One Hundred Dollar Hemorrhoids

I had a patient in the office today who doesn\’t have insurance.  He told me that a recent prescription he got was too expensive.  This is not surprising, as many of the brand name, and even some of the generic medications are quite expensive.  What surprised me was the fact that the expensive medication was for hemorrhoids, and it cost over $100.  I certainly would never recommend anything but good care for that part of your body; and the symptoms of hemorrhoids can definitely have a big effect on your social life.  But come on, $100??
This medication had all of the usual components that most hemorrhoid creams have.  The real difference was the delivery system: it\’s a foam.  There is no generic substitute for this, apparently.  As I spoke with this man, it became clear to me that this is a central issue in the crisis in healthcare.

What?  Hemorrhoid foam is the cause of the healthcare crisis?

No, that is not what I am saying.  The significance of this encounter is that the $100 medication is one that I prescribe frequently, and that insurance companies have never rejected.  The insurance companies are paying $100 for hemorrhoid medication.  True, they probably have wrangled some sort of discount, but the reason the company who makes this magic medicine can charge $100 is that somebody pays $100 for it.  I don\’t think there are enough constipated millionaires to explain this phenomenon.

The main problem in healthcare is the total lack of value.  We pay a lot for care and don\’t get a lot in return.  Costs are going up but we are not seeing an increase in quality along with those rising costs.  Why is this happening?  $100 dollar hemorrhoids show us what\’s going on.  The medications contained in this concoction are not anything expensive – mainly cortisone.  The delivery system isn\’t space-age.  The company spends very little money on marketing (I don\’t think I\’ve ever seen a drug rep for this hemorrhoid foam).  The R&D budget was probably spent on researching a way to get someone to pay $100 for hemorrhoid foam.

While in Vegas last week Dr. Wes told us about a patient he put in for 23 hour observation with a heart problem who racked up a $180,000 bill.  Insurance got a discounted rate but still covered $120,000.  How can they justify this?  How come there isn\’t someone at the insurance company who says: \”Hey, that\’s an awful lot to spend on a 23 hour visit,\” or \”Wait a minute, why the heck are we paying $100 for hemorrhoid medication?\”  The answer is at the root of our system\’s problem: they pass on the cost to us.

If I was in the hemorrhoid foam business (my kids wouldn\’t tell their friends, I am sure), I would accept the $100 check for each can of foam.  I\’d even start singing \”God Bless America.\”  But I am not in that business (my kids are relieved), and instead I have people with insurance rates so high that they have to drop it.

Something is wrong with this picture.  $100 is more than I get paid for most of my visits, and congress is now arguing about whether they are going to cut my pay; yet nobody seems to be bothered by $100 for hemorrhoids?

Will I get paid better if I claim to shrink swelling and relieve itching?  Will it help if I deliver my care as a foam?

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25 thoughts on “One Hundred Dollar Hemorrhoids”

  1. Rob, I have to say, this is one of my favorite health care reform related posts right now. Thanks for bringing a bit of wit to an otherwise dry topic: “Will I get paid better if I claim to shrink swelling and relieve itching? Will it help if I deliver my care as a foam?”. Encore!

  2. Rob, I have to say, this is one of my favorite health care reform related posts right now. Thanks for bringing a bit of wit to an otherwise dry topic: “Will I get paid better if I claim to shrink swelling and relieve itching? Will it help if I deliver my care as a foam?”. Encore!

  3. Dr. Rob you’ve put your finger right on the problem (ewww!) Maybe I should put this a different way . . .I’m a nurse and paramedic. In my work on the ambulance and around the ER, I see many patients who let little problems become big problems until they have to seek care in an ER or urgent care facility. They don’t seek treatment earlier because of lack of health care.

    On the flip side – there are patients with insurance who wait with a toothache all day and then call an ambulance (yes, an ambulance) to take them to the hospital because they need something for the pain. I’ve seen two different toothache patients in similar circumstances and they all say the same thing, “I’ve got insurance that will pay for this.”

    While I’m a big-time patient advocate, when do we stop supporting the idiots who use a 1,500 hundred dollar ER visit and a $500 ambulance transport for a toothache. I’d like to tell them to wait and call the dentist in the morning. A real emergency might come up and require a paramedic while we transport Mr. Toothache. Alas, I can’t – only the patient can refuse transport. If they call and want to go, we must take them.

  4. Dr. Rob you’ve put your finger right on the problem (ewww!) Maybe I should put this a different way . . .I’m a nurse and paramedic. In my work on the ambulance and around the ER, I see many patients who let little problems become big problems until they have to seek care in an ER or urgent care facility. They don’t seek treatment earlier because of lack of health care.

    On the flip side – there are patients with insurance who wait with a toothache all day and then call an ambulance (yes, an ambulance) to take them to the hospital because they need something for the pain. I’ve seen two different toothache patients in similar circumstances and they all say the same thing, “I’ve got insurance that will pay for this.”

    While I’m a big-time patient advocate, when do we stop supporting the idiots who use a 1,500 hundred dollar ER visit and a $500 ambulance transport for a toothache. I’d like to tell them to wait and call the dentist in the morning. A real emergency might come up and require a paramedic while we transport Mr. Toothache. Alas, I can’t – only the patient can refuse transport. If they call and want to go, we must take them.

  5. An ounce of prevention is better (and cheaper) than a pound of cure. So right now I’m uninsured (recently out of college, trying to pass the NCLEX so I can officially get a nursing job … taking the test in a little over a week!).
    But of course there are plenty of people that are healthy that get sick, and I’m most sympathetic to them.

  6. An ounce of prevention is better (and cheaper) than a pound of cure. So right now I’m uninsured (recently out of college, trying to pass the NCLEX so I can officially get a nursing job … taking the test in a little over a week!).
    But of course there are plenty of people that are healthy that get sick, and I’m most sympathetic to them.

  7. Yes, but think about the therapeutic power of those bubbles! Healing foamy bubbles popping all over that sore anus– Come on, it has to be worth the extra $90!
    America has the best healthcare in the world. British and Canadian socialist may live longer, but without the fizzy, foamy bubbles, who cares?

  8. Yes, but think about the therapeutic power of those bubbles! Healing foamy bubbles popping all over that sore anus– Come on, it has to be worth the extra $90!
    America has the best healthcare in the world. British and Canadian socialist may live longer, but without the fizzy, foamy bubbles, who cares?

  9. Doctor D you may be on to something here. Perhaps this innovative hemorrhoid foam could be marketed using the same team that brought us Dow Bathroom Cleaner’s scrubbing bubbles. Just picture them spinning around, shrinking those hemorrhoids!

  10. Doctor D you may be on to something here. Perhaps this innovative hemorrhoid foam could be marketed using the same team that brought us Dow Bathroom Cleaner’s scrubbing bubbles. Just picture them spinning around, shrinking those hemorrhoids!

  11. This issue is estmic. Everyone wants the best or to appear they are so well off they can buy the best. Every marketer knows you need a $5 item, a $50 item and $500 item even if they are all the same. I work in the computer industry. You don’t really think it costs $100+ dollars to sell you Windows 7?
    I think the problem is we lost will to dicker on a price. You look cheep if you ask for a discount. One place it still works is health care. My Dad does it all the time. He is a lawyer and worked insurance industry for years. He asks them “What does Medicare pay for this?” and they says, “If you are willing to do this for that price then that is all I will pay.” I have yet to see it work.

  12. This issue is estmic. Everyone wants the best or to appear they are so well off they can buy the best. Every marketer knows you need a $5 item, a $50 item and $500 item even if they are all the same. I work in the computer industry. You don’t really think it costs $100+ dollars to sell you Windows 7?
    I think the problem is we lost will to dicker on a price. You look cheep if you ask for a discount. One place it still works is health care. My Dad does it all the time. He is a lawyer and worked insurance industry for years. He asks them “What does Medicare pay for this?” and they says, “If you are willing to do this for that price then that is all I will pay.” I have yet to see it work.

  13. Patrick Honsinger

    Dr. Rob,
    I too am a primary care doc in southern Oregon. Recently, a friend and I were exploring a mountain trail when he fell and lacerated his thumb on a trail post sticking out of the ground. It being a Sunday morning, I took him in to my office, sewed up the wound (it went down clear to the palmer fascia and muscles) with several stitches. He wanted to have me bill his insurance, historically not having used much of his “benefits” with a $5000 deductable but free “office visits”. Recently, he received the bill which he asked me to bill as an “office visit”. I billed as honestly as I could as a CPT “repair of low-moderate complexity laceration”. His insurance covered his tetanus update ($16) but did not cover the repair ($270). What is it that I did wrong? I swear, this was done in my office and not in the emergency room, hospital operating room or outpatient surgery center. How does his insurance define “office” in office visit? Did his insurance lure him to a plan so they could collect monthly revenue and shed any significant costs to him. Are we as care providers to know which insurance companies will pay such a visit without hesitation vs. those that will pull out the small print versions of rules to defend their denials and put us at odds with our patients (in this case, a close friend?).

    Enjoy your site and look forward to reading more.

    Sincerely,
    Patrick

  14. Patrick Honsinger

    Dr. Rob,
    I too am a primary care doc in southern Oregon. Recently, a friend and I were exploring a mountain trail when he fell and lacerated his thumb on a trail post sticking out of the ground. It being a Sunday morning, I took him in to my office, sewed up the wound (it went down clear to the palmer fascia and muscles) with several stitches. He wanted to have me bill his insurance, historically not having used much of his “benefits” with a $5000 deductable but free “office visits”. Recently, he received the bill which he asked me to bill as an “office visit”. I billed as honestly as I could as a CPT “repair of low-moderate complexity laceration”. His insurance covered his tetanus update ($16) but did not cover the repair ($270). What is it that I did wrong? I swear, this was done in my office and not in the emergency room, hospital operating room or outpatient surgery center. How does his insurance define “office” in office visit? Did his insurance lure him to a plan so they could collect monthly revenue and shed any significant costs to him. Are we as care providers to know which insurance companies will pay such a visit without hesitation vs. those that will pull out the small print versions of rules to defend their denials and put us at odds with our patients (in this case, a close friend?).

    Enjoy your site and look forward to reading more.

    Sincerely,
    Patrick

  15. Agree. I have been heard many say (and I agree) that transparent pricing would do a lot to fix problems.

  16. Agree. I have been heard many say (and I agree) that transparent pricing would do a lot to fix problems.

  17. Excellent story . It illustrates the point very well. You could have just billed as a 99213 with “Laceration” as the ICD-9 code, but it seems stupid that we can’t run our business as we want. We have to know how to navigate the maze. It’s dumb.

  18. Excellent story . It illustrates the point very well. You could have just billed as a 99213 with “Laceration” as the ICD-9 code, but it seems stupid that we can’t run our business as we want. We have to know how to navigate the maze. It’s dumb.

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