When medical care becomes a matter of life and death, the money demanded by the health care ecosystem reaches a wholly different order of magnitude, churning out reams of bills to people who can’t focus on them, let alone pay them. Soon after he was diagnosed with lung cancer in January 2011, a patient whom I will call Steven D. and his wife Alice knew that they were only buying time. The crushing question was, How much is time really worth? As Alice, who makes about $40,000 a year running a child-care center in her home, explained, “[Steven] kept saying he wanted every last minute he could get, no matter what. But I had to be thinking about the cost and how all this debt would leave me and my daughter.” By the time Steven D. died at his home in Northern California the following November, he had lived for an additional 11 months. And Alice had collected bills totaling $902,452. The family’s first bill — for $348,000 — which arrived when Steven got home from the Seton Medical Center in Daly City, Calif., was full of all the usual chargemaster profit grabs: $18 each for 88 diabetes-test strips that Amazon sells in boxes of 50 for $27.85; $24 each for 19 niacin pills that are sold in drugstores for about a nickel apiece. There were also four boxes of sterile gauze pads for $77 each. None of that was considered part of what was provided in return for Seton’s facility charge for the intensive-care unit for two days at $13,225 a day, 12 days in the critical unit at $7,315 a day and one day in a standard room (all of which totaled $120,116 over 15 days). There was also $20,886 for CT scans and $24,251 for lab work. Alice responded to my question about the obvious overcharges on the bill for items like the diabetes-test strips or the gauze pads much as Mrs. Lincoln, according to the famous joke, might have had she been asked what she thought of the play. “Are you kidding?” she said. “I’m dealing with a husband who had just been told he has Stage IV cancer. That’s all I can focus on … You think I looked at the items on the bills? I just looked at the total.”

In December, when the New York Times ran a story about how a deficit deal might threaten hospital payments, Steven Safyer, chief executive of Montefiore Medical Center, a large nonprofit hospital system in the Bronx, complained, “There is no such thing as a cut to a provider that isn’t a cut to a beneficiary … This is not crying wolf.”

Actually, Safyer seems to be crying wolf to the tune of about $196.8 million, according to the hospital’s latest publicly available tax return. That was his hospital’s operating profit, according to its 2010 return. With $2.586 billion in revenue — of which 99.4% came from patient bills and 0.6% from fundraising events and other charitable contributions — Safyer’s business is more than six times as large as that of the Bronx’s most famous enterprise, the New York Yankees. Surely, without cutting services to beneficiaries, Safyer could cut what have to be some of the Bronx’s better non-Yankee salaries: his own, which was $4,065,000, or those of his chief financial officer ($3,243,000), his executive vice president ($2,220,000) or the head of his dental department ($1,798,000).

Mercy Hospital is owned by an organization under the umbrella of the Catholic Church called Sisters of Mercy. Its mission, as described in its latest filing with the IRS as a tax-exempt charity, is “to carry out the healing ministry of Jesus by promoting health and wellness.”.... The overall chain had $4.28 billion in revenue that year. Its hospital in Springfield, Mo. (pop. 160,660), had $880.7 million in revenue and an operating profit of $319 million, according to its federal filing. The incomes of the parent company’s executives appear on other IRS filings covering various interlocking Mercy nonprofit corporate entities. Mercy president and CEO Lynn Britton made $1,930,000, and an executive vice president, Myra Aubuchon, was paid $3.7 million, according to the Mercy filing. In all, seven Mercy Health executives were paid more than $1 million each. A note at the end of an Ernst & Young audit that is attached to Mercy’s IRS filing reported that the chain provided charity care worth 3.2% of its revenue in the previous year. However, the auditors state that the value of that care is based on the charges on all the bills, not the actual cost to Mercy of providing those services — in other words, the chargemaster value. Assuming that Mercy’s actual costs are a tenth of these chargemaster values — they’re probably less — all of this charity care actually cost Mercy about three-tenths of 1% of its revenue, or about $13 million out of $4.28 billion.

Steve H.’s bill for his day at Mercy contained all the usual and customary overcharges. One item was “MARKER SKIN REG TIP RULER” for $3. That’s the marking pen, presumably reusable, that marked the place on Steve H.’s back where the incision was to go. Six lines down, there was “STRAP OR TABLE 8X27 IN” for $31. That’s the strap used to hold Steve H. onto the operating table. Just below that was “BLNKT WARM UPPER BDY 42268” for $32. That’s a blanket used to keep surgery patients warm. It is, of course, reusable, and it’s available new on eBay for $13. Four lines down there’s “GOWN SURG ULTRA XLG 95121” for $39, which is the gown the surgeon wore. Thirty of them can be bought online for $180. Neither Medicare nor any large insurance company would pay a hospital separately for those straps or the surgeon’s gown; that’s all supposed to come with the facility fee paid to the hospital, which in this case was $6,289.

His bill — which included not only the aggressively marked-up charge of $13,702 for the Rituxan cancer drug but also the usual array of chargemaster fees for basics like generic Tylenol, blood tests and simple supplies — had one item not found on any other bill I examined: MD Anderson’s charge of $7 each for “ALCOHOL PREP PAD.” This is a little square of cotton used to apply alcohol to an injection. A box of 200 can be bought online for $1.91.

Wright said the hospital’s lawyers had decided that discussing Steve H.’s bill would violate the federal HIPAA law protecting the privacy of patient medical records. I pointed out that I wanted to ask questions only about the hospital’s charges for standard items — such as surgical gowns, basic blood tests, blanket warmers and even medical devices — that had nothing to do with individual patients. “Everything is particular to an individual patient’s needs,” she replied. Even a surgical gown? “Yes, even a surgical gown. We cannot discuss this with you. It’s against the law.” She declined to put me in touch with the hospital’s lawyers to discuss their legal analysis.

“We think the chargemaster is totally fair,” says William Gedge, senior vice president of payer relations at Yale New Haven Health System. “It’s fair because everyone gets the same bill. Even Medicare gets exactly the same charges that this patient got. Of course, we will have different arrangements for how Medicare or an insurance company will not pay some of the charges or discount the charges, but everyone starts from the same place.” Asked how the chargemaster charge for an item like the troponin test was calculated, Gedge said he “didn’t know exactly” but would try to find out. He subsequently reported back that “it’s an historical charge, which takes into account all of our costs for running the hospital.”

“One of the benefits attending physicians get from many hospitals is the opportunity to cruise the halls and go into a Medicare patient’s room and rack up a few dollars,” says a doctor who has worked at several hospitals across the country. “In some places it’s a Monday-morning tradition. You go see the people who came in over the weekend. There’s always an ostensible reason, but there’s also a lot of abuse.”

1. The lawsuit is captioned Charles Carreon v. Matthew Inman; IndieGogo Inc.; National Wildlife Federation; American Cancer Society; and Does [Does are as-of-yet-unnamed defendants], Case No. 4:12 cv 3112 DMR.

2. Charles Carreon appears as "attorney pro se," meaning "I am attorney but am representing only myself"....

3. CNS included the following description of the case, which is most likely drafted by CNS upon review of the complaint: "Trademark infringement and incitement to cyber-vandalism. Defendants Inman and IndieGogo are commercial fundraisers that failed to file disclosures or annual reports. Inman launched a Bear Love campaign, which purports to raise money for defendant charitable organizations, but was really designed to revile plaintiff and his client, Funnyjunk.com, and to initiate a campaign of "trolling" and cybervandalism against them, which has caused people to hack Inman's computer and falsely impersonate him. The campaign included obscenities, an obscene comics and a false accusation that FunnyJunk "stole a bunch of my comics and hosted them." Inman runs the comedy website The Oatmeal."

Carreon replied that under California law, you must be properly registered to conduct a fundraiser, something he is certain that Mathew Inman (operator of The Oatmeal) and IndieGoGo (the crowdfunding site being used The Oatmeal) are not.

"You might think of it as the 'Pseudo Santa' law," he explained. "Anybody can get a Santa suit. Then around Christmas time, you can probably make pretty good money wearing one outside of Macy's, ringing a bell, and saying you'll give the money to the Salvation Army. But you can't do that."

Carreon went on to say that he had been in contact with the American Cancer Society and the National Wildlife Federation and confirmed that Indiegogo had not executed the proper fundraiser paperwork. He explained that this missing documentation gives a sponsoring organization the power to shut down a campaign that may bring a charity itself into disrepute or injure its goodwill...or might be "using a charity as a human shield for a slander campaign inciting people to cyber vandalism," Carreon added.

1. In that interview with Nafpliotis, Carreon makes some odd justifications for why he thinks it's okay to blame Inman for various attacks on his site (and a fake Twitter account). He basically says that because the comics that Inman draws are "dehumanizing," it's fair to assume that the attacks are because of that -- and (I'm not joking) compares it to Disney drawing cartoons that mocked Japanese people leading to Truman dropping the bomb on Japan:

   "It might not have seemed very dehumanizing when Walt Disney made Japanese people look silly with buck teeth and big glasses who could not pronounce their 'R's or their 'L's. But it was dehumanizing, and the purpose was to direct evil intentions against them, which ultimately resulted in the only nuclear holocaust that ever occurred in the history of humanity. I don't think Truman would have ever done that if we hadn't so dehumanized the enemy."
   
   "When you dehumanize someone, that is the first step to inciting people. The emails that I've gotten...many of them wish me death or wish for the complete collapse of my law practice...and they are virtually all uninformed."

   If people are sending Carreon nasty emails, that's a pretty stupid thing to do, but it's silly to blame Inman for it.
   
   Carreon also hints that Inman might be responsible for someone setting up a fake Twitter account in his name which had some "offensive statements." His evidence that Inman was responsible? At the same time that the fake account tweeted some stuff, Inman posted a tweet mocking Carreon in somewhat offensive terms. That tweet did not link to or reference the fake account, but according to Carreon: "I don't know if that's coincidence. Why was he on twitter at the same time the impersonator was? I don't know."
   
   We've suggested in the past that Carreon might want to learn a bit more about how the internet works. And here's one reason why: many people who use Twitter are pretty much always on Twitter. There's nothing surprising or odd about being on Twitter all the time. Inman's tweet indicates that he uses TweetDeck, one of (if not) the most popular Twitter applications, which you leave running all the time and thus has you "on Twitter" basically all the time.
   
   
2. As most people know, you will find perhaps no person around who is more vehement in saying that copyright infringement is not theft. I have argued that at length for years. Copyright infringement is not theft. It's not theft, it's not stealing. It's just not. That said, in no way do I think that someone who discovers that their work has been infringed and then refers to it as "theft" or "stealing" has "defamed" someone else. That's just crazy. It's an inaccurate portrayal, but one that is used colloquially all too frequently. To rise to the level of defamation would be something else entirely. Of course, it does not appear from the description that defamation is even a consideration here, since the lawsuit is from Carreon not Funnyjunk.