Senator Eliot Shapleigh - El Paso, Texas

We hear about the miracles.

We hear about the life-saving research, the testimonials from grateful patients, the lauds from sources such as U.S. News & World Report, which ranks it the best cancer hospital in the country.

But we rarely hear about the ugly side of The University of Texas' M.D. Anderson Cancer Center: the pressure on uninsured or underinsured patients to pay the bill before they get the care.

An article last week in The Wall Street Journal, headlined "Cash Before Chemo: Hospitals Get Tough," told the story of Lisa Kelly, a 52-year-old Lake Jackson woman who went to M.D. Anderson after being diagnosed with leukemia in 2006.

According to the Journal report, M.D. Anderson refused to accept Kelly's "limited-benefit" insurance and asked for a certified check for $45,000, then an additional $60,000 before it would admit her.

'Blocked' for nonpayment

Kelly said the hospital eventually lowered its demand to $30,000 and granted an "override" that allowed her to get care without paying the whole bill.

But Kelly described relentless efforts by M.D. Anderson's business staff to collect her payments. On a few occasions, she showed up for chemotherapy to find her appointment had been "blocked" for lack of payment.

Once, she said, she was on an exam table when a business office representative walked in with her doctor and at some point suggested she go to another facility.

M.D. Anderson officials tell me their collection policies don't differ much from other hospitals, squeezed by the growing uninsured population and less government compensation for Medicaid patients.

"There still is that awkward situation of 'we have to talk about this bill.' And it is unfortunate and it is very sensitive and it is not the most palatable, I guess you could say, part of providing care," said spokeswoman Wendy Gottsegen.

Sad trade-off

M.D. Anderson says it instituted the pay-upfront policy for initial visits in 2005 after its unpaid patient bills jumped by $18 million to $52 million that year. The hospital told the Journal that its increasing bad-debt load threatened its mission to cure cancer, a goal on which it spends hundreds of millions of dollars a year.

There seems to be a sad trade-off. The quality of the institution's care and its research are contingent on accepting fewer patients without the financial means to pay.

"Every place is like this," Dr. Ron Walters, medical director for clinical operations, told me last year in an interview. "They look at the situation and see what expertise they have and then they'd say, 'And by the way, how are you planning to pay for this?' "

Kelly's story might have been more shocking if it didn't sound so familiar. Last year, I heard similar complaints from Brian Coker and his wife, Emily Asel, a then-29-year-old Harris County assistant district attorney who was diagnosed with a Stage 4 brain tumor while six months pregnant with her first child.

The couple had recently relocated to Houston but had no health insurance because insurance through their new jobs hadn't kicked in, and the private insurance Asel had purchased through Kaiser Permanente was worthless outside of the Washington, D.C., area.

Asel said doctors at Methodist Hospital operated on the brain tumor without discussions about money. But when she was referred to M.D. Anderson, they wouldn't let her in the door without $13,000.

"It's really sick," said Asel's husband. "It's almost like blackmail."

'Shame and anger'

Coker calls M.D. Anderson's business staff "the arm-twisting department," and he said they probably called him on his cell phone 10 times asking if they had insurance, when they would get insurance and when they would make the next payment.

The first day his wife showed up for radiation treatment, Coker said, they were told they couldn't attend the appointment until they visited the business office first.

Coker said he felt "shame and anger" that a hospital would refuse to treat his wife if she couldn't come up with the money. And he couldn't believe it was happening at an institution as revered as M.D. Anderson.

"When you're the place that's recognized, when you're held out to be the highest standard of care, that which everyone who wants to live needs, I think there is a duty to provide that same level of care for everyone," he said. "Why shouldn't the middle class be entitled to the level of care that the ultra-rich or even the ultra-poor (receive)?"

From a business standpoint, Coker says, he understands that M.D. Anderson has to collect for its services. But morally, he says, the upfront payment requirement sickens him.

M.D. Anderson is far from a cash-strapped institution. In 2007, the nonprofit institution recorded net income of $310 million, bringing its cash, investments and endowment to nearly $1.9 billion.

Charity-care funds down

M.D. Anderson acknowledges that its charity-care spending has dropped but says that's because the hospital provides doctors and other staff to the county's LBJ General Hospital, allowing it to expand its reach to more than 1,400 patients that it wouldn't have seen at its primary institution.

Even if M.D. Anderson can't change the shameful state of our nation's health care system, it can certainly afford to expand its charity care as its revenues increase and to bring the bedside manner in the business department up to par with its doctors' and nurses'.

A hint of the callousness alleged against some members of the department is illustrated in the Journal article in a quote by John Tietjen, vice president for patient financial services, who equated asking for payment after a cancer patient has received care with "asking someone to pay for the car after they've driven off the lot."

It's unfathomable that a doctor or nurse at one of the world's best cancer hospitals would compare a car to life-preserving cancer treatment. It shouldn't be acceptable from the bill collectors, either.