In middle of miscarriage, woman was pressured to pay $3,500 bill at Fort Worth hospital
Kara Gardeen knew there would be blood, cramps and grief.
Her doctor had confirmed the worst: The baby she and her husband had hoped to welcome to their family had not survived. Gardeen was about nine weeks pregnant. Now, she needed to find time to take the pills that would allow the miscarriage to conclude more quickly, instead of possibly waiting days or even weeks for the miscarriage to happen naturally.
After a Wednesday doctor’s appointment that confirmed the miscarriage, Gardeen tried to manage the process around the schedule of her almost 2-year-old son. The next day, she took him to his gym class and to the library. On Oct. 29, a Friday, Gardeen dropped him at day care. She finally had some privacy. In the bathroom of her Keller home, she took the medicine that began to empty her body of her child — whom she and her husband had referred to for weeks as “Baby.” Lost, too, would be the plans and dreams she and her husband had for their second child.
Even though her doctor had warned her about the drug’s effects and the process of miscarrying, Gardeen was still shocked by the blood. She noticed bruising on the side of her leg and called a pharmacist in the afternoon to ask if that was normal. He told her that misoprostol can, on rare occasions, cause blood clots, and recommended she speak to her doctor. Not wanting to wait another day, she drove herself to the emergency room of Texas Health Harris Methodist Hospital Alliance, which is part of the Texas Health Resources hospital system. Her husband stayed home with their son.
As she waited in a flimsy gown on a bed at the hospital off North Riverside Drive, bleeding through pad after pad as she lost her baby, Gardeen thought this was the worst that things could possibly get.
She was wrong.
A staff member, who Gardeen later learned was part of the hospital’s patient access team, came into the exam room and began to go over paperwork. The woman verified Gardeen’s name, insurance and emergency contacts.
“I’m just sitting there, bleeding so much that I had to keep calling the nurse to ask for more pads, and more wipes and all of that because I had to keep getting myself to the bathroom to get cleaned up because it just progressively gets worse,” she said. “And I’m just not in a very clear mental state.”
The woman turned to her and asked, “Are you ready to pay any portion of your $3,500 estimate?” Gardeen remembered.
Gardeen was shocked. She felt emotionally and physically vulnerable and could not understand why, in the middle of her lowest moment, someone was asking her for payment — especially because she had not been seen by a doctor yet.
“I just looked at her and was like, ‘Now?’” Gardeen said. “I (was) actively miscarrying. I (was) bleeding on the table,” Gardeen said, recalling the moment.
She remembers the woman pausing, looking at her — and offering to hand Gardeen her purse.
No longer a heartbeat
Before her miscarriage, Gardeen — like many people — thought losing a baby was a sudden, singular event. But miscarriages can last weeks, and cause a variety of health issues.
Miscarrying has long been a taboo topic because of the shame that can accompany the loss of a pregnancy, said Dr. Katherine Gold, a family physician who studies pregnancy loss. Only in recent years has the general public begun to recognize how many people suffer miscarriages, and to grapple with the grief that comes with that loss. An estimated 15% of recognized pregnancies end in miscarriage, which occurs before 20 weeks of gestation, and the American College of Obstetricians and Gynecologists estimates that it is the most common form of pregnancy complication.
Because her first pregnancy was uncomplicated, Gardeen, 36, did not even think about the possibility of a miscarriage until she went to her doctor when she was eight weeks pregnant. She found out she was pregnant in September, shortly after her family had moved to Keller from Minneapolis. They had not even moved into their house — she discovered the pregnancy while they were staying in a nearby hotel.
At her first appointment with a Texas Health Resources OB-GYN, however, something was wrong. The doctor said the baby’s heartbeat was a little slow, and the baby was not as big as he or she should be.
The next week, Gardeen noticed she was spotting blood. She made another appointment, where the doctor performed an ultrasound.
“It was at that point that the OB told me there was no longer a heartbeat,” Gardeen said. “So that’s when I knew, it’s over. And at that point, too, I was like, ‘What do we do now?’”
Patients experiencing a miscarriage have several options for how to manage the experience, depending on how far along the pregnancy is and their preferences. Gardeen opted to take misoprostol, a drug that helps speed up the body’s process of ending a pregnancy.
Gardeen knew that privacy was hard to come by with a toddler, so she waited until he was at day care on Friday to take the medication. Within a few hours, she was worried enough about the bruises forming on her leg that she decided to go to the hospital.
“I don’t want any more to go wrong in what was already a really awful situation,” she said.
She was admitted at about 4:30 p.m. that Friday and ushered into an exam room, according to her hospital records. She changed into the hospital gown, was hooked up to a blood pressure machine and told to wait for the ER physician to see her.
‘I needed empathy’
Gardeen has delivered a baby before. She knows quite well that health care is expensive and she is under no impression that the health care she sought at Texas Health Resources would be free. But being asked to pay thousands of dollars while in the middle of actively losing her baby? That is a concept that Gardeen cannot move past.
“That’s where I think things have gone terribly wrong with how we treat patients,” she said. “I needed compassion, I needed empathy. But to me it was just very transactional to the billing department.”
Gold, who is also an associate professor at the University of Michigan, said Gardeen’s unexpected and traumatic billing experience is not an isolated event. She has heard stories from across the country about patients or families who were further traumatized because of hospital practices. One family, for example, watched their child die in an ER only to later receive an itemized statement listing every dose of epinephrine and CPR compression the child received.
“Hospitals have routine ways of doing things and there are times when, to give the best patient care, you need to suspend certain practices,” Gold said. “And be mindful of a timely, appropriate approach.”
Stacey Pogue, a health policy expert with independent policy research and advocacy organization Every Texan, said she was concerned that asking for payment when a patient is dressed in a hospital gown and unsure about what’s going to happen next could discourage patients from actually seeking care.
“Common sense tells me that that patient’s been put in a position where, before she knows if she’s going to be OK and can think about how to pay, she’s being asked whether she can or can’t,” Pogue said. “That’s pretty intimidating.”
After the woman from the billing department asked Gardeen for payment, Gardeen, still in shock, asked the staffer to send her a bill in the mail. Gardeen said she knows that some people might want an estimate of their bill, but that her experience went beyond an estimate and into an attempt to collect payment.
She sent a text to her family members, who she had been talking to throughout the day.
“Our medical system is so messed up,” she wrote.
In response to questions about Texas Health’s billing policy and Gardeen’s concerns, spokesperson Kimberly Walton wrote in an email that, “When patients raise concerns about a bill or our processes, we work with them to explain the charges and resolve their concerns.
“Our priority is to always meet the patient’s clinical care needs first,” the statement said. “But we also want to make the billing and payment process as simple and straight-forward as possible. Oftentimes that means providing a real-time estimate at the initial point of care and information about our payment plans.”
Lack of mental health support
Shortly after the patient access team member left, the ER physician came in to treat Gardeen. He was kind and empathetic as he removed the “multiple large clots and tissue” from her body, according to her medical records.
“You’re just laying there and just knowing that nothing is going to look the same anymore,” Gardeen said. “And all the dreams that you had, it’s just over.”
After a miscarriage, doctors will sometimes order genetic testing on the fetal tissue. Which is why, after removing the remnants of Gardeen’s pregnancy, the doctor handed her a clear bag that contained the tissue samples. He told her to put the samples in her fridge and take them to her next OB-GYN appointment. She was discharged at about 10 p.m., five hours after she arrived at the hospital.
“To just walk out with the remnants of your miscarriage in a bottle just added to the trauma of the experience,” she said. “They said it was OK for me to go and I got dressed and I had my clear bag with my samples and I just walked out into the dark, into the night.”
Another aspect of Gardeen’s medical experience that further traumatized her was the lack of mental health support and resources.
“At that point, I needed mental health resources,” she said. “And there was not a single person to offer me a list of hotlines to call or a 24/7 forum to have resources available. Instead it’s just, ‘Are you prepared to pay?’”
The shame surrounding miscarriage can make the experience of losing a child particularly isolating and emotionally traumatic, Gold said.
All emergency rooms and labor delivery suites should have standard policies on how to support someone who has lost a child, Gold said. Patients and families should receive a list of mental health resources, for example, and be offered counseling if needed.
Outside of hospital hallways, the nation is also grappling with how to support parents who have experienced a miscarriage. Employers in the U.S. are not required to offer paid time off to an employee who has experienced a miscarriage. Legislation proposed in Congress would require employers to offer at least three days of paid leave after a miscarriage or other fertility or parenting losses.
Changes to patient care
The American health care system has a long way to go in how it cares for and supports families and women experiencing the loss of a child, Gold said. For overwhelmed medical staff, a miscarriage can be viewed simply as a medical event that they see quite often.
“It can be easy for an individual staff person to lose sight of the fact that this is a patient who is going through something quite difficult and traumatic,” Gold said.
At Gold’s hospital, a group of people get together from across various disciplines and analyze how to help families experiencing loss.
This process is important to how someone heals emotionally, Gold said. The manner in which people are treated during a crisis affects how they recover and process it. In Gardeen’s case, an already traumatic situation was made worse by a set of practices that may need re-examining.
“It’s going to matter how you’re told that information and how you’re cared for after,” Gold said.
Many hospitals also place markers on the doors of patients who are dealing with a loss so that any staff going into the room know the situation. Hospitals should also have a planned way to follow up with families to support them after a loss, Gold said.
By law, emergency rooms are required to provide care to people regardless of their insurance status or their ability to pay their bill. But most experts consulted by the Star-Telegram on the law said it doesn’t dictate when a hospital can ask a patient for payment, as long as staff do not withhold life-saving treatment or delay care.
Had Gardeen gone to the ER just a few months later, she might have avoided the billing encounter entirely. On Jan. 1, a federal law went into effect with new protections for patients against surprise medical bills. The law regulates how hospitals and emergency rooms bill patients like Gardeen, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. Pollitz explained that in any medical emergency, a patient with private insurance can only be asked to pay the standard cost-sharing amount for emergency services covered by their insurance. Put more simply, an emergency patient would only be charged their deductible or their co-pay at an emergency room, even if they’re treated by an out-of-network doctor.
“The only way (hospitals) can avoid making that very expensive mistake is to find out the name of your insurance company and check before they send you any bill,” Pollitz said.
In Gardeen’s case, that would have meant sending her claims to her insurance company first, before presenting Gardeen with any estimate or asking her to pay.
Hospitals that don’t follow the law risk a $10,000 fine.
Gardeen was ultimately billed about $7,600 for the treatment she received at Texas Health Resources’ emergency room. After her insurance company negotiated the bill and paid its share, Gardeen paid about $3,400 to the hospital and another $160 to an out-of-network radiology group.
Response from Texas Health
Gardeen hopes by sharing her story, Texas Health Resources and other hospitals will change their policies to better emotionally support patients and not cause more trauma. The emergency room Gardeen went to is part of a large network of hospitals and offices run by Texas Health Resources, a nonprofit health system.
Especially for people who may have a mental health disorder or financial struggles, she said, being confronted with a bill at such a vulnerable moment could push someone over the edge.
“There are so many people that can’t be met with that financial burden at that moment in time,” she said. “And to have that coming at you at the same time you’re trying to process your grief? That is too much for anyone to handle.”
Gardeen emailed Texas Health Resources about her experience, explaining that while she understands “the hospital may not have broken any laws,” she believes it “most certainly broke your code of values.”
“I cannot let this go until I know my voice has been heard and could make a difference for other women experiencing trauma,” she wrote later in the email. “Can you imagine the added trauma this brings to other women who don’t speak the language, who don’t have the financial means or who don’t understand their own patient rights?”
Texas Health Resources responded on Nov. 10 and said it would investigate. A month later, a patient advocate responded in a letter, and wrote, “We were extremely sorry to hear of your recent loss and would like to offer you our condolences and hope that you are recovering well.”
In response to Gardeen’s concerns about Texas Health Resources’ billing policies, the letter said the employee was following a “correct process in presenting you with your benefits and estimate.”
However, the letter added that “we can understand how this could have a negative impact on your experience during such a sensitive time.”
“We are extremely thankful for your feedback,” the hospital said later in the letter, “and are considering your feedback as we work to re-evaluate and improve our patients’ experiences.”
Each month since she lost her baby, Gardeen has held her breath, hoping she might become pregnant again. She screenshotted a webpage from Mayo Clinic on her phone about the high percentage of women who have miscarried who go on to have successful pregnancies. She realized she set an internal deadline for herself; she hopes she will become pregnant again before Baby’s due date in May.
In the last four months, she has received flowers, poems and words of comfort from other women who have miscarried. One note in particular has stuck with her; “Grief is love with nowhere to go.”
Where to get help after a miscarriage
If you or a loved on has experienced a miscarriage, there is help available.
Share Pregnancy and Infant Loss Support provides multiple resources. The group hosts two monthly online group chats. The nonprofit also has three support groups on Facebook, which are closed to protect privacy. To request to join the groups, visit facebook.com/NationalShare/groups.
There is also a DFW chapter of MEND, a group that provides miscarriage, stillbirth, and infant loss support. You can learn more about MEND’s support groups online at mend.org/chapter-dfw-welcome.
This story was originally published March 7, 2022 at 5:00 AM.
