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Piles Upon Piles
In the days before managed care, most insurance plans operated on a fee-for-service basis. Patients paid 20 percent of medical fees; insurers paid 80 percent. But as health care costs have continued to rise, many patients are being required to pay an ever-larger part of their medical bills, and deductibles continue to increase. And to keep the system churning, close to 30 cents of every dollar spent on health care goes for administration, much of it spent generating bills and explanations of benefits.
"The number of bureaucrats between the point of service and the final cash reckoning is just incredible," said Dr. Thomas Delbanco, a professor of primary care medicine at Harvard Medical School who is a leader in the field of patient-centered care.
For many people, the piles of paperwork they must contend with reinforce a simmering discontent with a system that aggravates tensions among patients, hospitals, doctors and insurers.
Insurance companies are, by and large, unapologetic.
"Even though the amount of paperwork a patient has to deal with might seem to be a lot, it would be much worse if there wasn't a unifying organization like a health plan easing that burden," said Dr. Alan Sokolow, chief medical officer at Empire Blue Cross Blue Shield in New York.
This might come as a surprise to Ellen Mayer, an artist who lives in Chester, N.Y. Ms. Mayer, 54, has a rare type of gastrointestinal cancer that requires constant monitoring through blood work, CT scans and PET scans.
The paperwork nightmare started for Ms. Mayer when her oncologist switched hospitals. Everything suddenly seemed to need a justification, or a new piece of paper with an authorization.
The stacks of papers, folders and Post-It notes related to Ms. Mayer's treatment have started to take over her house. They fill manila envelopes, boxes and files, which fill closets. They spill from the dining room table onto chairs.
"You can't just be sick," she said. "You have to be sick and be drowning in paperwork."
So overwhelming has the paperwork grown that Ms. Mayer has considered giving up and ceasing all treatment because of the bureaucratic hassle that accompanies it.
"It's comical, it's unbelievable," she said. "And I think to myself, 'What if I was an elderly person, or a single person? What if I wasn't healthy enough to handle it?' "
Dr. Michael Mustille, associate executive director of the Permanente Federation in Oakland, Calif., said medical paperwork often delivered "a double psychological whammy."
"People get these things that look expensive that they can't understand," Dr. Mustille said, "and then there's the worry that the people they've paid for insurance may decline to assume responsibility for it."
In Mrs. Klausner's case, her son bought her an elaborate paper organizer, hoping it might help her face the chaos. She never used it.
Creditors began to call. Whenever a collection notice showed up, Mrs. Klausner panicked and wrote a check or reached for the telephone to call her son for help.
In the end, Medicare and United Healthcare paid most of Mrs. Klausner's bills, which added up to more than $150,000. And although the unwelcome mail has ceased, she cannot bring herself to throw out the bags filled mostly with unopened envelopes dating back to 2002, as if doing so might violate a law.
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