My mama told me, way more than a few times: Go to College. The first time she told me that was after a buddy and myself made a deal with our neighbor to pull two of his stumps, I think for $10 a stump. Not being professional stump pullers – actually these were our first stump jobs – we had no idea how long it might take to dig around an old maple tree, whack off its roots with axes and hatchets, put a come-a-long on the thing and haul it out. Like pulling a giant tooth, how hard could it be?

Two days later, blisters on both our hands, we finally disgorged the monster stump. Nothing to it! Course, we had the other one to do and now we knew – and dreaded – the work ahead of us. But a contract was a contract, a handshake a handshake, even for us 15 year olds. So much for our summer vacation. Our neighbor gave us each 10 bucks and no tip, no bonus, no thank you. Four days of hard labor. My mother, on the other hand, had a tip waiting for me at home.

“What do you think you made an hour?” she wanted to know. “Not much,” I said, pretty bummed and very tired. I figured a quarter an hour. And yeah, don’t say it, I know a quarter was worth more in 1965.

My mom asked if I had any idea how much my father made an hour. Actually, I didn’t, not a clue, but I hazarded ‘fifty cents?” Mom, well, let’s just say she didn’t have the greatest sense of humor, especially not wise-ass son humor, so she cut right to her Lesson of the Day, told me he made 50 times what I just made, all because – and here was the crux – He Went to College.

Now, I didn’t tell her I’d eventually have my own stump removal company, hire a hundred kids to pull them, franchise the whole she-bang and become a millionaire when the stock went public. I just put my head down and said. “I got it Mom.” I did go to college but ended up working stump pulling wages at various dead end jobs before becoming a starving artist.

Today I was at an oral surgeon seeing about yanking a tooth too far gone for a root canal and crown. My doc came in, said hello, snapped on some blue exam gloves, looked in my pie hole and said make an appointment at the desk for an extraction while you’re paying for this exam. At most, 5 minutes. The bill came to $100. If you’re as expert at math as me, a college graduate, that comes to $1200 an hour.

So okay, Mom, happy now??

See more by Skeeter Daddle 

“Time perception matters because it is the experience of time that roots us in our mental reality.” That’s precisely what acclaimed BBC broadcaster and psychology writer Claudia Hammond explores in Time Warped: Unlocking the Mysteries of Time Perception (public library) — a fascinating foray into the idea that our experience of time is actively created by our own minds and how these sensations of what neuroscientists and psychologists call “mind time” are created". Read more

“There is one book that I would rather have produced than all my novels,” Willa Cather rued in her most candid interview about creativity. That book was Rocky Mountain Flowers: An Illustrated Guide For Plant-Lovers and Plant-Users (public library| public domain by the pioneering plant ecologist and botanical artist Edith Clements (1874 –1971). Read more

If you’re a savvy investor like myself, no doubt you’ve been sniffing around the cryptocurrency phenomenon, wondering if it’s time to plunk down some of those 20th Century dollars and trade em in on bitcoins. You might even be wondering what exactly cryptocurrency is, possibly googled it, and undoubtedly come away realizing you haven’t got a clue. But then, what is an Andrew Jackson, really? Just cloth with dyes and inks and watermarks. Worth what it says on the bill if everyone keeps believing it’s real even if no gold is sitting in Ft. Knox to back it up. Economics, a faith based religion?

Cryptocurrency, forget about the gold standard. What you got is blockchain. Okay, I know, you don’t actually understand blockchaining. That’s fine, neither do I and neither do most people who own bitcoins or any other cryptomoney. You just know some economists think this is the future of monetary transactions, safer than greenbacks in your bank account some lowlife hacker can empty faster than you can say Bad Password. Bitcoins, well, their password is unhackable, but … if you forget it, no way can you or the hackers get at it, sorry.

But what you do notice is that bitcoins and their brethren virtual cash move up and down in value the way Apple stocks do, a breathtaking hedge against minimum interest rates on your savings. Now, you could ask yourself, before, hopefully, you convert your life investments and 401-K and the pension to bitcoin, what kind of currency can change value 20% in a day, up, down, you just never know. Would you put your money in a bank that offered the potential to drop in value half overnight?

Well obviously some people would. If it looks like a pyramid scheme and smells like a pyramid scheme and acts like a pyramid scheme, I think you and I know it probably isn’t a real smart investment, it’s just a high tech form of gambling cloaked in crypto-babble. Me, I’d rather bury money out in the yard. Just so long as I don’t lose the map showing where I put it. 
Read more Skeeter Daddle Diaries

"Remembrance of things past is not necessarily, the remembrance of things as they were" .. …......"Consider that our memory only retains a fraction of what we have attended to in moments past. In the act of recollection, we take these fragments of fragments and try to reconstruct from them a totality of a remembered reality, playing out in the theater of the mind"...... Read more

See more of Randall Munroe's work at xkcd.com - This work is licensed under a Creative Commons Attribution-NonCommercial 2.5 License,

Johann Friedrich Von Schiller (1759 - 1805) - German playwright, poet, and philosopher. He authored an extraordinary series of dramas, including The Robbers, Maria Stuart, and the trilogy Wallenstein. He best known for his  influence on German literature.

If you can keep your head when all about you
Are losing theirs and blaming it on you;
If you can trust yourself when all men doubt you,
But make allowance for their doubting too;
If you can wait and not be tired by waiting,
Or being lied about, don't deal in lies,
Or being hated, don't give way to hating,
And yet don't look too good, nor talk too wise:

If you can dream, and not make dreams your master;
If you can think, and not make thoughts your aim;
If you can meet with Triumph and Disaster
And treat those two imposters just the same;
If you can bear to hear the truth you've spoken
Twisted by knaves to make a trap for fools,
Or watch the things you gave your life to, broken,
And stoop and build 'em up with worn-out tools;

If you can make one heap of all your winnings
And risk it on one turn of pitch-and-toss,
And lose, and start again at your beginnings
And never breathe a word about your loss;
If you can force your heart and nerve and sinew
To serve your turn long after they are gone,
And so hold on when there is nothing in you
Except the Will which says to them: "Hold on!"

If you can talk with crowds and keep your virtue,
Or walk with kings, nor lose the common touch,
If neither foes nor loving friends can hurt you,
If all men count with you, but none too much;
If you can fill the unforgiving minute
With sixty seconds' worth of distance run,
Yours is the Earth and everything that's in it,
And, which is more, you'll be a Man, my son!

Joseph Rudyard Kipling (1865 – 1936) English journalist, short-story writer, poet, and novelist. He was born in India, which inspired much of his work. His works of fiction include  "The Man Who Would be King" and the "Jungle Book"/ His Poems include "Mandalay", "The Gods of the Copybook Headings", "Gunga Din"and "If...."

Walter Mondale (1928 - 2021) American politician, diplomat, and lawyer . He served as the 42nd vice president of the United States from 1977 to 1981 during President Jimmy Carter administration. 

ACLU, a defender of digital privacy, reveals that it shares user data with Facebook : Fortune

533 million Facebook users' phone numbers and personal data have been leaked online : Business Insider

Facebook Built the Perfect Platform for Covid Vaccine Conspiracies  : Bloomberg Businessweek

  “You can be 100 percent confident in your vivid memory and still be 100 percent wrong.” from "Remember": "The Science of Memory and the Art of Forgetting." -  Lisa Genova's book exploring the intricacies of how we remember, why we forget, and what we can do to protect our memories, Click to read the New Yorker's article by David Kortova,

Kyunghee Lee’s right hand hurts all the time.

She spent decades running a family dry cleaning store outside Cleveland after emigrating from South Korea 40 years ago. She still freelances as a seamstress, although work has slowed amid the covid-19 pandemic.

While Lee likes to treat her arthritis with home remedies, each year the pain in the knuckles of her right middle finger and ring finger increases until they hurt too much to touch. So about once a year she goes to see a rheumatologist, who administers a pain-relieving injection of a steroid in the joints of those fingers.

Her cost for each round of injections has been roughly $30 the past few years. And everything is easier, and less painful for a bit, after each steroid treatment.

So, in late summer she masked up and went in for her usual shots. She noticed her doctor’s office had moved up a floor in the medical building, but everything else seemed just the same as before — same injections, same doctor.

Then the bill came.

The Patient: Kyunghee Lee, a 72-year-old retiree with UnitedHealthcare AARP Medicare Advantage Walgreens insurance who lives in Mentor, Ohio

Medical Service: Steroid injections into arthritic finger joints

Service Provider: University Hospitals Mentor Health Center, part of the University Hospitals health system in northeastern Ohio

Total bill: $1,394, including a $1,262 facility fee listed as “operating room services.” The balance included a clinic charge and a pharmacy charge. Lee’s portion of the bill was $354.68.

What Gives: Lee owed more than 10 times what she had paid for the same procedure done before by the same physician, Dr. Elisabeth Roter.

Lee said it was the “same talking, same injection — same time.”

Lee and her family were outraged by the sudden price hike, considering she had gotten the same shots for the far lower price multiple times in the years before. Her daughter, Esther, said this was a substantial bill for her mother on her Social Security-supplemented income.

“This is a senior citizen for whom English is not her first language. She doesn’t have the resources to fight this,” Esther Lee said.

What had changed was how the hospital system classified the appointment for billing. Between 2019 and 2020, the hospital system “moved our infusion clinic from an office-based practice to a hospital-based setting,” University Hospitals spokesperson George Stamatis said in an emailed statement.

That was a change in definition for billing. The injection was given in the same medical office building, which is not a hospital. Lee did not need or get an infusion, which requires the insertion of an IV and some time spent allowing the medicine to flow into a vein.

Nonetheless, that change allowed the hospital system to bill what’s called a “facility fee,” laid out on Lee’s bill as “operating room services.” The increasingly controversial charge — basically a room rental fee — comes without warning, as hospitals are not required to inform patients of it ahead of time.

Hospitals say they charge the fee to cover their overhead for providing 24/7 care, when needed. Stamatis also noted the cost of additional regulatory requirements and services “that help drive quality improvement and assurance, but do increase costs.”

But facility fees are one reason hospital prices are rising faster than physician prices, according to a 2019 research article in Health Affairs.

“Facility fees are designed by hospitals in particular to grab more revenue from the weakest party in health care: namely, the individual patient,” said Alan Sager, a professor of health policy and management at the Boston University School of Public Health.

Lee’s insurance had changed to a Medicare Advantage plan in 2020. The overall cost for the appointment was nearly three times what it was in 2017 — before insurance even got involved.

The National Academy for State Health Policy has drafted model legislation for states to clamp down on the practice, which appears to have worsened, Executive Director Trish Riley said, as more private practices have been bought by hospitals and facility fees are tacked onto their charges.

“It’s the same physician office it was,” she said. “Operating in exactly the same way, doing exactly the same services — but the hospital chooses to attach a facility fee to it.”

New York, Oregon and Massachusetts are pursuing legislation to curtail this practice, she said. Connecticut has a facility fee transparency law on the books, and Ohio, where Lee lives, is considering legislation that would prohibit facility fees for telehealth services.

But Riley noted it’s difficult to fight powerful hospital lobbyists in a pandemic political climate, where hospitals are considered heroic.

The Centers for Medicare & Medicaid Services has attempted to curtail facility fees by introducing a site-neutral payment policy. The American Hospital Association sued over the move and plans to take the case to the Supreme Court.

Resolution: Lee’s daughter, Esther Lee, was furious with the hospital over the fee. Her mom, who is fiercely independent, finally brought her the bill after trying for weeks to get the billing office to change it.

“This is wrong,” Esther Lee said. “Even if it was a lot of money for services properly rendered, then of course she would pay it. But that’s not the case here.”

When Lee called her doctor’s office to complain, they told her to talk to the billing department of the hospital. So Lee, with Esther’s help, repeatedly called the billing department and filed a complaint with Medicare.

“I don’t want to lose my credit,” Kyunghee Lee said. “I always paid on time.”

But after receiving a “final notice” in February, and then being threatened with being sent to collections, the Lee family gave up the fight. Esther Lee paid the bill for her mother. But she’s worried her mom will delay getting the shots now, putting up with the pain longer, as she knows they are more expensive.

The Takeaway: When planning an outpatient procedure like an injection or biopsy, call ahead to ask if it will happen in a place that’s considered a “hospital setting” — even if you think you understand the office’s billing practices. Ask outright if there will be a facility fee — and how much — even if there’s not been one before. If it’s an elective procedure, you can search for a cheaper provider.

One easy place to scout for more affordable care is the office of a doctor whose practice has not been bought by a hospital. It is the hospital, not your longtime doctor, that is adding the fee, said Marni Jameson Carey, executive director of the Association of Independent Doctors.

“This is one of the terrible fallouts of consolidation,” Carey said.

Sources:

Stephanie O’Neill contributed to the audio version of this story.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.