Self Pay


               The temperature in the waiting room was cool as I signed the doctor’s daily appointment register at the front desk.  I was number eight on the afternoon’s sign-in sheet.  I looked at the line across from my name, and the moment I had dreaded for months was upon me.  I had played and replayed the question in my mind.

             Any changes to insurance since last visit? Yes / No     

            I circled “Yes” and spoke to the young, attractive receptionist, who was intently focused on her computer screen and hadn’t appeared to notice me.  Her expression was harried, as if she was so far behind in her duties she would never catch up.

            “Excuse me,” I said.  “I circled ‘Yes’ today for change of insurance because I no longer have insurance.”  I looked apologetically at her and spoke in my best “inside” voice.  I didn’t want the other people in the room to hear me confess my failure to produce the key to the kingdom of good health care.        Her fingers froze on the computer keyboard.  Her reaction confirmed my biggest fears.  She sighed heavily and began to disassociate herself from her mental and physical connection to the World of Important Matters.  Without glancing at me, she began to rummage through manila file folders in a drawer beneath her workstation.  At last, she pulled a single form from a folder, wrote something on it, attached it to a clipboard, and pointed to a round glass holder containing four ballpoint pens.  “Fill this out and bring it back to me when you’re finished,” she said flatly.  “Bring an ID with you, too.”  She still hadn’t looked at me, and as I picked up the clipboard, I had a sinking feeling that I was wearing Harry Potter’s Invisibility Cloak.

            I selected a pen and sat down to complete the form.  It took me longer to pull my driver’s license out of the stubborn leather slot in my billfold than it did to finish the paperwork.  Name, address, telephone number, date of birth, emergency contact, social security number.  The remainder of the lengthy document required detailed insurance information, but that had been marked through with a large “X” by the receptionist when she handed me the form.  She had written SELF PAY above the “X.”  In red ink.  I felt a sense of impending doom.  

           I couldn’t remember a time in my life when I didn’t have health insurance, and I had recently celebrated my sixty-fourth birthday.  Eighteen months ago, my employment was terminated due to a medical disability from ophthalmic herpes zoster, or shingles, in my right eye and other places in my head and on my face.  I participated in my employer-sponsored COBRA plan during those eighteen months for ongoing coverage, but on day one of the month nineteen—BAM!  No more insurance.  I had explored alternatives for personal insurance policies, but costs were prohibitive.  Medicare, the government-sponsored program for senior citizens, wasn’t available until my next birthday.  Alas, I was like a tightrope walker on a rope suspended high above a river rising as quickly as the price of my medications.  I was alarmed.  No, beyond alarmed.  I was afraid of a future with no insurance safety net.

            I took the clipboard and ID to the front and laid it down on the receptionist’s desk.  She was again immersed in her computer screen and clearly involved in the World of Important Matters.  Then, without looking up, she said, “Thanks.  Have a seat, and I’ll be with you in a few minutes.”  My Invisibility Cloak worked well, I thought.

            I returned to the chair I had claimed and sat down.  I looked around the large waiting area and saw five other people waiting to see Dr. Thong—one of a group of four dermatologists who shared the practice.  Their business had clearly expanded in the ten years I had been an “established” patient.  The building was the same as when I first started coming to see them, but now the group occupied the entire space.  The entrance was moved, and the lobby area was much more elaborate.  A new, large, trendy flat-screen television hung from the wall to allow good visibility from any vantage point.  One of the major cable news networks showed financial data from Wall Street at the moment, but the sound level was appropriately low and inoffensive.  The brown faux leather chairs were definitely an upgrade from the uncomfortable ones in the previous lobby, too.  The quiet room shouted first-class.

           Two hands on a large clock on the wall near the front door marked our waiting time.  I was at twenty minutes when I heard the receptionist call my name.

       “Miss Morris,” she said.

       I rose and walked to her desk.  For the first time, she looked at me.  Not smiling or friendly, but she did look.

     ” Here’s your ID.  Someone will call you in a few minutes.”  She had placed my ID on the counter.  Was it possible my I nvisibility Cloak had been stolen while I listened to the financial news?

     I picked up my driver’s license and sat down again.  I busied myself for several minutes with re-arranging the items in my billfold so that my ID was easier to reach.  That done, I daydreamed about the old days when I had good health and little interest in doctors or insurance.  Occasionally, the door to the examination rooms opened, and a nurse called someone’s name.  At thirty-three minutes and counting, I noticed that only two of us were left in the waiting area.  Time must truly be money for Dr. Thong, I thought.

       “Miss Morris,” I heard.  I was startled from my musings about the lobby, doctors, medicine, and insurance.

      I stood and walked toward the smiling lovely young nurse who held the door to the examination rooms for me.  She was dressed in a loosely fitting blue uniform that looked like the ones worn by actors in the medical dramas on television nowadays.  Not the super-starched white uniforms of the medical series of the 1970s like Marcus Welby, M. D., but she looked good in blue.  She was pretty in that wholesome all-American look and seemed very efficient as she carried what I presumed was my chart.  Her smile belied her no-nonsense demeanor.

     “And how are we doing today?”  She motioned me to follow her past the maze of tiny rooms with the doors shut.

     “Well, it’s not my best day, but I’ve had worse.”  I walked as fast as I could to keep pace with her.

      She smiled on, indicating a room with an open door, and I went in first.  I sat down on the large, gray, leather exam chair with a thin layer of white paper pulled over it to prevent my germs from being spread to the next person.  The agreeable young nurse continued smiling as she sat on a stool across from me.  She studied my chart thoughtfully.

     “Are we having any new problems today?” she asked.

     “Actually, I am,” I replied.  “I have a new trouble spot on my face that’s been there for two months.  It’s probably like the other ones Dr. Thong biopsied last year, but he always wants to know about the ones that don’t go away.”  I had a history of malignancies from skin cancers on my face, and any lesions from the herpes virus that refused to disappear in a reasonable time were suspicious, according to Dr. Thong.  He was scrupulous about early detection of any potential problems.  I had always admired that quality in him.  An ounce of prevention was worth a pound of cure.  Wasn’t that what my daddy had always told me?

     I saw the nurse was taking notes, and I added, “Oh, and I got a tick bite about six weeks ago when I was in Texas.  It still hurts and itches, and I wondered if it’s okay.  It’s in an awkward spot at the top of my right hip, and I can’t see it.”

    “Tick bite,” she said, and wrote more.  Her good humor seemed to be fading for some reason, though.  The perky smile was gone, and that made me uneasy.  “I see you’re due for your annual full-body check today.  I also see you have no insurance.  Do you still want to do the exam?”

      I was taken aback by the question.  Was it possible to not have an annual check-up?  The thought had never occurred to me.  I had been having annual checkups, well, annually, for my entire life.  My mother took me every year when I was a child, and I continued each year of my adult life.  So, at sixty-four years of age, I’d had my share of regular doctor visits.  Of course, I reasoned quickly, maybe that just applied to my primary care physician.  The dermatologist might be different.  But, then, they had never given me a choice before.  What was going on here?  My anxiety level leaped ahead several notches.

     “Well, yes,” I said.  “I’ll go ahead with the full-body exam.”

     “Okay.”  Closing my chart, she stood up and went to a cabinet in the little room.  She retrieved a large neatly folded piece of white paper and handed it to me.  “Here’s a sheet for you. Get undressed, and Dr. Thong will be with you in a few minutes.”

     I took off my clothes and unfolded the white paper sheet.  It was enormous and unwieldy, but I managed to cover my naked body in what I imagined was an absurd look.  I now sat on paper and was covered with paper.  When I moved, the paper made an annoying crackling sound.  I was very uncomfortable and quite cold.  My mental state matched my physical discomfiture.  Would that man never get here?  I looked at my watch, and my 2:00 p.m. appointment had lasted forty-five minutes so far.

     Shortly thereafter, I heard whispered conversation outside my door followed by a quick knock and the appearance of Dr. Thong with yet another nurse.  They were both dressed in the same spiffy, blue, multi-purpose unisex uniforms.

     Dr. Thong looked remarkably the same every time I saw him.  He is a small Asian man in his late forties with flawless skin and an inscrutable expression.  His eyes betray nothing, but they are not unkind.  When I worked as a stockbroker before my retirement, he indulged in small talk and liked to give me his favorite stock tips.  He amused himself that way, and I was happy to have something to distract myself while he inspected my complexion.  Post-retirement chitchat was limited, however.

     “So, let’s have a look at you,” he said with no preliminaries.  He began with my hands and arms and made his way to my back.  “And, where is this tick bite that everyone is so concerned about?  Oh, I see it now.”  He muttered something to the nurse who wrote feverishly on my chart. 

     “Okay, nothing to worry about there.  It’ll get better on its own.”  With that dismissal, he moved around to the front and concentrated on my face.  “Now, let’s see this other problem a little closer.”  He hummed to himself thoughtfully.  “How long has it been there?”

     “A couple of months,” I said.  “It just doesn’t want to go away.”

     “Well, let’s see if we can make it go away faster.”  He motioned to the nurse, who handed him a contraption that looked like a bug spray can.  He gave three quick squeezes that made loud puffs of very cold air that hit the offensive red spot on my face.  Then, I felt an unpleasant burning sensation.  He took another look, appeared satisfied, and returned the can to the nurse, who struggled to write notes and handle the can simultaneously.

     “That should do the trick.  Very good luck,” he said.  “No problems.”

     “Thank you,” I said.

     He turned to leave and had his hand on the door.  “Anything else this time?”

     “No,” I replied.

     “Goodbye, then.”  He was gone.  No biopsies, no be sure to make an appointment for six months, no admonitions to wear sunscreen, nothing.  Just three puffs, and he was up, up, and away.  I sat transfixed and horrified by the visit.  I felt a “disconnect” between this doctor and my well-being.  I had a vision of being dismissed as an old woman whose health no longer required attention in a world of cheerful young medical professionals who moved briskly from one tiny sterile room to the next without making eye contact with the patients in those rooms.  It was a scary feeling.

     “You can get dressed now,” the nurse said.  “Just carry your chart to the checkout desk.  Follow the arrows.”  With that, she was gone, too.

     I glanced at my watch.  It was now 2:50.  My annual body check, complete with tick bite and face freezing, lasted approximately five minutes.  It took me longer to retrieve my driver’s license from my billfold for the receptionist. 

     I got dressed and followed the signs to the checkout desk.  A middle-aged woman wearing tiny reading glasses looked away from her computer screen to take my chart that now read SELF PAY.  I saw her comparing numbers in columns highlighted with different colors on a laminated sheet of paper.  Evidently, charges were relative, and she wanted to verify the amount for each procedure.

     “The total for today is $128,” she said sweetly.  “Will that be cash, check, debit or credit card?”  She paused, and then added, “I see no follow-up appointment is scheduled.  Do you think you’ll want to come back next year?”  Her tone was hopeful, and I saw she must be an asset to the practice by facilitating a warmer atmosphere during the payment process.

    “Debit card,” I said and handed my plastic card to her.  “I’m not sure about coming back, but thanks for asking.  I’ll call if I have a problem.”

    She quickly handled my payment and gave me my receipt.  I thanked her again and exited through the lobby area.   The hands on the clock on the wall showed 3:10 p.m.

     I officially joined the ranks of millions of Americans who are uninsured with little fanfare.  I now totally understood the magic of the phrase, “Your co-pay today is $35, and I’ll be happy to file your insurance claim for you.  May we schedule your next appointment?”  I complained each year that my co-pay increased.  I complained loudly that Dr. Thong was an “out-of-network provider,” which made my annual deductible higher for him.  And, of course, I complained regularly about the exorbitant cost of insurance.  Who didn’t?  It was acceptable cocktail-hour conversation.

    Now, we see through a glass darkly, I thought.

    In the spirit of fair play, I located my statement from my appointment with Dr. Thong the prior year.  I had two biopsies and an annual exam that day.  The office visit was $90, and the biopsies with laboratory analysis totaled $574.  I paid the $35 co-pay on the day of service, and my insurance carrier negotiated a reduction of $388 for reasonable and customary charges against the bill.  The insurance company eventually paid $45 to Dr. Thong, and I owed the balance of $196 to apply toward my annual deductible.  On the surface, my “self-pay” visit this year saved me $103.  Not to mention the fact that I no longer pay those outrageous insurance premiums.  Why don’t I feel better?

              ———————————————————————————–

The debate on healthcare reform and public policy in the United States follows the political fortunes of the fortunate.  In a country that prides itself on offering hope and freedom for all, we often reserve quality health care for the few who are wealthy enough to afford it.  The issues are complicated, and the systems and their operatives are deeply entrenched by decades of corruption and abuse that will make positive change a battleground for many years.  To sum up succinctly, it’s a mess.

As my daddy used to say, “When you’re up to your ass in alligators, it’s hard to remember your initial objective was to drain the swamp.”

On March 23, 2010, the Affordable Care Act became law in this country.  It’s an attempt to wrestle some of the alligators that love to snap at the reasonable objective of quality health care for every citizen.  This particular swamp won’t be drained quickly or completely, as an assault on the law continues by its opponents through the judicial system in 2011.   For me personally, Self Pay is over since I turned 65 in April of 2011 and am now covered by Medicare, but that’s another story with a different swamp of alligators.

About Sheila Morris

Sheila Morris is an essayist with humorist tendencies and a passion for photojournalism. She has published four nonfiction books including two memoirs, an essay collection and a collection of her favorite blogs from I'll Call It Like I See It. She has been blogging for seven years as her alter ego, The Red Man, her rescued Welsh terrier but now is reduced to writing as herself since the Red Man left Casa de Canterbury for good in February of 2016. She is a displaced Texan living in South Carolina with her wife Teresa Williams and their dogs Spike and Charly.
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