Couldn't go with that flow: Why one of my medical bills went past due

In a frustrating shuffle known to millions, I recently paid one creditor with funds from a different line of credit. I don't normally pay debts with borrowed money, but we didn't have the cash. And after years of good relations, a merchant had decided to play hardball with a balance I had failed to resolve. Time flies when you are all tapped out and feeling uncooperative: 90 days after sending me the first bill, 60 days after denying my appeal, three weeks after a Final Notice, they sent in the bag men.

Though I have heard the tune in which Rihanna asks, in effect, if you happen to have the money you owe her, this was my first time getting a letter from a collections agency. I can report that there is something harmful to the customer-merchant relationship in being downgraded from buyer to deadbeat. After years of loyal patronage, I had been handed off to a north-metro operation that conducted its shakedown on blue paper and in Western Union prose. I viscerally disliked the sight of my name in its fonts from the 1980s. I was prepared to do whatever it took to get this call center out of our lives.

I normally stay on top of the finances, but we had been busy paying other expenses — some of them owed to the same vendor for purchases made by my wife. The charge in question had been laughably overpriced — marked up with swagger. And I now know I could have lived without this $521 impulse buy — like a pair of $200 stretch pants or $300 headphones. But I'd had no way of judging the value of these goods. In fact, I wasn't given a single term of the sale.

The vendor, not I, had decided I would be buying the service. The vendor withheld discussion of price, or cheaper alternatives, or any sort of context to help a person understand its value. It goes without saying that if I was not happy with this item, I could never get a refund.

And I absorbed these Dali-esque conditions of sale under subtle pressures thanks to a host of cultural norms, including the importance of being a good user of this particular product line, the importance of showing deference to this particular type of salesman, and, on a personal level, the importance of avoiding early death.

If you haven't guessed by now, all of this can only mean one thing: I had gone to the doctor.

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For patients buying insurance on the federal exchanges, having "skin in the game" has become more of a traumatic de-gloving, with median annual deductibles running $3,000 in Des Moines, $5,000 in Miami. By law, insurers can only assess individuals $6,600 a year in total out-of-pocket costs. That would suggest that the great deductible hidey-hole is almost at capacity and that any brake it once placed on premium increases is wearing thin.

Neither raising deductibles or premiums enabled UnitedHealth and Blue Cross to make money selling health insurance to individuals; both recently announced they are pulling out of that market. The coming spike in premiums and cost shifting already in place has been depicted as a failure of the Affordable Care Act to force enough healthy young people into the regulated market.

But their premiums wouldn't be as critical if there were any kind of price transparency and consumer protections on costs for a person entering the hospital. As a result, the average American already paying for premiums must buy the equivalent of a 90-inch flat screen before getting health care covered. That can be all it takes to introduce a solvent household to the collections community.

Which is what happened this year in our home (and many other homes like ours). As of last year, 1 in 3 Americans reported needing to stagger a tough medical bill over a period of months or let it slide altogether, according to the Kaiser Family Foundation, and most of them were insured. Like me, a third had to reach for a credit card so that the greatest health care system in the world could continue pricing its goods according to whimsy, daring and generous rounding up.

Medical debt has become the leading source of negative entries on credit reports — it makes up over 52 percent of all entries that are not credit card debts, according to the Consumer Financial Protection Bureau. And the damage is outsized to losses. According to the CFPB, the median medical bill triggering hits to credit ran just $207. For 1 in 5 credit reports tagged for unpaid medical bills, the only negative entries involved medical charges. Half of these Americans never had a bad entry prior to encountering an unexpected medical charge.

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Which is about as long as a guy can delay spilling the beans on how he ran up a $521 charge for testing that can be replicated by relieving yourself onto a plow pile behind a beer hall. It's not pleasant to take a deep dive into the urology charge that put my family in arrears. But hopefully the tale is representative of how easily an encounter with the health care system can make sticking to family budgets impossible.

That the encounter was with a medical brand known for best practices and involved a person in good health and who was under a generous large-employer insurance package suggests how much worse things must get for those with bad health, bad coverage and bad doctors. And besides, medical care may be complex, but everyone understands plumbing.

So with apologies for a brief discussion of bodily functions, sometime last winter I began to experience a mild fever coupled with a concern that my role in the continuous movement of water between land and sea was becoming stalled. I knew such an obstruction could lead to injury. There are kidneys to protect. I have seen "Seinfeld" and the Flomax commercials. So I called urology at the venerable Mayo Clinic, a health system I have used for years. I was given an appointment and told to show up needing to use the men's room.

Having male friends of a certain age, I'd heard diagnosing this kind of obstruction required a trip to the restroom followed by an ultrasound. I was more than happy to pay for the imaging of my aqueducts to get an answer and be on my way. As it happened, that test was negative, and, as I would eventually learn, would end up being billed at just $124.

Preventive screening in the Affordable Care Act forced the insurer to cover a portion of the visit billed as the office exam. It was a little steep for 15 minutes with a physician assistant, but at $243 that, too, was defensible, given the knowledge involved. And the ACA made my insurer pay for a so-called PSA reading they added to my blood panel. At $115, the cancer screening throws up too many false positives to be worthwhile, according to a panel that evaluates the wisdom of medical tests. So I would have said no to learning my PSA was fine. But as we all know, they don't ask.

"We're going to have you use the uroflowmetry machine," my physician assistant added as I was on my way to see that man about a horse. Had he said that it was going to cost $500, but that it would tell me whether I could still empty with the force it takes a guy to write his name in a snowbank, I would have told him: Let's skip that one. As best as I can tell, uroflowmetry elicits data from the placement of a plastic funnel above the porcelain throne, followed by a small pass-through unit calibrating flow.

He could have just asked me how many bars of "Oh! Susanna" I was able to whistle before wrapping it up.

Back in the exam room, my physician assistant reviewed for my benefit a small printout with a bell curve representing my output in volume over time. Uroflowmetry had concluded I was healthy. Like the vast majority of mammals, I had executed the function at rising and then descending speeds over a 20-second window. (As a team of Georgia Tech physicists discovered in 2014, there is a universal Law of Urination, with animals large and small voiding their contents in the same 21-second time frame.)

Hey, I didn't care. I was just relieved (sorry) to learn I had no logjam in the drain tile and was free to leave the building. My total stay — less than 15 minutes.

Yes, that sounds like something a retiree who calls into C-SPAN might do.

Listen: I could have accepted the eventual blue letter stating, in the immortal words of Rihanna, don't act like you forgot — if my unpaid debts had been self-inflicted. If my tab had been created from a massive bender ending in front-row seats at Caesar's Palace, yes, shake me by the ankles. But it was for taking a leak. The fee, explained a reply to my questions from Patient Account Services, is for the use of the calibrated equipment, the nursing staff, the physician to read and analyze the results, and various supplies.

Six weeks after that, an automated billing center located 10 states and 1,350 miles away sent me my Final Notice.

I live across the street from the Mayo Clinic.

I looked up the collections agency used by Mayo. In an irony of ironies — and if anonymous posters on employee complaint forums can be trusted — it turns out that workers for my doctor's collection agency are getting saddled with unmanageable cost-sharing, too.

If the people chasing medical debt have this much in common with the people saddled by medical debt — and if health care cannot find a way to treat its customers with the same transparency and predictability provided by every other business — we may end up demanding a health care system in which there are no more customers. Just patients.