My daughter does well in emergency rooms. She likes a captive audience. She knew what the people waiting in the Southampton Hospital ER on the night before the Fourth of July needed. They needed to be offered some blueberries by a four year old with blood running out of a gash on her head, and they needed to meet her dolly. She was nearly within arms reach of both my mother and I when she fell. She got her arms out fast enough, but of course her arms went to either side of the leg of the tuneless piano that sits in the corner of the kitchen, and its edge sliced her scalp quite decisively. Ilaria’s good behavior may have bought us some extra time in the waiting room, but after a couple hours of trying to get the party started, only intermittently remembering her boo-boo and sending her hands up to her face with a wail, she was called back for her stitches. The nurse asked if I wanted them to page plastics or just have the ER physician stitch her up. I asked if insurance would cover stitches from the plastic surgeon, even as the implications of this choice settled on my brain—do you want your little girl to grow up with an ugly scar on her face, or would you like a bit more time and training behind this procedure? She said generally yes, just as the plastic surgeon appeared. I knew Ilaria would have to be restrained, and that this would be the worst part for both of us. I helped the nurse wrap her in a grey mummy suit, her arms pinned to her sides and thick Velcro across her chest. I know what it feels like to forcibly hold someone still in the effort to help them. I would still rather do it myself than have someone else do it to her. I am a nurse. Dr. Miller was kind and gentle, and I held my baby’s sweaty head still with my own hands, my face next to hers, inches away from his needle as he numbed her forehead with lidocaine and then put seven stitches into the muscle wrapping her skull and ten into the skin, while she screamed the scream that tangles in the back of the throat and chokes you raw, and soaked the mummy suit with pee. Dr. Miller said he would see us at his office in ten days to remove the stitches, but on July 6th, after I’d left her in Bridgehampton with my parents and gone back to work in Baltimore, my mother sent me an email: AGAIN! This time, she had bitten her lip when she fell and her sharp young incisor had gone clean through it. My mom called Dr. Miller, whose card I had given her, and he met them at the hospital for another moment with the mummy suit and seven more stitches. I wish that were the end of this story. The non-scary injuries of a healthy child, rambunctious and klutzy in an unfamiliar house, feel like a rite of summer. The care she was given was straightforward, compassionate and appropriate. Three days between ED visits was embarrassing, though Dr. Miller assured us that wasn’t the fastest he’d seen a kid come back for more. But in November, a bill for $10,803.77 and a handwritten note instructing me to call my insurance company and demand payment in full brought my idyllic memory of functional healthcare tumbling from its pedestal. As a full-time registered nurse at one of America’s best hospitals, I carry a premium Employee Health Plan that allows us to see specialists without a referral and covers emergency room visits at 100% after a hefty copay. When I got the $10,803.77 bill, insurance had already paid Dr. Brady $1600 and the hospital $1400 for these two dates. So I began the rewarding process of banging my head against the bureaucratic wall thrown up by my insurance company. They claimed that resolving the bill wasn’t their responsibility, and deflected me towards an entity called NCN DataISight, the company that tells them how much to pay for each diagnostic code. The bill wasn’t a mistake, there was just a large difference between what Dr. Miller charged and what DataISight determined was a reasonable fee, and it took a year of appeals by myself and by Jeffrey, a polite, gung-ho man from the doctor’s billing office, to get the bill paid. Even though Jeffrey was the one sending me the bill every few months, he was actually helping me through his own efforts to get the insurance company to pay, and he was, notably, a person. (All communication from my insurance company—i.e., their letters repeatedly denying further coverage—was signed “Sincerely, Adjudications Department.” Thanks for the update, glad you’ve got my back. Can I call you Judy for short?) My mother said the stitches were probably so expensive because Dr. Miller was a plastic surgeon, that Ilaria’s forehead had healed so well you could hardly see the scar. Maybe it was worth it. That’s not the point. I appreciate Dr. Miller’s immaculate work. But I have health insurance that is supposed to cover these charges, and more importantly, stitches shouldn’t cost this much money. This is the kind of bill that puts people out of their homes. This is the kind of bill that can ruin lives. The last bill I received had a handwritten note telling me to call the billing office itself “to discuss the options for payment. .” Was that second period merely a stray pen mark, or did the writer truly lean halfway towards an ellipsis, suggesting that our communication was reaching its ominous, unspeakable end? But Jeffrey just gave me another pep talk. “If you keep calling them, chances are they’ll pay. We don’t even need them to pay the whole bill. Sometimes we go for, like 85%.” Jeffrey approached this like a game, and he managed to make me feel like we were on the same team. I asked him why the bill was so enormous. Was it because Dr. Miller is a plastic surgeon? Did I sign myself up for this headache when I chose a prettier scar? He said no. The fee schedule is only slightly based on physician specialty. It may be a little higher than it would have been for an ER physician, but not much. “It’s really because it was in Southampton,” he said. “It’s about the zip code, really. This would have been much cheaper if you were somewhere out in Nassau. But the good news is, it’s still much cheaper than if you had been in Manhattan.” My insurance company was based in gritty Baltimore, and their reimbursement schedule didn’t align with Hamptons-style billing. Next time you have a medical emergency, make sure you’re not visiting well off relatives. As an ICU nurse, I have ample opportunity to observe the excess that defines America’s current medical system, but this bill gave me a new perspective. I’m familiar with the pursuit of detailed information drawn from ailing bodies to no real end and surgery performed on patients whose bodies and minds have already been destroyed by illness or injury, where a look at the big picture begs a simpler and gentler approach, but in the case of Ilaria’s stitches, the big picture was actually very small. Last summer a little girl got a cut that needed stitches, twice, and those stitches cost fourteen thousand dollars. I told Jeffrey, after giving him the news that the $10,803.77 balance would be paid, that the victory felt bittersweet. Did Dr. Miller even know that he was charging this much? “Probably not,” said Jeffrey, “and the thing is, it’s not like he’s making any money. Miller pays upwards of $300,000 a year to malpractice insurance, you know, and his overhead is very high.” I thought about everyone I’d spoken to about this bill over the past year: people from my insurance company, people from NCN DataISight, Jeffrey. Everybody but me was at work during the time they spent bouncing this bill along, and these jobs are part of the “overhead” that drives costs. In addition to the unnecessary tests and procedures going on inside hospitals, the bloat consists of the inflated prices for necessary procedures that support the salaries of the non-clinical people working on the outskirts of the system, salaries that go in part towards paying for the time spent deliberating over these inflated prices. When I told Jeffrey that I am a nurse who hopes not only to care for patients but to help improve health care by talking about it’s weaknesses and flaws, he told me that he was just finishing med school. He worked his way through school in Dr. Miller’s office, and now he has an intimate knowledge of the absurdities of the medical system, and he hopes to help too.