THINKING ABOUT HEALTH
By Trudy Lieberman, Rural Health News Service
Crowd-sourcing May Bring Transparency to Medical Charges
In a recent column I reported on an effort in Ohio to bring price transparency to medical services. Ohio state representative Jim Butler had spearheaded passage of legislation that would require healthcare providers including doctors and hospitals to disclose prices for their services. The law was supposed to take effect last summer, but Gov. John Kasich, the Ohio Hospital Association, and other health groups that oppose transparency have stymied implementation. The governor’s budget for next year calls for repealing the law.
Ohio’s law may disappear, but the demand for information is not going away. Many readers are downright angry after trying hard – and unsuccessfully - to get information to make good medical decisions.
James Friesen, a lending officer at a bank in Kearney, Nebraska, told me when he wanted to pay cash for a cardiac test his insurer wouldn’t pay for, he couldn’t find out the negotiated price his insurer had agreed to pay the hospital. Neither his insurer nor the hospital would say. “The doctor who ordered the test didn’t even know,” he said. “They intentionally keep patient consumers in the dark about pricing.”
When Naomi Johnson, a South Dakota retiree, tried to find out the price of a colonoscopy, she asked her insurer for the billing code the medical business uses to identify various procedures. Johnson used that code when she called the health facility where the procedure would be performed and asked for the cost of a simple colonoscopy barring complications. The facility told her they couldn’t even give her a ballpark number until after the procedure because there would be several codes for many different things. “They acted like I was insane for asking.”
A California woman, Saskia Mills, told me getting an estimate for a simple outpatient procedure her family was paying for out of pocket was like “pulling teeth.” After more than 10 phone calls, they thought they knew they would have to pay $4,750 for the surgery and facility charges. The bill turned out to be $10,456, including $1,400 in pharmacy charges that were never mentioned beforehand.
Is this the patient-centered care healthcare executives claim they are providing?
Hardly. In reality it’s part of a process cooked up by doctors, hospitals, and insurers that keeps patients from learning how much they must pay and for what. It’s responsible for those undecipherable bills we all get.
As former New York Times reporter Elisabeth Rosenthal describes in her new book “An American Sickness,” the inability of patients to find out what their medical care charges will be stems from a gigantic bill coding business that involves the health system’s biggest players in a game of one-upsmanship to make big profits. The codes determine what providers are paid. The more individual codes included in the bill and the higher levels of service a code specifies, the more money providers make.
There are tens of thousands of codes that have become increasingly specific, Rosenthal says. For example, there are different codes for earwax removal depending on the method used to remove the wax.
Furthermore, prices negotiated between insurers and hospitals are secret. A study commissioned by the New York State Health Foundation late last year found that contracts insurers negotiate with hospitals often say they can’t disclose the prices they’ve negotiated, such as listing those prices on their website. If they do, hospitals can terminate their contracts and refuse to accept the insurer’s patients.
No wonder patients are fighting back.
I checked in with Jeanne Pinder, who heads an organization called ClearHealthCosts, https://clearhealthcosts.com/ Its mission is to tell patients what their medical care costs. The organization now partners with media organizations in Miami, Tampa-St. Petersburg, and New Orleans and with MedPage Today. It has also worked with news outlets in California and Philadelphia to publish prices of 35 procedures that consumers can actually shop for such as MRIs and mammograms.
ClearHealthCosts has just launched its latest site in New Orleans, and Pinder says, “Traffic is through the roof. People are sending us bills and calling us with horror stories.”
ClearHealthCosts uses crowd sourcing to build a community-created guide to health costs. Patients from all parts of the country send in their explanations of benefits, dates of their procedures, names of providers and insurers, and amounts they paid, which are posted on the news outlet websites. They show wide variation in the price for the same service in a given area.
In San Francisco, for example, they found that an MRI of the lower back without contrast could cost as little as $475 or as much as $6,221 depending on where it was done. Most patients would want to know that, but as the Ohio experience has shown, healthcare businesses and governments sometimes work together to keep prices under wraps.
“So many people have lost faith and hope that government regulators or industry will fix this problem,” Pinder says. “We are supplying the fix, and the fix is transparency.”
What experiences have you had finding out the price of care? Write to Trudy at email@example.com.
By Trudy Lieberman, Rural Health News Service
Anyone facing a hospital stay for themselves or a family member should look at new data the government released right before Christmas showing that it http://khn.org/news/769-hospitals-penalized-for-patient-safety-in-2017-data-table/ penalized 769 of the nation’s hospitals for having high rates of patient injuries. The monetary penalties – a reduction for the year in their reimbursement for treating Medicare patients – do bite. Larger teaching hospitals could lose as much as $1 million or more.
This is the third year the government has penalized hospitals in an effort to prevent avoidable patient deaths in hospitals, which emerged as a big issue about 18 years ago. This year the government added injuries caused by MRSA and C diff infections to their list of other harmful conditions patients contract in a hospital such as urinary tract and surgical site infections resulting from hysterectomies and colon procedures. MRSA – a staphylococcus bacterium - can cause pneumonia and bloodstream infections. C diff is a germ that can multiply in the gut when patients are taking other antibiotics to kill other germs.
While some facilities like those serving children and psychiatric patients and critical care hospitals are exempt from penalties, this year’s data show that more than 200 facilities, including some of the nation’s most well-known hospitals, have the dubious distinction of being on the government’s penalty list for all three years. They include the Cleveland Clinic, Ronald Reagan UCLA Medical Center in Los Angeles, Northwestern Memorial Hospital in Chicago and Boston’s Brigham and Women’s Hospital. The message for patients: A hospital’s TV advertising campaign for its great cancer care may obscure significant safety issues.
Have penalties and other harm reduction initiatives made hospital care safer?
This time 347 hospitals penalized last year are not on the bad-guy list, which shows that some are paying attention. But hospital injuries have not vanished. The federal Agency for Healthcare Research and Quality says there were 3.8 million hospital injuries last year. That translates to 115 injuries per 1,000 patient stays.
Antibiotic-resistant bacteria infect some two million people annually. One quarter of a million cases occur in hospitals.
I wanted to know why more progress hasn’t been made. While the new government data reflect improvements at many hospitals, why is there still such a long way to go? I rang up Lisa McGiffert, the head of Consumers Union’s Safe Patient Project who has been a leading voice since 2004 to bring attention to infections and medical errors. She told me there’s been a significant shift in the way hospitals view infections. Twelve years ago they used to say they were not preventable. “Now, most people in healthcare believe most infections are.”
In the early days of her campaign, government agencies like the Centers for Disease Control and Prevention were reluctant to back public reporting of hospital mistakes and other data to help patients. Now they support it. Still, she says, “what I am most frustrated about is the lack of urgency in the country and at the agencies for eliminating these infections. They are aware of them, but there’s not a sense of urgency to stop them.”
The financial penalties levied by the Medicare agency have made a significant difference because they get the hospital CEO’s attention. Unless the CEO is involved, change is not going to happen.
But the penalties along with the entire program to eliminate hospital-acquired conditions were authorized under the Affordable Care Act. They could be in jeopardy if the law is repealed. Some hospitals probably would be happy if they disappeared.
Patients need to make use of the data that is available and study it to inform their decisions about where to go for care when they have a choice. McGiffert advises looking at how your hospital compares to similar facilities. Look for improvement. If a hospital was penalized the first or second year of the program but not this year, that indicates it could be serious about safety. Also look to see if a facility’s scores are moving in the right direction. If the numbers show they are not performing as well on some dimension as they previously were, patients need to ask why.
Some states and some hospitals are using other strategies. Illinois and California, for example, have passed legislation that requires hospitals to screen for MRSA when patients are admitted. Some hospitals have stewardship programs to address the overuse of antibiotics, which contributes to drug resistance.
To start learning about your hospital, consult the government’s Hospital Compare website https://www.medicare.gov/hospitalcompare/search.html. Follow the prompts to find the hospital you are looking for and then search the tabs for “complications.” This will let you look at actual numbers to help you see how your hospital is doing.
What experience have you had with patient harm in a hospital? Write to Trudy at firstname.lastname@example.org.
By Trudy Lieberman, Rural Health News Service
Surprise medical bills spell big trouble for consumers, especially those who find themselves in an emergency room. Such “surprises” have surfaced as a major patient problem, but because of entrenched healthcare interests, a solution is not likely any time soon.
Here’s what happens. Patients arrive at the emergency room of a hospital that is in their insurer’s provider network. However, the physician who treats them is out of network.
Because ER docs are usually assured a steady stream of patients, many believe they don’t need to accept potentially lower fees from insurers in exchange for any new patients they might attract by belonging to a network. That’s not the case for other specialists who may rely on insurer networks for more business.
Whatever the reason, emergency room patients may be stuck with huge bills their insurance company may not cover, or it will pay less than if patients had used in-network doctors.
If you think this is unfair, it is.
A study by Yale researchers of more than 2 million emergency room visits across the country was just published in the New England Journal of Medicine. It found that out-of-network doctors treated 22 percent of the patients who visited emergency departments; the departments themselves were part of their insurers’ networks.
The average bill patients incurred was $623. The highest bill was more than $19,000. To put that number in perspective, this year the Federal Reserve reported that 46 percent of Americans were unable to pay a $400 expense without running up credit card debt or selling assets.
Not surprisingly, researchers found out-of-network ER doctors ended up getting paid a lot more than those who were part of a network. “The fact this type of price gouging has become routine operating procedure in so many emergency departments is shameful and appalling,” says Chuck Bell, programs director for Consumers Union.
A recent study in Texas by the Center for Public Policy Priorities shows how prevalent out-of-network ER doctors are. Using a 2013 report from the Texas Department of Insurance, the Center found that 45 percent of in-network hospitals in the state used by United Healthcare had no in-network ER doctors. Fifty-six percent of Humana’s hospitals had none. “Consumers would be astonished to see how poor the odds are of getting an in-network doctor in the emergency room.” Bell added.
The odds of getting redress are also low. Too many consumers don’t contest their bills. Only about 25 percent of those getting surprise bills do, Bell told me. Of those who do protest to their insurer, only half get their bill forgiven or reduced.
Surprise bills are a variation of what’s called balance billing, the gap between what insurance, including Medicare, pays and what a doctor charges. It’s been around for decades, but in the late 1980s, the outcry from Medicare beneficiaries became so loud that Congress did something about it.
For doctors who accept Medicare’s payment in full, there is no balance billing - called “excess charges” in Medicare speak. Doctors, including ER physicians who don’t accept that payment, can sock beneficiaries with excess charges. But Medicare limits what they can charge.
Beneficiaries can protect themselves from these excess charges should they use a doctor who doesn’t accept Medicare’s fee schedule by buying Medigap policies Plan F and Plan G. For those with Medicare Advantage plans, there’s no protection until the beneficiary reaches the plan’s out-of-pocket spending limit. After that, the doctor can’t balance bill separately.
There’s no similar help for those not on Medicare.
Many consumers are unaware that an out-of-network doctor is treating them.
The standard advice - to ask if your doctor is in the network - is silly when it comes to care in the ER. What patient having a heart attack is going to look up and say, “Hey doc, are you with Aetna?”
A few states - New York, California, Illinois, Connecticut, and Florida - hold patients harmless if they find themselves with a surprise bill or require outside arbitration to decide a case. But Bell says it will take an act of Congress to solve this problem. Public outrage will have to get much louder if that’s to happen.
Because chances are high you’ll find yourself with such a bill, think twice before you choose to go to the ER for a problem that can wait until you see your regular doctor.
Although Obamacare was supposed to cut down on emergency room use, that hasn’t happened. People are still going to ERs for less serious conditions, many being enticed by hospitals themselves that advertise their ER wait times on billboards.
Our healthcare system is all about making money. And balance billing, its causes and consequences, is another sorry example.
What is your experience with surprise billing? Write to Trudy at email@example.com.--30--
What you need to know about choosing health insurance
By Trudy Lieberman
Rural Health News Service
Rural Health News Service
Even though the election is over and Republicans are in a position to repeal and replace Obamacare as they’ve been vowing to do for several years, that doesn’t mean you should avoid signing up for 2017 insurance coverage.
If you’re eligible and need insurance, the state shopping exchanges are open for business even if options this year are limited in many counties, particularly in rural areas. More than 40 percent of the counties where residents can buy an Obamacare policy have just one insurer selling them. That’s not a lot of choice, and policies that are offered are likely to have high premiums and limited options for doctors and hospitals.
Still, some careful shopping is in order to minimize any surprise bills. After the election, White House Press Secretary Josh Earnest urged Americans to sign up and announced “the vast majority” of eligible consumers would be able to buy insurance for a monthly premium of $75 or less, which has been the administration’s sales pitch.
Assuming the White House math is correct, that doesn’t mean the vast majority should automatically buy a policy with a $75 premium. That strategy can mean expensive trouble later on. Reviewing the basics before wading into the Obamacare marketplace this year is essential.
For starters, recall that platinum policies, generally the most costly, cover 90 percent of someone’s medical costs; gold plans cover 80 percent; silver plans pay 70 percent; and the bronze variety pays the least – only 60 percent of a patient’s healthcare expenses. Silver plans have been the most popular, largely because those who buy them and have family incomes below $60,750 get extra government subsidies to help pay their deductibles, copays and coinsurance.
Bronze policies are popular, too, because they have low premiums, but people buying those policies won’t get the extra subsidies, a point that’s worth remembering. Those subsidies can be a big help if you need a lot of medical services. Both bronze and silver policies generally come with lower monthly premiums, but that doesn’t mean they are cheaper in the long run.
Here’s where comparison-shopping gets tricky. It’s possible a bronze policy and maybe a silver one could end up costing more than a gold one with a higher premium if you get sick. That’s because of the relationship between the premium, copays, coinsurance and deductibles. Insurers mix and match these features to fit their marketing strategy.
In general, a lower premium means higher deductibles and higher other out-of-pocket expenses. A policy with a higher premium often means lower out-of-pocket costs.
For 2017 the maximum amount a family would have to pay out-of-pocket for copays, coinsurance and deductibles is $14,300. That’s a lot of money and enough to deter some people from signing up. Many people say paying that much before insurance pays isn’t really insurance. It’s also high enough to keep people from seeking medical care even when they need it. If people go to the doctor less, the country’s national health expenditures will drop - at least that’s the rationale for the high out-of-pocket limit.
An Indiana couple I’ve written about before in this column recently sent an email updating me on the family’s insurance options for next year. Their carrier had increased their $836 monthly premium to about $1,300; their cost even after an Obamacare tax subsidy was applied. What’s more, the reader said, the insurer had raised the amount of coinsurance for hospitalizations from 20 percent to 50 percent.
Given how much a hospital stay costs, they worried they’d be on the hook for a lot of money until they reached the $14,300 out-of-pocket maximum. It was a risk they weren’t willing to take, and they shopped until they found new coverage for only $700 a month with their subsidy.
Choosing an Obamacare policy or any other insurance coverage comes down to how much risk you want to assume. If you are reasonably certain you won’t need many medical services, you may want to take a chance and buy less expensive insurance that comes with high deductibles, copays, and coinsurance.
But if you’re like the Indiana couple, and afraid of high expenses for unexpected medical care, buy the best policy you can afford that reduces that risk.
Another thing to keep in mind! Beware of policies with really low premiums, prices that seem too good to be true. Consumers who bought insurance from the Obamacare co-ops learned that.
Almost all of the 23 co-ops authorized to compete with the big carriers have gone out of business. They priced their policies too low, and too many sick people signed up. Government regulators closed them down, sending thousands of people scrambling for new coverage – an unwelcome chore for anyone.
What have your experiences been shopping for insurance? Write to Trudy at firstname.lastname@example.org.
By Trudy Lieberman, Rural Health News Service
Is the message that the nation is getting too fat beginning to sink in?
The answer is “yes but,” says the Trust for America’s Health, a nonprofit, non-partisan group that aims to protect the health of communities and make disease prevention a national priority. And a study of healthcare quality and quantity across the nation suggests some reasons why things are not improving uniformly.
This year’s results show that after a decade in which every state’s obese population rose, a few states have finally experienced a decrease.
“We’re seeing the rates plateau albeit at a very high level,” says Richard Hamburg, the interim president of the Trust.
Although rates have dropped in Montana, Minnesota, New York, and Ohio, even those decreased rates are still high. Twenty-six percent of adults in Minnesota were still considered obese, and nearly 30 percent were in Ohio. Even in the states with the lowest rates - Colorado, California, Utah, Montana, Hawaii and Massachusetts - rates remain between 20 and 25 percent.
Twenty-two of the 25 states with the highest adult obesity rates are in the South and Midwest, including Kansas and Kentucky, both of which experienced an increase.
To put this in perspective, Hamburg told me that in 1980 no state had a rate above 15 percent; in 1990 no rate was above 20 percent. “Colorado is the healthiest state but exceeded the 20 percent rate years ago,” he said.
What happened? Hamburg explained that many societal changes have conspired to increase obesity rates. Children have less opportunity for physical activities; parents are no longer comfortable sending their kids out to play and telling them to come home by dark.
- Sedentary activities like computer games have replaced physical activity.
- Many schools no longer offer physical education, and are not always open for physical activity after the school day ends.
- More kids arrive at school via car or bus. In 1969, 89 percent of kids walked or rode their bikes to school. By 2009, the number had dropped to 35 percent.
Hamburg told me 30 million people don’t have easy access to a supermarket; many residents in dense urban areas have to walk or take public transportation more than a mile to get more than a “convenience store” selection. Many in rural areas must drive 10 miles or more.
Powerful marketing from the food industry is also a culprit, beckoning consumers to eat pizza, overstuffed tacos, and sodas without regard for the effect on their weight or health.
I usually don’t pay much attention to state rankings from various groups. Most people aren’t going to move to another state just because it ranks better on whatever is being measured. But this time I did because as the obesity report came out, a personal finance website, WalletHub, announced its latest report “2016’s States with the Best & Worst Health Care.” And I was struck by a possible connection.
What did WalletHub have to say about those states in the South and Midwest with high numbers of people who are obese? Were they getting routine examinations, and dental care? Were physicians accepting Medicare? Were there adequate hospital beds particularly, in rural areas where many hospitals have closed?
Now I didn’t attempt to do a scientific correlation, and there may be many reasons why a state’s healthcare system ranks high or low on the WalletHub site. But for me, the take-away from these studies is that communities must offer not only treatment for health problems relating to obesity but also ways to prevent the underlying cause in the first place.
Communities must have not just enough and appropriate medical facilities and personnel but also programs to encourage better eating habits and more physical activity.
The Trust report offers suggestions that point in that direction. To learn more about how your state ranks on both these studies, go to stateofobesity.org and wallethub.com.
New Hospital Safety Ratings Available to the Public
By Trudy Lieberman, Rural Health News Service
Aug. 8, 2016
The Centers for Medicare and Medicaid Services (CMS) recently signaled to the nation’s hospitals that it was getting serious-and tough-about patient safety and the quality of care hospitals provide. The government’s rating system-five stars for the best hospitals and one star for the worst-sends a message that patients have a right to know what’s going on inside the hospitals they entrust with their lives or those of their family members.
The overall star ratings, the first for CMS, are a composite of 64 measures the government has used the past few years to rate hospital performance. They include factors such as complication rates for patients who’ve had knee and hip replacement surgery, urinary tract infections associated with catheter use, death rates among patients with serious but treatable complications after surgery, and patients’ reported experience with their care.
Only 102 hospitals out of the 3,600 rated received five stars, and they included less well-known specialty facilities such as Lincoln Surgical Hospital in Lincoln, Nebraska, and the Orthopaedic Hospital of Lutheran Health Network in Ft. Wayne, Indiana. Medicare gave 129 hospitals one star. They included two prominent hospitals in Washington D.C. - MedStar Georgetown University Hospital and George Washington University Hospital - as well as several hospitals in New York City. Geisinger Medical Center in Danville, Pennsylvania, that health policy experts and politicians cite for exemplary quality involving new ways of delivering and coordinating care, received a below-average two-star rating.
The ratings reveal a contradiction between scientifically measured evidence and the advertising hospitals use to build their brand. Hospitals like to tell their communities about new cancer treatments or new children’s wings, not mediocre ratings. In my neighborhood New York City’s Mt Sinai Hospital has used banner ads on the street to create an awareness of the hospital, which received only a mediocre three-star rating.
Those of us who have written about hospitals know that smart patients need to look way beyond the nightly advertising on TV.
Medicare often caves in to healthcare industry demands and has backed off many proposed rules that powerful doctors, hospitals, and drug companies opposed. But it isn’t pulling any punches on this one despite attempted roadblocks. Last April some 200 members of the House of Representatives and 60 U.S. senators sent letters to CMS urging delay in releasing the star ratings.
They argued that the ratings may not take into account that many hospitals treat low-income patients with complex conditions and, thus, may not be fair to providers. “The star system is an irresponsible slap in the face to America’s most essential hospitals, those that take in the sickest patients,” Dr. Eric Dickson, the chief executive of UMass Memorial Health Care, told the Boston Globe. His flagship teaching hospital in Worcester, Massachusetts, received one star.
But as Leah Binder who heads The Leapfrog Group, which advocates for patient safety, has noted on Forbes.com, the letter sent by the senators did not mention responsibility to patients who may suffer harm in a hospital. The British Medical Journal reported in May that researchers who examined the scientific evidence concluded that in 2013 medical errors were the third-leading cause of death in the U.S. behind heart disease and cancer.
That’s cause for alarm and may be a reason why CMS didn’t bow to political pressure this time.
Jordan Rau, a staffer at Kaiser Health News who has written about the evolution of hospital ratings, told me the stars may influence low-rated hospitals to improve their scores.
Hospitals may also fear that consumers will see the stars, which are easy to understand, dig into the numbers behind them, ask questions, and perhaps choose other facilities if they can. If that happens, CEOs may feel mighty uncomfortable going before their boards and explaining why they received only one or two stars.
Medicare has also just released the names of hospitals required to pay monetary penalties for having more patients than expected return to the hospital. About one-third of readmissions, considered a marker of quality, are preventable. The government looks at readmissions for such conditions as heart attacks, pneumonia, and hip and knee replacements.
Clearly, if you’re planning a hospital stay for major surgery or any reason, check both CMS sites for the star ratings (https://kaiserhealthnews.files.wordpress.com/2016/07/hospital-stars-july-2016-pdf1.pdf) and the readmissions penalties (https://kaiserhealthnews.files.wordpress.com/2016/08/medicarereadmissionpenaltiesyear5_pdf_final1.pdf). Examining the ratings for facilities you are considering should either give you peace of mind-although nothing is guaranteed in the patient safety business-or cause for concern.
My advice: see how the “stars” align before you’re a patient at any hospital.
What’s been your experience finding a good hospital or with hospitals where you or a family member have experienced a medical error? Write to Trudy at email@example.com.