay a percentage of the charge and that sets up a cat-and-mouse game: Bayfront raises its charges and these insurance companies respond by lowering their percentages.

The gap gets wider and wider until charges eventually bear no relationship to actual costs.

This disparity usually doesn't matter, because so few people pay the full charge.

Occasionally, a Kalyan Sircar comes by. No one negotiated in advance for him.

And that's how a $200 toothache turns into a $1,367.30 one.

Other hospitals use similar billing systems. Tampa General Hospital, for example, sets its charges way beyond its costs.

People who use the ER for nonemergency care could face a big financial hit, says TGH chief financial officer Steve Short. More importantly, a doctor's office or clinic might be a better option in those cases.

"Every (ER) patient gets triaged,'' Short says. "When we see them is based on the severity of their illness. People end up waiting 10 to 12 hours and it becomes a burden to the flow of patients.''

Trip to the emergency room for a toothache costs man more than $1,300 11/13/11 [Last modified: Monday, November 14, 2011 8:17am]
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