First, Drew Calver had an unexpected heart attack, collapsing in his bedroom on a spring morning in 2017.
Then came the bill: $164,941 for his four-day hospital stay, which included the cost of having four stents put in a clogged artery. As a teacher and swim coach at a public high school in Austin, where he lives with his wife and two daughters, Calver is luckier than some, with health insurance provided to him by Aetna. But even after the insurance kicked in and covered $56,000, Calver was left with nearly $109,000 in unpaid fees billed to him by the hospital.
Calver’s story, which was first reported by NPR and Kaiser Health News as part of a series that examines health-care costs, has captured attention far and wide, a cautionary tale about the way that even those with health insurance can find themselves buried under bills after receiving treatment because of loopholes and surprises in hospital and insurance policies and fine print.
After the story was reported on Monday, the hospital said that it was willing to accept $782 to resolve Calver’s balance, based on a financial-assistance program it has, according to the two media outlets. But Calver said he doesn’t know if he’ll pay the balance and said he remains shaken by the experience.
“I shouldn’t have ever had to deal with this bill,” the 44-year-old father said in a phone interview with The Washington Post, noting that the debt has been hanging over his head for more than a year. “I’m supposed to be reducing stress in my life with this heart condition, so it will be nice for this to end."
The hospital disputes Calver’s assertion that he was only offered financial assistance after the story was reported.
“In addition to providing Mr. Calver with financial assistance information during his hospital stay, as well as it being provided on each of his statements, we sent this information to him in writing in April 2018 and again in August 2018,” St. David’s HealthCare said in a statement distributed by spokeswoman Kristin Marcum. “Although Mr. Calver has not yet submitted a financial assistance application, we were able to calculate his amount due of $782.29 using financial data obtained from a credit reporting agency.”
St. David’s was an out-of-network provider for Calver, but it told him it would accept his insurance, Calver told Kaiser Health News and NPR. Calver said the first he heard that the hospital would offer financial assistance was in early August, after the reporter of the story contacted the hospital.
The financial dispute reflects two billing practices that “bedevil” many Americans after receiving health care, according to Kaiser Health News and NPR: surprise bills and balance billing. As the two outlets write:
Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor who does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver’s, where insurers will pay for needed emergency care at the closest hospital — even if it is out of network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.
Kaiser Health News and NPR
Texas is one of several states that has laws meant to protect consumers in these instances, Kaiser Health News and NPR reported, but there is a loophole:
“Those state-mandated protections don’t apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or public employers pay claims out of their own funds,” they wrote. “Federal law governs those health plans — and it does not include such protections.”
St. David’s HealthCare, where Calver received treatment, is run by HCA Healthcare, the largest for-profit hospital chain in the country, according to Kaiser Health News, which quoted experts saying that the chain has a reputation for exorbitant billing.
WellRithms, a company that analyzes medical-care costs, said that a reasonable price for Calver’s treatment should have been about $27,000. Another company, Healthcare Bluebook, told the news outlet that the fair price for a hospitalization and four heart stents should have been about $37,000.
St. David’s charged more than $19,000 each for two of the stents made by Boston Scientific given to Calver, even though the median price that hospitals paid for the stent was $1,153, according to Kaiser Health News and NPR.
“There is no reputation here for unusual billing practices,” St. David’s said in a statement. “A review of the account indicates that the charges were reasonable and customary and in line with this type of procedure. Our market-based charge rate is consistent with hospitals across our market and with other major healthcare systems across the country. There are a number of factors that determine the amount a patient pays for hospital services. As is standard across the healthcare industry, charges reflect the ‘retail’ price for a procedure, treatment or visit and do not take into account the discount negotiated by a patient’s health insurance company or other discounts that we routinely provide due to financial hardship.”
Aetna did not respond to a request for comment.
Calver said the process was the culmination of dozens of hours spent on the phone, calling both Aetna and the hospital about every two weeks for more than a year.
“It’s exhausting,” he said. “I’ve been strung along. They always leave me with some tiny glimpse of hope, but always ending with disappointment and the stress of this looming over my family’s head.”
Finally, after his wife heard the “Bill of the Month” series on NPR, he submitted his story, heeding a prompt for submissions at the end of the show. He said it is a relief that the bill has been lowered, but doesn’t yet know if he’ll consent to pay the $782. And he said he’s worried about others who don’t receive the same media attention as him.
“I’ll worry about the person who got a $20,000 bill,” Calver told The Post. “They talk you into paying that off. And people do it. I had nowhere else to turn, besides saying this was wrong.”