Health bill threatens to bankrupt man

A year ago, Tom Carlo's back was killing him. And now it's simply threatening to send him into bankruptcy.

Carlo, 63, has struggled for more than 40 years with back pain, since falling out of the second floor of an Air Force barracks in 1968, when his unit was under attack in Vietnam. Last spring, he was unable to sit for very long because of the pain, and he was taking drugs that were wrecking his stomach. He opted for a spinal surgery -- his third -- recommended by a doctor.

The surgery was supposed to lead to a cure from pain, and Carlo has found some relief. But his financial problems were just beginning. In June, his insurance carrier, CareAllies, OK'd the operation. In July, Carlo checked into Winthrop-University Hospital in Mineola. In August, CareAllies reversed its decision and denied payment to the two surgeons who operated.

"When the insurance company gives you the OK, you figure, let's do it," Carlo said. "Two months later they told me I should have tried physical therapy or shots -- well, it's too late now."

This is an unpredictable moment in the business of medicine, with costs soaring, the federal government rewriting rules, and insurance companies and doctors vying for some control over the inevitable changes. But people like Tom Carlo, a retired U.S. Postal Service letter carrier who drives a school bus in Garden City, shouldn't have to bear the brunt of these tectonic shifts. He appears to be caught by an insurance carrier balking at astronomical fees from an out-of-network doctor.

New York, unlike other states such as New Jersey, doesn't have a law against excessive billing.

CareAllies, a unit of Cigna, provides health services under contract to the National Association of Letter Carriers. Carlo's plan is a PPO -- a preferred provider organization -- which supposedly gives him the freedom to shop around for a surgeon, provided he shoulders a greater share of the bill. PPOs often pay 70 percent of the "usual and customary" costs of out-of-network care.

The whopper surgeons' bills may have had something to do with CareAllies' change of heart. The primary surgeon billed $355,000, and the assistant surgeon $160,750. Enough to pay for Carlo's tidy Wantagh house and then some.

He has appealed the decision up the chain to the U.S. Office of Personnel Management, which is ultimately responsible for the letter carriers' insurance contract. A representative of that office didn't return phone calls for this story. In a letter to Carlo, CareAllies said that his records had been checked as part of a random audit, and that an independent reviewer had determined the surgery was not medically necessary. Winthrop Hospital and Cigna said they will look into Carlo's case.

In Nassau County, the "usual and customary" rate for this surgery would have ranged between $49,750 and $64,750, according to Empire BlueCross BlueShield. Dr. Scott Breidbart, Empire's chief medical officer, said that out-of-network billings are an area of heated dispute between insurance companies and doctors.

Normally, the insurance company and the doctor would try to negotiate. But Carlo has been appealing CareAllies' decision for 10 months. If the Office of Personnel Management denies his claim, the next resort will be to sue in federal court -- an exhausting and expensive prospect.

Carlo's tale isn't unique. Medical expenses are a leading cause of bankruptcy. But it's an example of why we need health care reform. It doesn't get much worse than having a $515,750 bill dumped in your lap.

First published in Newsday

Globalization pauses to take a breath

Today's New York Times has a well-displayed story about how rising fuel prices are making it less attractive to outsource jobs overseas. Actually, New York Gov. David Paterson mentioned this in a speech last week (6th paragraph), predicting hopefully that companies could return to blighted upstate New York to be closer to their American customers. I think Paterson is grasping at any sign of prosperity, and Times writer Larry Rohter seems to agree (see below). Still, this trend is good news for American workers, rising from a sea of bad news for many months. Here is what the Times story says in its last two paragraphs.

But a trend toward regionalization would not necessarily benefit the United States, economists caution. Not only has it lost some of its manufacturing base and skills over the past quarter-century, and experienced a decline in consumer confidence as part of the current slowdown, but it is also far from the economies that have become the most dynamic in the world, those of Asia.

“Despite everything, the American economy is still the biggest Rottweiler on the block,” said Jagdish N. Bhagwati, the author of “In Defense of Globalization” and a professor of economics at Columbia. “But if it’s expensive to get products from there to here, it’s also expensive to get them from here to there.”

It's funny that the Times would save this downbeat angle until the very end of a very long story. I think it shows that the newspaper is as eager as the rest of us for good news.

So, here is a dose, again from Rohter:

“If we think about the Wal-Mart model, it is incredibly fuel-intensive at every stage, and at every one of those stages we are now seeing an inflation of the costs for boats, trucks, cars,” said Naomi Klein, the author of “The Shock Doctrine: The Rise of Disaster Capitalism.”

“That is necessarily leading to a rethinking of this emissions-intensive model, whether the increased interest in growing foods locally, producing locally or shopping locally, and I think that’s great."

... To avoid having to ship all its products from abroad, the Swedish furniture manufacturer Ikea opened its first factory in the United States in May. Some electronics companies that left Mexico in recent years for the lower wages in China are now returning to Mexico, because they can lower costs by trucking their output overland to American consumers.

Decisions like those suggest that what some economists call a neighborhood effect — putting factories closer to components suppliers and to consumers, to reduce transportation costs — could grow in importance if oil remains expensive.

The emergence of global supply chains is one villain cited by Robert Reich in his book "Supercapitalism," which I have just finished reading. Companies have sought low wages in China, call centers in India and the like to reduce their costs, which forces their competition to do the same. American companies seek ever-higher profit margins so their investors will stick around. It does seem that we live in a hyper-fast, hyper-competitive world now.

I think it would be a good thing if globalization were to slow down. The diaspora of American jobs overseas certainly raises the living standard of people in poor countries, and that's a good thing. But it's happening so fast that individual Americans have little time to seek other options, and it can be devastating to us and our families.

I'm thinking about a narrative writers' conference I attended in Cambridge, Mass., in 2002. Larry Summers, the Harvard president who quit after implying that women aren't as smart, gave a speech applauding globalization because it helped poor countries. He chastized jouralists for overplaying the pain Americans were experiencing as a result.

I have not done the relevant content survey. But I would bet with a high degree of confidence that reading the press generally, one would find that there was almost no discussion of the benefits in terms of international trade of making goods cheaper for people to buy and therefore making people richer. And that there was relatively little discussion of the experiences of individuals who have better jobs than they otherwise would have because of the opportunities to export created in the American economy by trade agreements, in contrast to an enormous volume of writing about jobs lost. There are almost certainly tens of thousands of jobs that have been lost because of the increases in the price of steel that were imposed by trade policies in the United States nine months ago. I would be surprised if the up-close-and-personal story of a single one of those job losses has been told. In contrast, the story of pain in Steeltown has been told again and again and again.

Meanwhile, back home in Pittsburgh, my kids were being cared for by the wife of a retired steelworker, whose company had gone under, taking his pension with it. They were living hand-to-mouth. I wanted to sock Summers, but subsequent events have done it for me. It's nice when life works that way.