Copyright © 2020 Joseph George Caldwell. All rights reserved. Posted at Internet website http://www.foundationwebsite.org. May be copied or reposted for non-commercial use, with attribution to author and website. (19 December 2020)
Contents
The High Cost of Medical Care in the United States: Personal Examples 1
Cost of insulin for treatment of diabetes. 3
Cost of dialysis for treatment of kidney failure (end stage renal disease, ESRD) 6
Cost of inguinal hernia operation. 12
Cost of diagnosis of ministroke (transient ischemic attack, TIA) 16
Appendix A. Links to files containing copies of insurance statements 20
Appendix B. Some information about diffusion and osmosis. 21
Some time ago I wrote an article discussing the high cost of medical care in the United States, and proposing an alternative system based on provision of basic health-care services at no cost to the patient. It is published at Internet website http://foundationwebsite.org/ANewHealthCareSystemForAmerica.htm. That article cited a number of statistics on average health care costs in the United States and other countries. This note presents a few examples of health care cost from my personal experience. These examples serve to illustrate further, rather dramatically, the very high cost of US medical care, both relative to the actual cost of treatment and compared to the cost of treatment in other countries. Since they represent a self-selected sample of one, they are of little value as indicators of the overall state of the US health-care system, but they are nonetheless interesting as anecdotes reflecting the absurdly high cost of US health care. Statistics about the cost of medical care are rather “dry,” and some personal background is provided for each of the examples, to make them more interesting.
The examples to be presented are the following:
1. Cost of insulin for treatment of diabetes (for wife).
2. Cost of dialysis for treatment of kidney failure (end stage renal disease, ESRD; for wife).
3. Cost of inguinal hernia operation (for self).
4. Cost of colonoscopy (for self).
5. Cost of diagnosis of ministroke (transient ischemic attack, TIA; for self).
The word “cost” in the above refers to the price charged by the medical service provider. In all cases, the cost to me and my wife was zero, since the treatments were covered in toto by Medicare and Medicare supplement insurance (for persons aged 65 and over). The cost is not the amount collected by the provider, since, under Medicare, the service provider agrees to accept the amount that is paid by Medicare and the supplemental insurer. The “cost” bears little or no relationship to the actual cost of delivering the treatment.
For people without medical insurance, the prices represent amounts demanded by the service providers, and they must be paid. The prices of many common procedures are so high that many US households do not have the financial resources to cover a single episode. Patients on Medicare have the assurance that the government will negotiate a reasonable price for these services. Patients without Medicare have no such assurance, and face bankruptcy.
My wife was born in 1937, and I in 1942. The examples to be presented include just some of the medical treatments we have received, and they are limited to the last few years. In addition to the above medical treatments, my wife underwent an operation to place a stent in her coronary artery, implant of a heart defibrillator, and replacement of a heart valve; and I underwent implant of a heart pacemaker (for treatment of atrial fibrillation), appendectomy, treatment for Ménière's disease, lens replacements in both eyes, treatment for retinal detachments in both eyes, treatment for glaucoma, several bouts of pneumonia, four strokes (including the one listed above) and several dental implants.
Of the numerous treatments and procedures that we received over the years, the ones listed above were selected for discussion because they involved substantial cost and occurred fairly recently (mainly since 2015, so that I still had access to the billing documentation).
My wife developed diabetes in the 1980s. She treated it with diet, exercise and oral medications until the mid-1990s, when she began using injectable insulin. We were living in Malawi at the time (1993), and the cost of a 10-milliliter vial of insulin (concentration 100IU/ml) was about $2.00 (all prices in this note are US dollars). When we returned to the US in 1994, we were struck with “sticker shock” – the price of a 10-ml vial of insulin was about $20. Since then, the cost of a 10-ml vial has risen steadily, and today a 10-ml vial can cost $100 – 200 or more.
(The concentration cited above, 100IU/ml (where “IU” denotes international unit and “ml” denotes microliter), is the usual concentration of prescribed insulin. An international unit (IU, conventional unit) of insulin is defined as the “biological equivalent” of 34.7 μg (micrograms), or .0347 mg (milligrams) of pure crystalline insulin. This amount will induce hypoglycemic convulsions in a fasting rabbit weighing two kilograms.
(Conventional units of measurement are used in insulin therapy (medical practice), and SI units in scientific research. The formula for converting insulin conventional (UI) units to Standard International (SI) units is 1 μUI/mL = 6.00 pmol/L (where “pmol” denotes picomole and “L” denotes liter). A 10-ml vial of 100IU/ml-concentration insulin hence contains 1,000 IU of insulin. Prices for insulin are often cited per IU. For example, the price of $0.10 per IU would correspond to a price of 10 ml x 100UI/ml x $0.10/IU = $100 for a 10-ml vial of 100IU/ml insulin.)
There are several different forms of insulin, differing in how quickly and how long they act, how they are manufactured, and how they are packaged (vial vs. injection “pen”). It is still possible to obtain insulin for about $25 a vial, but it is an older, fast-acting type that is difficult to use. Formulations that include a mixture of both fast- and slow-acting types are expensive (e.g., $200 – 400 for 10 ml in pen form). The average usage is about two vials per month.
The price of insulin varies widely by country. On October 12, 2020, PharmaNews Intelligence reported that in 2018, the average price of insulin in the US was $98.70 (supposedly for a 10-ml vial, although the article does not say), compared to $6.94 in Australia, $12.00 in Canada, and $7.52 in the UK.
The list price for Humalog insulin was $20 per vial in 1996 when Humalog entered the market, and about $275 per vial in 2019. An increase of 1,375 percent over 23 years corresponds to an annual growth rate of 12 percent, a rate that far exceeds the consumer-price-index growth rate (a standard general rate of inflation).
Why has the price of insulin risen so dramatically in the US? Basically, because the pharmaceutical manufacturers can get away with it. The US government, the largest purchaser of insulin, is prohibited by law from negotiating prices with drug companies. The manufacturers are free to charge whatever the market will bear. In the other countries mentioned above, the government negotiates a price with the manufacturers. Other factors contributing to the price rise are:
1. It is illegal to import insulin (and other biologic drugs) from foreign countries.
2. There are just three major producers of insulin in the United States (Eli Lilly, Novo Nordisk, and Sanofi), with little competition.
3. There is extreme regulatory complexity (Food and Drug Administration regulations) associated with brining generic insulins to market.
As is discussed at length in A New Health Care System for America, America’s very high health-care costs are a direct result of the nature of the system: a for-profit system implemented by insurance and designed to maximize profits for the system controllers. The high cost of insulin is a prime example of how the system works to maximize profits for the wealthy.
About 2014, my wife’s kidney function declined to the point where it could no longer be controlled by oral medications. The primary cause of her kidney failure was diabetes. A secondary but major cause was her use of ibuprofen. Diabetes destroys blood capillaries that are essential to kidney function. Combined with ibuprofen, the level and rate of destruction increases markedly. My wife took several ibuprofen capsules a day to alleviate pain in her knees. She and I were unaware of the extreme harm caused by ibuprofen, and, regrettably, none of her health-care providers ever mentioned this fact to her.
There are two main treatment alternatives for end-stage renal disease – kidney transplant or dialysis. Kidneys are in short supply in the United States, and their allocation is controlled by the government to promote the greatest health benefit to the recipients (and to maximize financial return to the medical establishment over the life of the recipient). Because of my wife’s advanced age and underlying health conditions, a kidney transplant was not an option.
Kidney transplants are available in foreign countries at low cost, but that is not a practical option for most US citizens. The medical cost of maintaining a kidney after it has been received is high – about $2,000 per month for immunosuppressive (anti-rejection) drugs, for as long as the transplanted organ remains in the body. For kidney transplants received in the US (in a Medicare-approved facility), for which Medicare paid for part of the cost of the transplant, the government covers this maintenance cost (under Medicare). If the kidney transplant is received in a foreign country, however, the government will not pay the maintenance costs. (In 2013, when my wife began dialysis, Medicare provided coverage for immunosuppressive drugs under Part B if the transplant was covered by Medicare and in an approved facility. Medicare Part B did not provide coverage for immunosuppressive drugs if the beneficiary was not eligible for Medicare at the time of the transplant or the transplant was not in a Medicare-covered facility.) This policy assures a high level of income for US kidney transplant doctors.
The cost of kidney dialysis is very high, ranging from about $30,000 to $75,000 per year in the United States. There are two main types of dialysis: hemodialysis and peritoneal dialysis. With hemodialysis, blood is extracted from the patient, dialyzed in a machine, and returned to the body. (Dialysis is the process of removing from human blood the wastes, such as urea and creatinine), that would be removed by kidneys in a person having healthy kidneys.) This is generally done in three four-hour sessions at a dialysis clinic, but it may be done at home. With peritoneal dialysis, a chemical solution, called dialysis solution or dialysate, is injected into the patient’s abdomen, around the peritoneum. The dialysate remains in the patient for a few hours (which time is called the “dwell time”), during which time toxins in the blood (such as urea and creatinine) are drawn out of the blood by diffusion into the dialysate. Excess water is removed from the patient by the process of osmosis. The used dialysate is then extracted from the abdomen and new dialysate injected. Peritoneal dialysis is done at home.
There are two types of peritoneal dialysis. The dialysate can be put into and extracted from the patient using a machine, several times a night, or the exchange process can be done manually, using plastic bags (an empty one for receipt of the used dialysate and another filled with fresh dialysate) and an intravenous (IV) pole, several times a day.
In the United States about ten percent of all dialysis is peritoneal dialysis, and about ninety percent is hemodialysis. Peritoneal dialysis is less expensive, and patients using it live longer than those using hemodialysis. The primary reason why hemodialysis is used to a far greater extent than peritoneal dialysis is that it generates more money for the medical establishment.
There are many informative articles about dialysis on the Internet, and this process will not be described in this note. The basis for dialysis are the processes of diffusion and osmosis across a semipermeable membrane, which is a synthetic membrane in the case of hemodialysis and the visceral peritoneum (abdominal organ sac) in the case of peritoneal dialysis. A good summary of hemodialysis is presented in the article, Hemodialysis: Diffusion and Ultrafiltration by Ramin Sam, posted at Internet website https://austinpublishinggroup.com/nephrology/fulltext/ajnh-v1-id1010.php. A good summary of peritoneal dialysis is presented in the Wikipedia article, Peritoneal dialysis, posted at website https://en.wikipedia.org/wiki/Peritoneal_dialysis. See Appendix B to this note for more information about diffusion and osmosis.
Because our medical insurance covered all of the cost of any of the dialysis alternatives, the decision that my wife and I made about which one to choose rested on non-financial factors, such as safety, effectiveness, intrusiveness, comfort and convenience.
After the characteristics of hemodialysis and peritoneal dialysis were known to my wife and me, we decided to utilize manual peritoneal dialysis. She had previously experienced hemodialysis for several weeks following a heart-valve-replacement operation (in which the contrast dyes caused acute kidney failure), and found it to be totally unacceptable. The four-hour exchange sessions in the clinic were extremely unpleasant. The hemodialysis machine cools the blood a little, so she was very cold, and no number of blankets helped. She could not hold her bladder for four hours, so for part of the session she was lying in urine. The exchange sessions were held on mornings of Monday, Wednesday and Friday. The treatments left her exhausted for the remainder of these days and for the following day. She was left with one day a week of feeling reasonably well. With this regimen, she was not able to do any of her normal activities, such as playing duplicate contract bridge, homemaking, or socializing. Her quality of life was extremely poor. She had no life at all. It was heartbreaking to see her suffer so. If the sole dialysis option had been hemodialysis, she would have unquestionably chosen death over the treatment, and I would have been totally supportive of that choice.
When my wife began peritoneal dialysis, about May of 2013, we were living in Spartanburg, South Carolina. The cost of the dialysis treatment was about $30 thousand to $35 thousand per month. Since we were doing manual peritoneal dialysis at home, most of the manual work associated with the procedure (exchange bag hookups) was done by me. She saw a nephrologist once a month, for about a 15-minute session, and a nurse, dietitian or physician’s assistant for a comparable amount of time.
In 2015, we decided to move to Tucson, Arizona, where two of my wife’s daughters lived. Although my wife continued with exactly the same manual peritoneal dialysis as she had done in Spartanburg, the cost of treatment was about double.
Links to .pdf files containing copies of the insurance statements for Medicare and our supplemental coverage (UnitedHealthcare) are presented in Appendix A (they are not integrated into the text of this note since they are very long).
It is interesting to note that, although the cost of manual peritoneal dialysis in Tucson was double the cost in Spartanburg, my wife rarely saw her Tucson nephrologist (and not a single time in her last month of life), whereas she saw her nephrologist in Spartanburg every month.
It is difficult to justify the high cost of manual peritoneal dialysis. An IV pole costs about $25. All of the manual labor associated with the dialysate exchanges was done by me. The cost of a monthly visit to a nephrologist or dialysis clinic is a few hundred dollars. Dialysate is simply a water solution of common chemicals, such as sodium chloride, sodium bicarbonate, calcium chloride, potassium chloride, magnesium chloride and glucose or icodextrin (maltodextrin glucose polymer). Worldwide, the cost of two liters of dialysate (the amount used in each exchange, three to five times a day; usually three or four) is about five US dollars. In the United States, the cost of two liters of dialysate ranges from about ten to forty dollars. A peritoneal dialysis machine can be purchased for $400 – $4,000 (or much more).
In summary, the actual cost of manual peritoneal dialysis treatment is a few hundred dollars per month, whereas the price charged by dialysis treatment providers is in the range of $30,000 - $75,000. These prices are an obscene example of the outrageous US health-care system, which is designed to generate vast profits for the system controllers.
As high as these prices are, the price may be much higher. An example of the absurdly high prices is posted at Internet website https://khn.org/news/first-kidney-failure-then-a-540842-bill-for-dialysis/. In this case, which occurred in 2019, a patient was billed $540,841.90 for 14 weeks of dialysis care (three days a week) at a dialysis clinic operated by Fresenius Medical Care, one of two companies (along with rival DaVita) that control about 70% of the U.S. dialysis market.
In this case, Fresenius charged $13,867.74 per dialysis session, or about 59 times the $235 Medicare pays for a dialysis session, and an amount that is more than the typical cost of a kidney transplant.
A 1973 law allows all patients with end-stage renal disease to join Medicare even if they’re younger than 65, but only after a 90-day waiting period. During that time, patients are extremely vulnerable, medically and financially. As the dominant providers of dialysis care in the US, Fresenius and DaVita can demand extraordinary prices for their treatments.
There are approximately 750,000 people with ESRD in the US today. Medicare spends about $114 billion on kidney disease each year. Persons with kidney disease represent one percent of the Medicare population but account for seven percent of the Medicare budget.
President Trump recently initiated efforts to allow the import of insulin to the United States, and to decrease the cost of peritoneal dialysis (e.g., by preparation of the dialysate at home, using purified tap water).
The major concern with home-based dialysis is the risk of infection, leading to peritonitis, which is life-threatening and costly to treat. The main reason why dialysate is transported to homes from the manufacturing plants, rather than prepared at home from tap water and chemicals, is to ensure sterility. In order for home-based dialysis to be safe, it must be carried out by persons who are extremely diligent in following the prescribed regimen for cleanliness. Good manual dexterity (eye-hand coordination) is essential to avoid contamination of the apparatus and materials, and introduction of germs into the peritoneal cavity. One stay in a hospital to treat peritonitis would eliminate all of the savings associated with low-cost treatment.
In 2018 I suffered an inguinal hernia, and had an operation to repair it. I had had an inguinal hernia previously, perhaps ten years earlier. The surgeon who performed the earlier operation did not use mesh to support the repair. I asked him about that prior to the operation, and he replied that he never used mesh. Perhaps had mesh been used in the first hernia operation, the second hernia would not have occurred.
I do not have ready access to the billing for the first operation, but, if my memory serves me well, the surgeon’s fee was about $800 and the hospital fee was about $13,000. I was struck by the large size of the hospital bill, and so I called UnitedHealthcare to inquire about it. After I described my concern to the UnitedHealthcare agent, she asked me whether the claim had been paid. I told her, yes, it had. She responded that in that case, everything was in order, and there was nothing further to be done.
For the second hernia operation, in 2018, the surgeon’s fee was $1,076.00, the assistant surgeon’s bill was $371.11, the anesthesia bill was $2,320.00, and the hospital bill was $64,978.30.
Links to files containing copies of the insurance statements for this procedure are presented in Appendix A.
As surgical operations go, an inguinal hernia is not a very sophisticated operation. These operations, like appendectomies, have been done for a long time. They are not comparable in complexity or use of advanced high-technology devices, such as heart operations or brain operations. The hospital charge of $64,978.30 is difficult to fathom. The total cost of an inguinal hernia operation in foreign countries is a few thousand dollars (including travel and lodging). From a quick Internet search, the usual price-range cost of such an operation in the US is about $8,000 to $20,000. Here follows additional information about the cost of inguinal hernia operations in from the New Choice Health website, at https://www.newchoicehealth.com/hernia-repair-surgery/cost. (The date of the data is not shown in the article, but the posting is current (December, 2020).)
How much does hernia repair surgery cost?
The average cost of hernia repair surgery in the United States is $7,750, though prices can range from $3,900 to $12,500. The average cost for an inpatient hernia repair is $11,500, while the average cost for an outpatient procedure is $6,400.
One factor that can greatly affect the cost of hernia repair surgery is whether you have the procedure performed in an inpatient facility, like a hospital, or an outpatient surgery center.
Outpatient centers are just as safe as hospitals but could save you thousands on your medical bill.
Based on our data, the target fair price for open and laparoscopic hernia repair surgery is $5,500, whether you have health insurance or not.
National Average: $7,750
National Range: $3,900 – $12,500+
Outpatient Facility Average: $6,400
Inpatient Facility Average: $11,500
Target Fair Price: $5,500
Below, you’ll learn what factors into the cost of hernia repair surgery, as well as how to find a fair price for your surgery.
Hernia Repair Surgery Cost Averages Around the Country
(Location, Price Range)
Atlanta, GA Hernia Repair Surgery Cost Average $4,700 – $11,100
Chicago, IL Hernia Repair Surgery Cost Average $4,700 – $11,200
Dallas, TX Hernia Repair Surgery Cost Average $4,400 – $10,500
Philadelphia, PA Hernia Repair Surgery Cost Average $5,200 – $12,300
Phoenix, AZ Hernia Repair Surgery Cost Average $5,500 – $12,900
Los Angeles, CA Hernia Repair Surgery Cost Average $6,600 – $15,700
Miami, FL Hernia Repair Surgery Cost Average $4,700 – $11,100
New York, NY Hernia Repair Surgery Cost Average $5,400 – $12,900
Houston, TX Hernia Repair Surgery Cost Average $4,700 – $11,000
Washington, DC Hernia Repair Surgery Cost Average $5,200 – $12,400
Specific Hernia Repair Procedures and National Cost Averages
(Procedure, Price Range)
Laparoscopic Hernia Repair Surgery – Groin or Abdomen Cost Average $2,775 – $27,500
Open Hernia Repair Surgery – Groin or Abdomen Cost Average $4,400 – $35,300
[End of New Choice Health information.]
Over the years I have had a number of colonoscopies. These were done as a routine colorectal screening procedure for a person of my age, and not in response to any untoward signs or symptoms.
The most recent was done in Tucson in 2019. The charges for this procedure were $780.00 for the colonoscopy examination, $1,590.00 for anesthesia, and $6,852.30 for the hospital.
Links to files containing copies of the insurance statements for this procedure are presented in Appendix A.
Here follows information about typical costs for a colonoscopy in the United States, from the New Choice Health website at https://www.newchoicehealth.com/colonoscopy/cost.
How Much Does a Colonoscopy Cost?
The average cost of a colonoscopy in the United States is $2,750, though prices can range from $1,250 to $4,800.
One factor that can greatly affect the cost of a colonoscopy is whether you have the procedure performed in an inpatient facility, like a hospital, or an outpatient surgery center.
Outpatient centers are just as safe as hospitals but could save you thousands on your medical bill.
Based on our data, the target fair price for a colonoscopy is $2,450, whether you have health insurance or not.
National Average: $2,750
National Range: $1,250 – $4,800+
Outpatient Facility Average: $2,550
Inpatient Facility Average: $4,350
Target Fair Price: $2,450
Below, you’ll learn what factors into the cost of a colonoscopy, as well as how to find a fair price for your procedure.
Colonoscopy Cost Averages Around the Country
Location, (Price, Range)
Atlanta, GA Colonoscopy Cost Average $925 – $3,000
Chicago, IL Colonoscopy Cost Average $1,000 – $3,300
Dallas, TX Colonoscopy Cost Average $950 – $3,100
Houston, TX Colonoscopy Cost Average $950 – $3,100
Los Angeles, CA Colonoscopy Cost Average $1,400 – $4,600
Miami, FL Colonoscopy Cost Average $1,000 – $3,300
New York, NY Colonoscopy Cost Average $1,100 – $3,700
Philadelphia, PA Colonoscopy Cost Average $1,100 – $3,500
Phoenix, AZ Colonoscopy Cost Average $1,000 – $3,300
Washington, DC Colonoscopy Cost Average $1,050 – $3,500
Specific Colonoscopy Procedures and National Cost Averages
Procedure (Price, Range)
Colonoscopy Cost Average $1,800 – $12,500
[End of New Choice Health information.]
Some background information
Over the course of the years, I have had a number of eye problems. The first was a retinal occlusion, about 1986. A retinal occlusion is a blockage of a blood capillary in the retina (and is referred to as a “vascular incident”). The rods and cones in the portion of the retina served by that capillary cease to function, and vision is lost in that area, resulting in a “blind spot.” Usually, some of the vision returns, and the blind spot after several months is not as large as immediately after the incident. For this particular incident, the resulting blind spot was not very large – just large enough to cover a digit on my alarm-clock radio beside my bed, if I closed the other eye.
In 2013, while living in Spartanburg, South Carolina, I noticed that I was having an irregular heartbeat – irregularly spaced beats and “skipped” beats. I immediately consulted my family physician about it, and he sent me for a heart stress test, which measured normal. As it turned out, that test was not appropriate. The stress test measures the capacity of the heart to pump blood; it is not used to diagnose irregular heartbeat. A couple of months later, I suffered a stroke in my right eye, which resulted in a large blind spot (sufficient to cover a television screen viewed from normal viewing distance). When this incident occurred, I did not know what had caused it. I consulted a retinologist. He told me that the blind spot was caused by a stroke. Furthermore, he told me that, in view of the fact that I had had two previous strokes (the retinal occlusion in 1986 and a ministroke that caused vision stress and vertigo for about a half hour about 2007), it was evident that I had a cardiovascular problem that was causing the strokes. He emphasized the importance of diagnosing and treating this problem. He warned that if the problem continued, another stroke was to be expected, and it could leave me paralyzed or dead.
I returned to my family physician, and told him what the retinologist had said. He referred me to a cardiologist in nearby Greenville, South Carolina. The cardiologist was a retired professor of cardiology, and he really knew his stuff. After reviewing the incident, he told me immediately that the strokes were occurring because I had a slow and irregular heart rate. He explained the causal link as follows.
1. I have a low heart rate (bradycardia), often under 50 beats per minute while resting (I was a cross country runner in college).
2. I now have an irregular heart rate (irregularly spaced and skipped beats, a form of arrhythmia).
3. With both of these factors present, the blood “pools,” and when it pools, it tends to clot. The clot blocks a blood vessel, and causes the stroke.
He told me that I needed to have a heart pacemaker installed. The pacemaker would increase the heart rate and thereby reduce the likelihood of stoke. I scheduled an appointment to have a pacemaker installed, and did so in February of 2014.
The irregular heart rate was addressed by the pacemaker (my heart rate is now never less than 60, and irregularly spaced beats rarely occur). Later, I was diagnosed as also having atrial fibrillation (a form of arrhythmia in which the atria quiver instead of pulse normally). In addition to the pacemaker, I was prescribed flecainide, metoprolol and an anticoagulant (initially rivaroxaban (Xarelto) and later apixaban (Eliquis). The flecainide and metoprolol failed to control the atrial fibrillation (according to the pacemaker, I am now in an atrial fibrillation state 100 percent of the time), and all I take now is the Eliquis.
The course of this episode is a sad reflection on our medical system. Immediately upon experiencing the irregular heartbeat, I consulted my family physician about it. He misdiagnosed the problem. As a result, a couple of months later I suffered a stroke that has left me with a permanent large blind spot (unlike the small blind spot caused by the 1986 retinal occlusion, this large blind spot did not decrease in size). Had my physician correctly diagnosed the problem, or had he referred me to a cardiologist who surely would have, the problem would have been quickly diagnosed and treated (arrhythmia (whether simple irregular pulse or atrial fibrillation) is a common problem in older people, relatively easy to diagnose, and effectively treated). Without appropriate treatment, it was just a matter of time until another stroke occurred, as one did, a few months after the arrhythmia began.
Another stroke occurs
As I mentioned, the previous retinal stroke occurred in 2013. On Monday, March 25, 2019, I suffered another stroke. It was not a major one, and I did not realize at the time that a stroke had occurred at all. What happened was that I developed double vision. I had a medical appointment scheduled with my cardiologist for the following week (on Tuesday, April 2), and the double vision was not worsening, so I decided to wait until that appointment to discuss the incident with a physician.
Well, my cardiologist was quite concerned to hear of this development. He told me that I should proceed directly to the emergency room (his office is located in a hospital building) to have it looked at. He sent me, via wheelchair, to the ER. I was immediately seen by a triage doctor, who recommended that I have a brain scan. The brain scan was taken about an hour later, and showed nothing irregular.
I then proceeded directly to my ophthalmologist, for an eye examination. The ophthalmologist performed a few tests (asking me to describe the double vision as I tilted my head at various angles), and then told me that the source of my double vision (or diplopia) was palsy of the fourth left cranial nerve. In other words, another stroke. He told me that the double vision would likely return to normal within a few weeks, which it did.
The costs associated with the visit to the ER were as follows. The ER doctor’s fee was $602.00; the radiologist fee for performing the CT scan of my head was $130.00; the hospital cost of the CT scan was $3,352.84; and the hospital cost of the ER visit was $2,755.96. The ophthalmologist’s fee was $190.00.
Links to files containing copies of the insurance statements for this medical episode are presented in Appendix A.
It is very interesting to note that the ophthalmologist was able to diagnose the problem for $190.00, without benefit of any high-tech tests (such as the CT scan), whereas the ER department was not able to provide any information about the problem, and its fee was $6,840.80. It is curious that the cardiologist would send me for a seven-thousand-dollar evaluation of an event that had occurred over a week ago, with minor effect, and which had remained stable. Why did he not choose instead to send me, for an eye problem, to my ophthalmologist (located in an adjacent building, the same distance away from his office as the ER)? Could a factor be that his practice was part of the same hospital that operated the ER, whereas the ophthalmologist was not associated with the hospital?
Here follow hyperlinks to files (in Adobe Acrobat .pdf format) containing copies of statements of insurance payments for the medical procedures described in the text.
Medicare statements for Jacquelyn Caldwell, front side of sheets
Medicare statements for Jacquelyn Caldwell, back side of sheets
UnitedHealthcare statements for Jacquelyn Caldwell, front side
UnitedHealthcare statements for Jacquelyn Caldwell, back side
Medicare statements for Joseph Caldwell, front side
Medicare statements for Joseph Caldwell, back side
UnitedHealthcare statements for Joseph Caldwell, front side
UnitedHealthcare statements for Joseph Caldwell, back side
Some information about diffusion and osmosis (from Wikipedia and other sources)…. A solution is a homogeneous mixture of two or more substances in which the molecules or atoms of the substances are completely dispersed, or dissolved. The constituents may be solids, liquids, or gases. A solute is a component of a solution which, upon becoming dissolved (going into solution), changes its form and loses its original characteristics. The solute is the substance that is being dissolved, while the solvent is the dissolving medium. A solute is usually in smaller amounts in the solvent, and the solvent in a larger amount. A common example of solute and solvent are salt and water. Salt dissolves in water and therefore, salt is the solute and water is the solvent. For solutions of fluids, the solvent is present in greater amount than the solute. Concentration is a measurement of the amount of solute present in a chemical solution, with respect to the amount of solvent. Usually, a solvent is a liquid. However, it may be a gas, solid, or supercritical fluid.
Technically speaking, a solution consists of a mixture of one or more solutes dissolved in a solvent. The particles of solute and solvent are molecules or ions, with one or more solvent molecules bound to each solute particle. A semipermeable membrane is a membrane (as a cell membrane) that allows some molecules to pass through but not others.
Diffusion is the net movement of anything (for example, atoms, ions, molecules) from a region of higher concentration to a region of lower concentration. Diffusion is driven by a gradient in concentration. The material that diffuses may be a solid, liquid or gas. Similarly, the medium in which diffusion occurs may also be in one of the three physical states.
Osmosis is the diffusion of fluid through a semipermeable membrane from a solution with a low solute concentration to a solution with a higher solute concentration until there is an equal solute concentration on both sides of the membrane. More specifically, osmosis is the spontaneous net movement of solvent molecules through a selectively permeable membrane into a region of higher solute concentration, in the direction that tends to equalize the solute concentrations on the two sides. It may also be used to describe a physical process in which any solvent moves across a selectively permeable membrane (permeable to the solvent, but not the solute) separating two solutions of different concentrations. Osmosis can be made to do work. Osmotic pressure is defined as the external pressure required to be applied so that there is no net movement of solvent across the membrane. Osmotic pressure is a colligative property, meaning that the osmotic pressure depends on the molar concentration of the solute but not on its identity (i.e., depending on the quantity of particles but not on their chemical nature). Osmosis is a vital process in biological systems, as biological membranes are semipermeable. In general, these membranes are impermeable to large and polar molecules, such as ions, proteins, and polysaccharides, while being permeable to non-polar or hydrophobic molecules like lipids as well as to small molecules like oxygen, carbon dioxide, nitrogen, and nitric oxide. Permeability depends on solubility, charge, or chemistry, as well as solute size.
For diffusion and osmosis to occur does not require net expenditure of energy. Examples of substances transported by diffusion include carbon dioxide, oxygen, water, food substances, and wastes such as urea. The substance transported in osmosis is usually water.
Similarities and differences between diffusion and osmosis
A similarity between osmosis and diffusion is that they are both passive in nature and no external force is required for the flow of molecules from one place to another. Solute potential is defined as the pressure that must be applied to a solution to prevent the inward flow of water through a semipermeable membrane. The flow of water stops because the pressure of the solution and the pressure of the water are equal. Osmotic potential is another term for solute potential. Diffusion is not dependent on the solute potential of the mixture, whereas osmosis is dependent on the solute potential of the mixture. Osmosis, therefore, is a selective form of diffusion. Diffusion is based on random flow of molecules and is much more common in gases while, osmosis is based on the inherent solvent capacity of the molecules of a substance in water (or other liquid).
Diffusion occurs with or without a membrane between two areas of different concentrations of molecules. However, osmosis occurs only across a semipermeable membrane.
The primary differentiating factor between the processes of osmosis and diffusion is the medium in which they occur. Osmosis can occur only in a liquid medium, but diffusion can occur in all three media (solid, liquid and gas). Furthermore, osmosis requires a semipermeable membrane, while diffusion does not. A major difference between osmosis and diffusion is that both solvent and solute particles are free to move in diffusion, whereas in osmosis, only the solvent molecules (water molecules) cross the membrane.
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