The hug shortage, the new abnormal, and the $7,000 COVID test. What we’ve learned in SEASON-19

Dan: Uché Blackstock is a doctor who works at an urgent care clinic in Brooklyn. In the middle of March, the place transformed in a matter of days. 

Uché Blackstock: It was almost like a wave. My colleagues, been practicing for about 35 years. They’ve never seen anything like this. 

Dan: Suddenly, they were seeing almost nothing but COVID patients. But that wasn’t all.

Uché: The demographics totally shifted. typically care for a very racially, socioeconomically diverse group of patients. when the pandemic hit it became mostly black and Latin X patients

Dan: Uché Blackstock had been PLANNING on big changes to her work life this year. 

In December, she left a faculty job at NYU Medical School to focus on an organization she founded called Advancing Health Equity— aiming to fight structural racism in health care.  

She started working at the urgent care clinic part-time as part of that change, and she was expecting it to be the easy part, after practicing in emergency rooms for more than a dozen years. 

Uché Blackstock: I thought that I would just be seeing really like benign, minor cases, but then the pandemic  hit.

So suddenly: One, it was pretty intense. And two, it was a new demonstration the reasons she’d left NYU to focus on advocacy in the first place: 

Uché Blackstock: This pandemic has really exposed and magnified our racial health disparities and inequities.

Dan: And she was seeing it first hand.

So, this year has brought DIFFERENT bunch of changes than Uché  Blackstock had imagined. 

I can relate. You probably can too.  

This is An Arm and a Leg— a show about the cost of health care. I’m Dan Weissmann.  

In the middle of March, I was putting final toUché s on some big plans for this year, starting with a big season I was gonna release in June.

Instead, we started putting out episodes EVERY WEEK, and called it SEASON-19, after COVID-19. We’re wrapping it up with this episode.  

I’ll have some news at the end about what comes next.

And as we wrap up this all-COVID popup season, I want to hit the pause button, and ask:  OK, what’s been happening here?  What is all this COSTING us? What have we learned so far?  What could possibly be coming next.

Those are big questions— as usual, I’m gonna look at them through individual people’s stories. 

We’re gonna talk with three people who’ve been seeing this crisis from totally different places.  

One is a nurse in Texas. Her job has been transformed in a bunch of ways: Some are sad and scary, some are sweaty and uncomfortable, and some… may not be entirely bad in the long run. We’ll see. 

Another is one of the country’s top health insurance experts— who says HER initial ideas about the best  way to address the costs of the pandemic were … WRONG. 

And one is Uché  Blackstocklackstock. 

The pandemic— and what she sees at that urgent care clinic first hand— has given her a LOT to talk about in her work as an advocate. 

In every shift at the clinic, she’s seen what big-picture data show: Black and brown people are getting hit especially hard. Her patients were folks getting caught where the virus could easily find them. 

Uché  Blackstock: 00:04:21 Many of them were essential workers or service workers. people who could not work from home, people who live in a crowded apartment, those were the patients that I was seeing in my practice.  

So Uché  Blackstocklackstock has had a LOT to say. And she’s found places to say it. She’s been making the rounds of national media, contributing to policy journals, and she’s a force on Twitter.

And when I talked with her in May, she was balancing all of that against whatever her three and five year old children happened to need that morning. She says the five year old is doing “remote learning.”

Uché  Blackstock: You know, the new abnormal,

Dan: Yeah. Right. Running homeschool, I mean, I’m running homeschool for a fifth grader, which is way easier. How do you run homeschool for a five-year-old?

Uché  Blackstock: You do it in like short amounts of time, that probably 15 minutes because his attention span isn’t that  long.

Dan: This is where I’m just like, hi, get me the Netflix channel. There’s like all Mr. Rogers and Sesame street. and just turn it on 

Uché  Blackstock: Exactly. I actually just gave him the iPad

Dan: There is no end to the questions this pandemic raises for Uché  Blackstocklackstock and her work.

There are specific innovations she’d like to see in the near term:  For instance, since Black and brown communities have been hit especially hard with both the health effects and the economic effects of the pandemic: How about some contact-tracing jobs to deal with both at the same time?

OK, now  on to our nurse-practitioner in Texas. She works for a clinic— part of a chain— that specializes in primary care for seniors.  Her employer has a STRICT rule: No talking to reporters, So to protect her, I’m not even using her real first name. She asked me to call her Amber. 

When we talked for the first time, in March, I didn’t think we’d be talking about COVID. She’d gotten in touch because her dad had just been hospitalized for something else— he’s an immigrant with a green card, but without health insurance. She was advocating for him with the hospital staff — trying to maneuver to protect his health and his bank account. 

But we ended up talking about COVID a bunch, because it was totally changing her job. 

This was the day after Texas Governor Greg Abbott put the state on lockdown.  And her clinic had a new rule: Nobody with a respiratory issue could come inside —because they might have COVID and infect everybody there. 

Amber: but there are some patients where I’m like, you have congestive heart failure and I I have to listen to your lungs. 

Dan: And so…

Amber: I’ve had to listen to people’s lungs out in the parking lot where we’re right by a major freeway. Like I can’t really hear.

We talked again last week, about two months after that first conversation.  She was still going outside to see patients. They’re pulling up BEHIND the building, where it’s quieter, but.. 

Brenda: And now it’s summer in Texas. So I have to go out and like 95 degree weather to see patients outside.

Dan: It’s a work in progress. And it’s only May. Texas hasn’t even started to get SUPER hot yet.

On a bigger level, COVID has completely upended  her practice, and her relationships.  Except for patients with respiratory complaints— the folks she sees outside— Amber’s clinic is only doing telemedicine. And she says right off the bat, there’s a cost to her.

Brenda: Covid 19 has stolen the tiny bits of joy that I would get in seeing patients face to face.

Dan:The patients who hugged her at every visit? No more hugs. No more actual eye contact. 

Brenda: Those were things that I considered as valuable in terms that was part of my compensation package to me. You know, like the rewarding feeling. The connection, the rapport, the trust.  

Dan: She says she feels cheated. And she sees the effect on patients.  A big part of doing geriatric primary care is coaching patients to manage chronic conditions. 

She tells me about a diabetic patient who’d been doing really well.

Brenda: we had established this relationship  and we set a goal together . And he said he wanted food from a particular restaurant and I got it for him . when he met his goal.

Dan: How nice is that?  Then the pandemic came, and he disappeared. He hit Amber’s radar again recently— when he had to be hospitalized. I mean, coming in didn’t just mean he got to see Amber. The staff at the clinic had always  loaded up his pillbox; telemedicine meant he was on his own for that. 

Amber says not getting those visits BY ITSELF has sent some of her patients to the hospital— for mental health reasons.

Brenda: a lot of my patients don’t have family and we are their family, right? We’re, we’re the consistent force in their life. you know, if you’re 72 and living alone and barely making ends meet, and now you can’t even go anywhere and your doctor doesn’t want to see you unless you’re sick, you know, it’s just very depressing. So. Yeah, I’ve had to send some people to inpatient facilities because they’re suicidal.

Dan:And even for folks who don’t end up in real trouble—  telemedicine has its own, uh, challenges for her patients.

Brenda: if you’ve ever tried to get seniors on a new app, register, create an account, confirm their account via email, and then figure out how to log in again, then you deserve a PhD.

Dan: There have been some improvements, some smart work-around. Amber’s clinic now has a bunch of tablets called GrandPads:  They’re built to be super-simple . Nothing to install, just a piece of hardware.

Brenda: with a green button and a red button, and we tell them, press the green button when I call you.

Dan: The clinic uses a delivery service to send them out. 

Amber says the Grandpads have actually brought some patients BACK into her practice. These are folks who had previously fallen away because they’re more tired, more frail, maybe have trouble getting a ride: leaving home and shlepping to the clinic had become too hard.  

She’s experienced  this upside of telemedicine as a patient herself. She did a routine follow-up visit with one of her own doctors recently. Took five minutes start to finish. 

Brenda: I didn’t have to take time off work. I didn’t have to drive. I didn’t have to pay for parking. I didn’t have to go up the six flights of stairs at his office. It was just great. 

Dan: It’s easy to imagine people getting used to that kind of thing. But there are still all kinds of questions about telemedicine:  Those GrandPads cost money. 

Which brings us to our next set of questions:  What’s all this gonna cost? And who’s going to pay it?   — say even just for testing? 

It’s one we’ve been asking a lot on this show, of course, throughout this COVID-19 popup season. Sabrina Corlette has been helping us a bunch. She runs the Center on Health Insurance Reforms at Georgetown University— which makes her one of the country’s top insurance nerds.

Last week she published an essay in the journal Health Affairs with the title: “I’ve Been Calling For Greater Private Insurance Coverage Of COVID-19 Testing. I’ve Been Wrong.”

That’s right after this.

This episode of An Arm and a Leg is a co-production with Kaiser Health News. That’s a non-profit news service covering health care in a America. Kaiser Health news is not affiliated with the big health care outfit Kaiser Permanente. We’ll have a little more information about Kaiser Health News at the end of this episode.

One question that’s come up a couple of times during this COVID-19 season. Didn’t Congress pass laws saying that individuals weren’t gonna be on the hook to pay for COVID testing?  So why do we keep hearing from people who say they’re getting hit with bills?  

And Sabrina Corlette has been there every time. She runs a team of health-insurance law experts at Georgetown University. And she’s pointed us to the places where those laws Congress passed… seem to have loopholes in them. So when we decided to wrap up this season and ask a few people what they’d learned, she was DEFINITELY on my list.

And then as I was asking her for the interview, I saw she had just published this essay saying:  Yeah, actually. When I said Congress should get insurance to pay for COVID testing?  I was wrong about that. So when we got on the phone, I asked her: Wait, you were wrong? How’d you come to that conclusion?  

Sabrina: Well, a couple of things. One is, um, getting lots and lots of calls from journalists about people who were,  doing the best they could to get. Tested and  running into these loopholes.

Dan: Right. Journalists like me. The laws Congress passed in March were supposed to say: If you get tested, insurance covers it, you’re off the hook: You’re not supposed to have to pay your deductible or other charges. It’s just supposed to be covered.  But it turned out…..

Sabrina: there were all sorts of tripwires

Dan: And Sabrina heard about so many of them, she was like: We’re not gonna be able to get Congress to just pass legislation that closes these. Because there’ll be more— it’s like playing Whack-a-Mole.

And then there was this other thing.

The way those laws were written created this other  loophole— that seems like it allows testing labs to engage in some serious price gouging. The law says that if a given lab didn’t already have a deal with your insurer— if they were “out of network” they could name their own price, and the insurance company would have to pay it.

And from what Sabrina was seeing, some labs were DEFINITELY taking advantage.

Sabrina: for example, I just got a spreadsheet showing that some labs are charging as much as $6,000 for a single test.

Dan:what? to run a single person’s covid 19 test, there’s a lab that wants six grand.   

Sabrina: Yeah. Um, I mean, that was an outlier, but some of them are  well over a thousand. That’s crazy.

Dan: crap.

Sabrina: Yeah.

 Dan: So wait, run this by me again. 

She does: If the lab and a given insurance company don’t already have a rate negotiated, then yeah: The insurance company has to pay the lab whatever it says its full charge is… 

Sabrina:  If the lab posts the charge on a publicly accessible website.

Dan: That’s a pretty low bar. Wow. 

Sabrina: Yeah

Narration: I looked up the law— it’s exactly as wild as Sabrina says— and she sent me that spreadsheet. She can’t say where she got it from. 

The first thing I noticed was that insanely expensive lab test, which was actually closer to 7 grand — $6,946.35 to be exact. (This is a test that medicare pays about 50 bucks for.) That lab’s website, by the way, does NOT seem to list a price anywhere, and I looked hard. 

I looked up some of the wildly expensive places. 

The spreadsheet shows about a half-dozen of them charging the same expensive price: nine hundred ninety dollars. They’re all free-standing ER facilities, and some Internet sleuthing shows they’re all tied to the same business. 

I couldn’t confirm that 990 dollar price— it’s not posted to their websites, and when I called, no one had a ready answer.    

But one of them did have this interesting “disclosure” page on their website. The page says 

1. they’re out of network for everybody’s insurance, and 
2. they charge every patient a “facility fee” — that’s like a cover charge, just for being seen— and that the average  for that is more than two grand.  AND
3. This is actually a new one on me: they ALSO charge patients an “observation fee” — more than 2400 per hour, on average. 

So, yeah, that’s the kind of place I might expect to bill 990 bucks for a COVID test. 

And yes, it’s insurance companies paying those prices. But where do insurance companies get the money? By charging us premiums. So, when they get gouged, that gets passed along to us.

So, Sabrina Corlette has a new proposal.  Basically, toss a bunch of money into a fund— collect it from all the insurers, maybe add some public money. And decide up front on a rate: what labs will get paid for running tests.  Just cut out this whole Wild West thing we’ve got going on. 

And then just RUN all the tests that need to be run. 

Because, you know, from a public-health standpoint:  We want to run a LOT of tests. Not just to confirm, when people are sick, if COVID is what they have. We want to test people with no symptoms. So we can stop it from spreading.  

She thinks providers— like labs— would probably be against it. It would limit what they could charge. But businesses might really be for it. Because they pay for a LOT of insurance, AND they wanna know: 

Sabrina: how do we get people back to work and back to any sort of semblance of normalcy and testing is just going to have to be a component of that.

Dan: And so when Congress goes back to do ANOTHER COVID relief bill at some point, paying for testing will probably be up for discussion.

Sabrina: I don’t know, where Congress would ultimately land on that, but, I can’t imagine that, that it’s not something that employers and the insurance industry aren’t focused on. Like, um, lasers.

Dan: So, that’ll be interesting to see.  She says she’s looking at the whole economic and health side as one big thing:  If people are too scared to go out to businesses, businesses will not do so good. And those businesses will lay more people off. And.. 

Sabrina: for me as an insurance person who cares a lot about people being covered and accessing healthcare, I worry about that because that just means more people will live that lose their insurance.

Dan: Beating the pandemic, saving the economy, figuring out health insurance— and paying for testing: All one big package.

Sabrina: I do think that sort of a key piece of getting back to any sort of normalcy is going to be this testing and contact tracing. and if we can’t figure out how to do that in a way that,  really allows  state officials and the public health professionals to contain this virus, then, um, we’re, we have a very, very long road ahead of us.

Dan: And if we don’t have some kind of new system for getting testing paid for, then I have a very, very long list of potential stories about people getting stuck in these loopholes. 

For now, this is how we end our popup season on COVID-19 and what it’s really costing us.  We’ve got an insurance nerd tipping me off to the lab that charges nearly SEVEN GRAND to run a COVID-19 test. 

We’ve got a nurse in Texas who misses the hugs from her patients and worries a LOT about some of them— and who taught me about the GrandPad. IT’S A THING.  

And we’ve a doctor in Brooklyn who is handing her 5 year-old an iPad so we can talk about structural racism and the cost of COVID-19.  

And we’ve got a LOT of unanswered questions about what happens next. That feels like our kind of wrap up on this show.  

It has been amazing doing this COVID-19 season with you. A lot of our best stories have come from your tips, your emails.

I have learned SO much— including:  Hey, I like producing this show in an ongoing way, instead of saving up a few stories for a season every now and then.

I’m gonna have to take a little pause, like a few weeks— to figure out HOW to do that in a way that’s sustainable for me— I’m thinking:  How about every other week?— and how to do it in a way that’s enjoyable and rewarding— even fun for all of us. With a topic this stressful, I think that’s super, super important. . 

I’d REALLY like your input on this:  What’s going to make this show the most enjoyable, and satisfying and useful it can possibly be for you?  So I’m putting a listener survey on our website, and I really hope you’ll fill it out.  Should take you about five minutes. 

I should say: There’ll also be some questions about you: Demographic stuff, marketing stuff. That’s because one of the ways we’ll be looking to sustain the show is by selling some ads.  

I’ve got one rule:  Nothing having to do with health care.  No insurance, no vitamin supplements, none of that.  We report on those folks, so we don’t take their money.

Otherwise, I’m DEFINITELY open to your suggestions — especially if you’re thinking you’d like to advertise on the show? Let’s talk.

But no matter what, I will SO appreciate it if you can take five minutes and answer a few questions:  Like, are you a cat or a dog person? 

And when you get to the end, you’ll get an invitation to sign up for our newsletter, which — I’m just going to say— is really, really good. Like this show it aims to be entertaining, empowering and useful. 

And it’s a GREAT way to keep up with what’s coming next— like when exactly we’ll put out our next episode. 

At which point, we’ll start putting your advice to work. 

We will NOT stop reporting on COVID— I mean, I don’t think it’s going anywhere soon, which I am EXTREMELY unhappy about— but we will be coming back to some of our other big-picture questions, like HOW exactly we protect ourselves from the outrageous costs of health care?

You may remember, our last season was about self-defense against those costs. We profiled a woman I called a medical-bill ninja, and when the season was over I was like, “Let’s build a dojo”  That’s coming up.

I had my eye on a few teachers for our summer season, and I’ve gotten back in touch with them.  One is Lindsay Goldwert— she writes about money, and has a podcast called spent, and she published a book in January that caught my eye in a big way: It’s called BOW DOWN: Lessons from Dominatrixes on How to Get Everything That You Want.

I was like, “I think a dominatrix might be EXACTLY the person whose secrets could help me when I call an insurance company.”  

And we’re gonna put that to the test. 

When we talked, Lindsay was getting ready to call a hospital about an Emergency Room bill she’d gotten that seemed pretty out-of-hand:  She was paying 750 bucks for a benadryl, a steroid pill, and a prescription. She thought that merited a conversation. She would bring to that conversation a lot of what she learned from those dominatrixes.

Oh, and Lindsay said she would record her side of that conversation for us.

Lindsay: You know, I’m not looking forward to this phone call.  I’d rather be doing pretty much anything, to be honest, and that’s what they’re counting on. They’re counting on me to just be like, Ugh, fine.  I’ll just pay it and just life sucks. And that’s how they get you. So I feel that in my heart as well.  but  I’m going to do it because if they knock off $200 that’s going to be pretty cool.  And I can do it without being a jerk. I can do it in a, in a kind, honest, and direct way. And that’s, that’s my goal in life.

Dan: So we’ll hear how it went — and the lessons of the dominatrixes — when this show comes back.

Meanwhile, please go fill out the survey!  It’s at arm and a leg show dot com, slash, survey.

That’s arm and a leg show dot com, slash, survey.

Thank you so much. I can’t wait to find out what you’ve got to say.

Till then, take care of yourself.

This episode was produced by me, Dan Weissmann and edited by Derek John. Daisy Rosario is our consulting managing producer, and Adam Raymonda is our audio wizard.  Our music is by Dave Winer and Blue Dot Sessions.

This season of An Arm and a Leg is a co-production with Kaiser Health News— a non-profit news service about health care in America that’s an editorially-independent program of the Kaiser Family Foundation. 

Kaiser Health News is NOT affiliated with Kaiser Permanente, the big health care provider— they share an ancestor. This guy Henry J. Kaiser— he had his hands in A LOT of different stuff. Concrete. Aluminum. Ship building. When he died, more than fifty years ago, he left half his money to the foundation that later created Kaiser Health News. 

You can learn more about him and Kaiser Health News at armandalegshow.com/kaiser

Diane Webber is National Editor for Broadcast and Taunya English is Senior Editor for Broadcast Innovation at Kaiser Health News— they are editorial liaisons to this show. 

Finally, thank you to some of our new backers on Patreon. Pledge two bucks a month or more, and you get a shout-out right here. I can’t tell you how much it means to me that you make this possible.  In the middle of a pandemic and an economic meltdown, you have stuck with me, and more of you have continued to show up. It is a huge, huge deal.

Thanks this week to folks who joined us for the first time— and some who increased their pledge. 

Thank you SO much to:

David Ho, Terrill N. Platt

Ashley Gross, Laura Certain, Lola

Matt Vivier, Evalynn Rosado

Ashley, Jazmin Patino, 

Michael Novello, Jason Shapiro,

Phoebe Downey, Lisa Hettler-Smith

Brent Johnson, Kaitlin Mroczka

and Caiti.

Thank you so much!