The doghouse: Seattle Women's Clinic

My wife gets severe reactions to hormones in various kinds of birth control pills, so we decided to get an intra-uterine device (IUD). Since we are (perhaps unjustly) somewhat skeptical of the quality of medical service where we live, we decided to get an IUD inserted during our trip to Seattle. We visited with Dawn Scheve at the Seattle Women's Clinic, and she turned out to be very nice - was appreciative, talkative, and appeared to have done the job well.

However, then we got the bill.

IUD insertion:$199.75
Paragard IUD:$355.00
Paracervical Block:    $339.15

The cost of the Paragard device itself - though it appears high for a 2 cm plastic-and-copper 'device' - seems normal; $355 is a price I've seen quoted elsewhere. The insertion, at $199.75 - okay, I understand, it only takes 5 minutes, but you need several years of medical training in order to not screw it up.

But the paracervical block, that's just outrageous. Yes, it did prevent my wife from feeling excruciating pain at the time - though it wore off quickly and she's currently suffering; this happens to women who get an IUD without having previously delivered a baby. But a single lidocaine injection for $340 bucks? Damn, we might as well have visited the pharmacy, bought some Advil for $20 bucks, and it would have worked nearly as well!

So there you have it, we got charged $340 for a lidocaine shot. What a ripoff!


Sunshine said…
In Slovenia, they have a better solution. :D The DO NOT insert IUD to the women who have not given birth. EVER. AT ALL. Under no conditions. No matter which papers are you willing to sign. No matter if you are a self payer (samoplačnik po naše) or covered by insurance.
denis bider said…
Yaaay... three times hooray for self-serving Soviet-style health care systems that are a purpose to themselves :-)

Indeed, better to have an expensive opportunity than none at all...

It appears that, outside of Slovenia, lots of nulliparous women - those who have not given birth - use an IUD. Apparently side effects are somewhat more common in nulliparous women than in those who have given birth, but not so much as to be a contraindication.

This article indicates that the actual reason for discrimination against nulliparous women might be because, as a group, they are at higher risk for STDs. Gonorrhea and chlamydia cause pelvic inflammatory disease (PID), which the presence of a foreign object can worsen.

Apparently, the Slovenian health-care system is using this as grounds for a Soviet-style one-size-fits-all decision for all members of the risk group - labeling all nulliparous women as unfit to have an IUD, ignoring all individual circumstance.

That is the sort of idiocy one would expect from the Slovenian health care system, which also makes it impossible for a person to get tested for all STDs. Like you said - can't ask for it. Under no conditions. No matter how much you're willing to pay, or which papers you're willing to sign. Service unavailable.

Soviet-minded idiots...
verbatim said…
This comment has been removed by the author.
verbatim said…
I think you can already get IUD in Slovenia if you want. In general, not inserting IUDs in Slovenia is a sort of technical nature. Countries which are inserting IUDs to women with no children are having regular preventing tests for STDs for population at risk. Those tests are currently not available in Slovenia but they will be in very near future. There are many other available and the same effective options of birth control to choose from so I wouldn't call our health care Soviet-Style as I wouldn't call american system - from a customer point of view - any better when you pay ridiculous 1000 USD mostly for a smile and for a simple medical procedure.

which also makes it impossible for a person to get tested for all STDs.

Option to choose aside, why would anyone (unless someone is a hypochondriac) wanted to be tested for all STDs? STDs are diagnosed by symptoms and confirmed by testing. This is the same idiocy as if your lung hurts and you wanted to be tested for a cancer in your colon. This "wanted to be tested for all ..." is popular lately as modern people (wannabe experts from all fields) google for all possible diseases and then wanted to be checked for all of them because people think google can replace years of doctor's experiences.
denis bider said…
verbatim: at least for 1,000 bucks you get to choose, whereas in Slovenia you don't. Yes, the Slovenian system is Soviet-style paternalistic medicine - in Slovenia, your doctor gets to determine what's good for you and if you're lucky, they tell you why. In the U.S., your doctor gives you the information you need, you do your research, and then you make an informed choice. There is a world of difference between these two approaches.

Secondly, I don't believe that people with health insurance would have to pay the full $981.45 - their health insurance would probably carry part of that. Also, the reason I wrote this article is because a particular clinic overcharges $340 for a lidocaine shot, not because they charge $355 for the Paragard and $200 for the insertion. I know that American health care is expensive.

Finally, if you want a good reason to get tested for all STDs, how about exposure? How about prevention before consensual sex between adults? You are assuming implicitly that everyone is consensually monogamous, which is again a Soviet-style assumption to make.
denis bider said…
verbatim: Also, you are wrong about there being many other options. There are the various hormone-based methods - estrogen and progestin taken in various ways - but my wife experiences severe side effects from all the hormone pills she's tried. There's the sponge + spermicide, which is rather unreliable. There's condoms, which provide for suboptimal intercourse. There's vasectomy and female sterilization, which requires a surgical procedure to perform and to reverse, and is not generally an option unless you're fairly sure you don't want another baby.

Then what? Have I left anything out?

If the hormones affect you badly and you want authentic intercourse experience and you want reliable birth control and you want to have children some day, then IUD is the way to go. For women who have not yet given birth, Slovenia won't let you have that option, and that, I am very firmly convinced, is socialist paternalistic medicine.
denis bider said…
Also, STD testing procedures are available in Slovenia for people who need to get regularly tested e.g. for insurance reasons. Testing is just not available to the general population, for reasons that have to do with bureaucrats deciding for others.
verbatim said…
Finally, if you want a good reason to get tested for all STDs, how about exposure? How about prevention before consensual sex between adults?

I didn't say that. I only said there is no reason to be tested for all STDs because majority of them are expressed by symptoms soon after exposure - as there is no reason to also make an x-ray of your leg if your arm hurts. This is just unncessesary panic. About prevention ... so you would test your every parner before sex? Because even with a condom you can get some STDs. With probability of catching anything very small and no visible symptoms it is personally enough.

In the U.S., your doctor gives you the information you need, you do your research

I agree about research in a way of finding a good hospital, good doctor, cheaper options but I don't agree with that you make a decision based on knowledge you get on internet. Internet can't replace doctor's experiences and knowledge, especially in case of more complex diseases ... for example there is no way you can adequately learn over the internet how to read magnetic resonance images. I see your assumption which I also noticed in your other articles that you can always educate yourself enough to make a good/best decision.

For women who have not yet given birth, Slovenia won't let you have that option, and that, I am very firmly convinced, is socialist paternalistic medicine.

I read article some weeks ago by slovenian gynaecologist and this option is already available to all ladies if they really want but doctors are unhappy to do it because of lack of preventive tests which are available in every developed western societies and is based on assumption that young lady will probably have more than one sex partner. So when testing will be in place IUDs will be available to general population although not advised but available, like everywhere. But at the moment if someone doesn't want to do it probably someone else will but with Slovenian bureacracy this is lenghty procedure. :)

I completely understand what was your article about. But as I have problems with expressing myself point was badly stated. My point was that in case of simple/routine procedures ... there are small or none differences in quality between expensive and less expensive health care providers so rational customer in the liberal market will choose a cheaper one ("outsourcing surgery" also show that) but as medical service markets not working properly there can be ridiculous price of 1000 USD (injection included).
denis bider said…
I didn't quite get your point about STD testing. First you say that testing is unnecessary unless there are symptoms; then you say that Slovenian doctors won't provide an IUD because of lack of preventative tests. So this unnecessary testing that you speak of, is necessary after all?

Yes, I do believe that a patient, given sufficient resources - which are not yet necessarily available in all cases - can educate themselves about their problem to a point where they can make a better decision than their doctor. This is not necessarily true for all patients - if you are not trained in rational thinking, then your decision-making process may not be rational - but if you are rationally trained, then yes, if you have sufficient information and sufficient time, you will make a better decision than the doctor. The doctor looks at many cases every day and hardly cracks open a book for each one of them. But as a motivated patient, you will generally spend days researching your condition, and can end up being better informed than the doctor. It doesn't mean you'll be able to read X-ray images, but you can make a good decision for yourself.

It may be that the reason that the market "doesn't work" in the case of the $340 lidocaine injection is because the market has been (intentionally or unintentionally) hobbled. I expect that most people who come to an ob/gyn have health insurance, which pays for part or most of their costs. The health insurance, in turn, spreads out these costs over the insured in a way that provides a disincentive for anyone to look at what items were charged and overcharged. If people generally paid for their procedures out of their own pocket, rather than through the stupid health insurance system, prices would be much more competitively set.
Denis, I am not a health professional (I am a programmer and an entrepreneur) but my guess as to the primary underlying reason for the high charge for the lidocaine injection is legal liability. Defending a lawsuit is so expensive that even if only a tiny fraction of patients sue and even if the defendant wins most or all of the lawsuits, the expected cost of a lidocaine injection is many times higher than it would be when there is no chance of being sued.

Note that in the U.S. legal system, a patient cannot decisively sign away her right to sue a medical provider. In other words, even when a patient has signed a waiver of liability, the courts often allow the patient to continue with a lawsuit. (The waiver is seen by the court as an invalid contract.)

I think you have a fine mind and a good attitude towards life. If you ever visit the San Francisco Bay Area, I would like to buy you and your wife lunch.
denis bider said…
Thank you for your comment, Richard, as well as for the invitation. We would like to visit San Francisco and California in general. I was there a few years ago and loved San Francisco.

The case of liability cost for the high American health care prices is one frequently made, but it is probably false. I believe I've seen actual figures estimating that the total cost of liability payments is some 2-3% of a clinic's revenue.

I think the high prices are generated by the very fact that most patients have no interest in choosing a clinic based on that part of the price which their insurance is going to cover anyway; yet the end, everyone is saddled with the resulting high costs of insurance.

It might be similar to the tragedy of the commons, in the sense that the insurance funds are the "commons" that it is in everyone's individual self-interest to over-exploit, yet still, everyone then has to pay for their own and everyone else's over-exploitation - but in a way that they cannot reduce by simply reducing their own consumption of the resource. So they do not.

If liability was the actual cause of the high prices, I agree that people should be able to sign away their right to sue, if that is going to fix the problem. But I don't believe that this is where the problem lies, even though it's often attributed this way in the media (but usually as a mere speculative assumption, with no substantiating data whatsoever).
You might be right, Denis.

Consider that care providers often charge uninsured patients much higher prices than they charge insurance companies for the same procedure.
denis bider said…
I have heard so, and I wonder why. Do people who pay out of their own pockets represent such a small share of the market that health care providers don't find them valuable to fight for?

This clinic we went to made it pretty much impossible to even know what the price was going to be before the procedure was done. They sure made it look like they hardly even ever encounter a self-paying customer.
The newspapers say that there are tens of millions of Americans without health insurance, and I tend to believe them. But I think the vast majority of uninsured Americans never use health care except in emergencies. Consequently among consumers (such as you and your wife) who are proactive about health, it is rare not to have health insurance.

A self payer seeking an elective procedure should demand to know the price of the procedure.

Usually that will require talking to an employee of the accounting department: the employees who greet patients and deliver care usually know nothing about prices or fees. If the first employee in accounting does not answer the patient's questions, the patient should demand to speak to a supervisor or manager (in the accounting department). Maybe you already know this, but I thought I would mention it because you are not a US resident and things work differently in different countries. (I only know how things work in the US.)

Also, if you have not paid the bill yet, it is not too late to call the accounting or accounts-receivables department and ask them to reduce the price. It is good to give a reason when you do this, but the reason does not have to make logical sense. I suggest giving the reason, "We are not citizens or residents of the US, and we could have gone to India or Mexico to have the procedure done." Again, I realize this reason makes no logical sense, but it suffices to establish that your case is somehow unusual and consequently might deserve unusual treatment. I would not use as a reason that the charge for the epidural was excessive or unreasonable: I expect that to make the employee defensive and unwilling to listen to you because most accounting and clerical employees will not entertain the hypothesis that their employer is exploitative or unreasonable.
I had that devise for 10 years and i loved it however in wanting to receive it again i was wondering if i was to purchase the devise itself on my own would my doctor insert it for me or do i have to get it through the office itself? If anyone knows...
denis bider said…
My limited personal experience makes me think that the price for the IUD is fairly uniform; it seems that doctors mostly differ in what they charge for their services on top of it. Are you able to get the IUD from somewhere at lower cost? You would probably have to ask a gyno if they would be willing to implant it in that case. My hunch is that at the very least they might require you to sign a responsibility waiver, if they would be willing to insert it at all. But you need to ask a gyno - I don't really know.

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