Thinking About Health columns (Rural Health News Service)

How to find the right follow-up care after hospitalization

By Trudy Lieberman, Rural Health News Service

If ever there were a weak link in hospital care, it’s what happens when you or a loved one leaves the hospital. It’s becoming clear that the process known as discharge planning is deficient, can be harmful, and sometimes results in a patient’s decline.

One in five patients across the country needs further care after discharge from a hospital, according to a series of four reports published by the United Hospital Fund in New York City. That’s a lot of people, and many times their families don’t know where to turn for help. The Fund reported that hospitals themselves sometimes prove to be of little assistance.

Patients are being sent not only to nursing homes but also to long-term acute care facilities (LTACs), a relatively new type of facility that treats sicker patients for an average of at least 25 days for recovery, or to sub-acute facilities, home care agencies or rehabilitation centers with little input from their families and little explanation of what these facilities can do.

How many families have ever heard of an LTAC, for instance? Mine never had, and neither had I when I found myself transferred to one early in 2018 after a long hospital stay necessitated by a series of ailments caused by what seemed to be a simple infection.

When my daughter called facilities in Manhattan – where we live – looking for care, most wouldn’t even take her calls. “I called around and realized you cannot find a place on your own,” she said. “That’s not how this works.”

Too often families find that hospitals limit the options for them. The United Hospital Fund found that even though hospital staff stressed patient choice, patients and their families actually had little choice.

One woman sent me a tweet not long ago saying that a VA hospital gave her father and his family “zero” time to make a choice. Instead they were given the names of three facilities, “all one star,” she said. Presumably she was referring to a ranking from the federal government’s Nursing Home Compare website that rates the country’s nursing homes. “We had to fight daily for basic human needs to be met,” she told me.

David Lipshutz, associate director of the Center for Medicare Advocacy, told me hospitals have electronic systems and share profiles of patients they are about to discharge with prospective recovery facilities. “They shop the patient around and say, ‘This is the facility to go to.’”

If hospitals are hitting the limits of what Medicare will pay for a patient’s care, they have a great incentive for moving people out. To them it doesn’t matter if a patient is moved to another state, as I was, or to another town. Either one can make it difficult for family to visit and keep an eye on the care, which is all-important.

The Hospital Fund also noted that legal safeguards don’t go far enough to protect patients and help their families and care givers choose high quality options. That means hospitals are not giving enough good information to families, already stressed by the illness of a loved one.

Even if a hospital recommended the Nursing Home Compare website, families often found the site lacking information about services families needed. Hospital staff did not have or provide information about the quality of care or a facility’s relevance to the patient’s needs.

In the end, when families did have a choice, location and transportation were key to their decision, the Fund reported. In the absence of any other compelling information about a facility, who wouldn’t select a place where you could easily visit your relative?

But even if a family did make an informed choice, if their preferred facility did not have a bed available, they had to go elsewhere. The hospital made the decision.

Because the system is such a mess, it’s hard to give good advice to families. But there are a couple things I can suggest.

Medicare requires a discharge notice, which sets out a patient’s appeal rights and procedures, to be given no later than two days after a person is admitted to a hospital. Some are given at admission, usually a time of confusion, and the explanation of rights is likely to be overlooked. Be aware of it, though, and read it carefully. You may need to rely on it if you think a relative needs to stay longer in the hospital.

And for all families who need more care after a hospital stay, the website of the Center for Medicare Advocacy has loads of information.

What has been your experience with hospital discharge planning? Write to Trudy at trudy.lieberman@gmail.com.

One more chance, until March 31, to look at options for Medicare or Medicare Advantage

By Trudy Lieberman, Rural Health News Service, Feb. 24, 2019

Solicitations for Medicare Advantage plans once again have been arriving in the mail, promising the best bargain since sliced bread. A case in point is one from Emblem Health, a managed-care company in my area that says it considers me what they call a “candidate” for their “special needs plan.” I don’t qualify for such a plan.

The solicitation was interesting, though, for what it promised. Free transportation to and from doctor, hospital, and lab appointments, but only up to 24 one-way trips a year. It also promised “no referrals.” Did that mean no referrals were necessary to visit specialists? The solicitation didn’t say.

That seemed highly unusual for what I am assuming is a Medicare Advantage HMO. HMOs usually require consumers to obtain referrals to specialists.

But shoving aside the questionable advertising pitches such solicitations are known for, that one reminded me that beneficiaries are now in a special enrollment period until the end of March. The special enrollment period, which began Jan. 1, gives seniors a three-month window during which they can switch some of their Medicare arrangements.

It’s also a good time for those who will soon be turning 65 to begin thinking of their options and learn what the rules are once they make their selections.

Until the end of March, if you have a Medicare Advantage plan, you are allowed to switch to another Medicare Advantage plan. Or you can drop a Medicare Advantage plan, return to traditional Medicare and buy a Part D stand-alone drug benefit, says Tricia Neuman, a senior vice president of the Kaiser Family Foundation and a Medicare expert.

What you cannot do, if you have traditional Medicare along with a stand-alone drug plan, is switch to a new drug benefit that might let you save more money on your prescriptions. You can do that only during the open enrollment period in the fall.

Keep in mind that if you drop a Medicare Advantage policy and switch to traditional Medicare, you might have trouble buying a Medigap policy to fill in holes in Medicare coverage. Only four states have what’s known as guaranteed issue Medigap insurance. In New York, Connecticut, Maine, and Massachusetts, people dropping Advantage plans in favor of traditional coverage can buy a Medigap even if they have preexisting conditions. In other states they may not be able to do that.

When might it be useful to consider other options during this brief window for switching?

If you have an Advantage plan that has a drug benefit built in as part of the coverage but you believe you can do better with another plan’s drug benefit, then you might want to do the math and see if a switch helps the budget.

Too many consumers fail to do their shopping for the drug benefit when, in fact, they can save thousands of dollars in pharmaceutical expenses by choosing one plan over another.

This special enrollment period gives you a second chance to save on drug costs.

But you may want to switch Medicare Advantage plans or choose traditional coverage, for other reasons that are becoming clearer. Research is beginning to surface that shows Medicare beneficiaries with high medical needs may have trouble accessing care in some Medicare Advantage plans.

Medicare defines those with high needs as people who have three or more chronic diseases and a functional limitation in activities of daily living or in performing routine daily tasks.

The U.S. Office of the Inspector General reported last fall that those with Medicare Advantage plans sometimes had trouble getting claims paid under those plans, or they reported other problems getting help from the plan.

The inspector general said that because so many seniors now have these plans, even low rates of inappropriately denied payments or services could cause “significant problems” for beneficiaries and their medical providers.

Just last month new research reported in JAMA Internal Medicine found that Medicare beneficiaries with high medical needs and those eligible for both Medicare and Medicaid were much more likely to disenroll from Medicare Advantage plans than other beneficiaries.

Researchers at Brown University and Columbia University found that disenrollment from Advantage plans “may indicate that plans do not meet the preferences of enrollees with significant chronic illness.”

This study and the inspector general’s findings offer a cautionary tale for people who will be new to Medicare in the coming months and for sick beneficiaries in Medicare Advantage plans who may want to reevaluate their options during this special open enrollment and next fall when open enrollment comes around again.

What has been your experience in choosing health insurance for this year? Write me at trudy.lieberman@gmail.com.

THINKING ABOUT HEALTH

Choosing Medicare Drug Coverage Can Be Tricky

By Trudy Lieberman, Rural Health News Service 

Karen R., a 70-year-old Medicare beneficiary living in a mid-size town in Indiana, contacted me recently about her Part D drug coverage. She and her husband both have traditional Medicare, a Medigap policy, and what’s called a stand-alone plan for their drugs. For a long time, her stand-alone plan offered through Humana worked well for them. Her out-of-pocket costs for most drugs was only $8.

This summer Karen, who takes 11 drugs for a variety of illnesses, including atrial fibrillation and kidney disease, was diagnosed with a new ailment – psoraisis. Not only did the diagnosis catch her off guard but so did the high price tag for Otezla, one of the newer drugs for treating this ailment. It was the only psoriasis drug that worked well with other medications she was taking. 

Karen and other seniors are discovering that some of these new drugs come with hefty price tags. 

Otezla is one of those expensive specialty drugs, which treat complex, chronic conditions. A drug qualifies for an insurer’s specialty tier if it costs more than $670 for one month’s supply; the insurer usually requires consumers to pay about one-third of the cost out of pocket. These sums have pushed more and more seniors over Medicare’s catastrophic drug coverage threshold, this year $5,000. Once over the threshold, their costs are high. 

More than one million beneficiaries with drug benefits had spending above the threshold in 2015, more than twice the number in 2007. 

With drug costs climbing for seniors, careful shopping is important this open enrollment season. That’s easier said than done. “It’s not easy to compare options, but differences do matter,” says Tricia Neuman, senior vice president of the Kaiser Family Foundation. 

Few seniors shop and compare Part D plans even though this year the average Medicare beneficiary has a choice of 27 stand-alone Part D plans that are purchased by people who choose to stay in traditional Medicare and a choice of 24 Medicare Advantage plans that have the drug benefit included. 

“The truth is they are not switching plans,” Neuman told me even though, she says, beneficiaries can save hundreds or even thousands of dollars over the year by choosing a different plan. Although the government’s Medicare.gov https://www.medicare.gov/ with its drug plan finder website provides a way to compare drug plans for your area, many people remain skeptical they can get a better deal and may lack computer skills to find the best choice. 

Then, too, one-third of beneficiaries have a cognitive impairment that further complicates their task. 

Here are a few suggestions for finding cheaper drugs. 

• Find out if your drug is in the insurance plan’s non-preferred or preferred tier. A drug might be in the non-preferred tier from one plan but in the preferred tier at another where it might be cheaper. Some drugs in the non-preferred tiers may call for 50 percent coinsurance, meaning that you pay 50 percent of the price of the drug.  Specialty drugs have their own tier, usually with 33 percent coinsurance for non-preferred drugs. 
• Generic drugs might not be cheaper. A generic in the non-preferred tier might be more expensive than a brand drug listed on a plan’s preferred tier. 
• Find out if the plan requires what is often referred to as “step therapy,” which means you must try lower-priced drugs first to see if they work. Is preauthorization for services required? A study by the Kaiser Family Foundation just released found that 80 percent of beneficiaries were in plans that required preauthorization for any service including Part B drugs administered in a doctor’s office. Many consumers find preauthorization a real hassle. 
• Have a conversation with your doctor about cheaper alternatives. Maybe there is one in a plan’s preferred category. Physicians are often not knowledgeable about the ins and outs of drug plans and may not have a patient’s financial wherewithal in mind when they write the prescription. These are not easy conversations to have, but it might be one way around the high prices for the drugs you take. 

I asked Karen what she was planning to do for next year. She told me she would ask her doctor again to request that Humana grant an exception to the $3,000 price of Otezla on its specialty tier. That exception brought the price down to the $1,900 she has been paying. She also asked for what’s called a “tier reduction,” which would have brought the price down even more. The insurer refused. 

She says she and her husband are also exploring the possibility of getting back on his former employer’s retiree plan. If not, they’ll be like millions of other seniors – exploring any and all options to lower their pharmaceutical bills.

By Trudy Lieberman, Rural Health News Service

Choosing Insurance in a Confusing Marketplace

Anyone buying health insurance this fall faces a daunting task: having to choose among multiple, often-complex options that offer widely varying degrees of protection.

For starters, association health plans are back, allowing small businesses to band together to buy insurance.  So are the short-term policies that may last from only a few months to a year. Then there are plans offered by church ministries that look like insurance but really aren’t.  Plus, multiple and complex options remain from the Affordable Care Act.

And to complicate matters further, if a bill just introduced in Congress passes, it would require insurers to sell policies to people with preexisting conditions and not use health status in determining the premium. But here’s the catch:  Although an insurer could insure a person with preexisting conditions, the carrier would still be allowed to exclude coverage for those specific conditions. It could, however, cover you for other illnesses you might get in the future. 

Prior to the Affordable Care Act, the insurance industry used this tactic for avoiding claims from sick people. They would sell the policy but would waiver or “rider out” coverage for any preexisting condition. That meant someone with asthma would not be able to get coverage for asthma-related illness. Some companies went even further: They would cover no diseases of the respiratory system at all.

But in general, before you comb through the fine print in an insurance policy, think about these major factors. 

The more you pay in premiums, the more you get in benefits. Many of the new options don’t have to cover all of the Affordable Care Act’s 10 essential benefits, and most insurance experts believe that in order to offer cheaper premiums, many of them won’t.

At first glance, a low premium and fewer benefits may seem attractive. Those essential benefits that are part of an Affordable Care Act policy include mental health and maternity coverage, which many older people have squawked about, arguing they don’t want to pay premiums for coverage they would never need.

The essential benefits, however, also include prescription drug coverage, generous hospital coverage, emergency services, and rehabilitative services that are important to older people. But those coverages get little attention in stories about 60-year-old women being forced to buy maternity coverage.

Look for some of this fall’s new policies, for example, to limit hospital coverage to a certain number of days, or they might limit radiology services or drug coverage. The new so-called short-term policies will come with few if any regulations from the federal government or state insurance regulators.  

After understanding the relationship between premiums and coverage, the next big decision is how much risk you want to assume if you become seriously ill.  In other words, how much can you afford to pay out of pocket?  For a large portion of Americans, the answer is not much. The Commonwealth Fund recently found that nearly half of working age adults could not pay an unexpected medical bill of $1,000 within 30 days.

Over the years, I’ve heard too many families say they are healthy, aren’t going to use the insurance, and might as well buy the cheapest policy possible – or none at all.  I’ve interviewed many people who took that position only to end up later in bankruptcy court when unforeseen illness struck because they had no insurance and not enough money to pay the bills.

How large a bill can your family assume? If you have a large pool of resources to weather a serious illness, then skimpy benefits might work. If you don’t, think carefully before buying a policy with few benefits.  Families tend to underestimate how much coverage they’ll need.  

Once you understand these two basic principles, the next step is to look at the offerings on your state’s insurance exchange. Obamacare polices have gotten a bad rep almost since the beginning because they tend to be pricy for families that don’t receive an income-related subsidy to help cover the premium. About 87 percent of people who buy on the exchanges do get a subsidy.

If you are eligible, see if you are also qualify for a second subsidy the law provides—the cost sharing subsidies that are available only for those with very low incomes who buy certain Obamacare policies. Those subsidies help pay for the deductibles and coinsurance that many of the policies require.

People not eligible for subsidies must brave the new confusing marketplace. For instance, the Texas Medical Association just reported that it is carefully watching the health care sharing ministries, which are not insurance but are organizations that allow those with similar beliefs to share each other’s health care costs.  The ministries, which I’ll explore in a future column, may be confusing consumers into thinking they have real insurance, according to the medical association. 

For 2019, there’s no longer a tax penalty for not buying health insurance.  But before rejoicing at that prospect, think about what it would mean for you and your family to be totally on your own when it comes to paying for health care.

What trade-offs are you prepared to make this year? Write to Trudy at trudy.lieberman@gmail.com.

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THINKING ABOUT HEALTH

By Trudy Lieberman, Rural Health News Service

Administration’s Plan for Drug Pricing Preserves Big-Picture Status Quo

The headline in the Wall Street Journal seemed to sum up the president’s plans for dealing with America’s high drug prices. “Drug Industry Relieved By Price Proposal,” it read and then described the president’s blueprint as falling short of  “more far-reaching ideas.” Since the plan contained no major threat to the status quo, it’s no wonder it boosted pharmaceutical stocks.

In other words, the plan continued the current system under which the government does not negotiate the prices it pays for medicines under the Medicare program, a far-reaching solution that I’ve discussed before in this space.  The 2003 law that gave seniors a drug benefit under Medicare prohibited such negotiations, which pharmaceutical manufacturers loudly and forcefully opposed.  They feared that allowing the government to use its muscle to bargain over drug prices might slow their escalating increases.

Drug makers weren’t about to let that happen, and the supporters of the law were so eager for a guaranteed benefit, they had little bargaining power to push back.

For a few years after the law was passed, pharmaceutical prices didn’t increase very much. In recent years, however, that has changed as prices for new drugs like Sovaldi and Harvoni to treat hepatitis C hit new highs. Sovaldi cost $84,000 for a three-month course of treatment when it was introduced in 2013.  Harvoni cost $94,500 for three months when it made its market debut a year later.

Consumers are also complaining about rising prices for more common medicines like insulin. Typical is this complaint from a diabetic who said the price of an insulin pen increased nearly 68 percent from $73 in July 2014 to $123 in March this year.  “This is not exactly a new drug,” he told me.

The pricing practices of all the players in the drug distribution system are responsible for the confusing pricing system we have.  Pharmaceutical manufacturers and PBMs or pharmacy benefit managers – third-party administrators brought in to help insurers manage their drug costs – bear responsibility. So do the pharmacies themselves when they offer coupons to consumers to lower their out-of-pocket costs, easing some individual burdens but doing nothing to solve the larger problem.

 What’s more, their actions are hardly transparent.

The odds are that the president’s blueprint will do little to bring clarity and lower prices. “Overall this is quite underwhelming in scope,” Craig Garthwaite, director of the health care program at Northwestern University’s Kellogg School of Management, told the Journal. “The proposal is vague on details and filled with more slogans than actual sound economic policies.”

For example, the blueprint calls for examining whether to allow Medicare drug plans to pay different amounts for the same drug depending on the illness involved. And the government wants to explore money-back guarantees in which a drug manufacturer promises to give back money if a medication does not work. Insurers are already engaging in this practice with pharmaceutical companies, but cost savings are unclear.

The administration also wants to consider listing the price of pharmaceuticals, but it’s not clear that affects consumer behavior or brings market pressure to bear.

Another idea the president threw out was to pressure other countries into raising the prices of drugs their citizens buy. Although he said high drug prices in the U.S. are subsidizing innovation that benefits the world and noted that “America will not be cheated any longer by foreign countries,” details for this proposal were vague.

In many nations prices are determined through negotiations between the government and the pharmaceutical industry. Would other countries raise their prices to please the U.S.?  Would American drug makers lower theirs? 

Nothing in this vague blueprint surprises me.

Until my recent illness – an infection that caused my system to shut down and resulted in a four-month hospitalization – I was following a campaign by the drug industry to rehabilitate itself and seize control of the public narrative over drug prices, as Politico described it.  One way the drug industry did that was to retool its lobbying machine, try to drive a broader discussion on health costs, and emphasize that other players had a role to play in keeping down costs. 

Almost daily, a drug company or a related business sponsored content in several online health newsletters that are read by Washington lobbyists, health experts, Congressional staff members, and journalists. Sometimes the sponsored messages looked like the regular content of the newsletter. Even though they were flagged as paid content, the format often made me think I was reading a legitimate news story.  One “story” sponsored by the pharmacy benefit management industry said they were not the ones to blame for higher prices.     

With clout like this, is it any wonder the industry has managed to keep drug price negotiation out of the picture?

How have high drug prices affected you?  Write to Trudy at trudy.lieberman@gmail.com.

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THINKING OF HEALTH

By Trudy Lieberman, Rural Health News Service

Patient-Centered Care Shouldn’t Be Just a Marketing Slogan

Recently I heard from a woman in rural Nebraska who told me about her 76-year old father, who in late April had a lemon-size cancerous mass removed from his brain. The man chose to have his chemotherapy and radiation treatments at a hospital close to his home instead of at one of the larger hospitals farther away. Not surprisingly he wanted family nearby.

Nearly two months later, in mid-June, his treatments finally began.

Why the delay?

His daughter told me the nearby hospital “had no record of two appointments they had made with my dad and rescheduled at least once.” She asked me if her father was being neglected because he was on Medicare, adding, “He is so angry. We are so angry. So much for urgency and professionalism.”

So much for patient-centered care – that buzz phrase that’s all the rage in healthcare circles. It goes by a lot of different names like patient engagement, patient activation, and shared-decision making.  If care is truly patient-centered, it revolves around eight principles identified in research by the Harvard Medical School and the Picker Institute. They include respect for patient preferences, coordination of care, information and education, physical comfort, emotional support, involvement of family and friends, continuity and transition, and access to care.

For the family in question, the Nebraska hospital simply didn’t meet those standards.

What passes for patient-centered care falls short for a lot of other people, too, like one man who spent weeks trying to get his diabetic test strips. His current supplier had lost its Medicare contract, and Medicare sent him a letter advising him of a new approved source. He called the number he was sent and ordered new strips. A week later he went to the pharmacy to pick up his supplies but was told they had no record of his order. Days passed before he got the strips.

Six months later he encountered another problem – this time with his supplier of pens used to inject insulin.  He ordered them and approved the charge to his credit card using a telephone automated order system.  Several days later the supplier called and left a message asking him to confirm the shipment. When he called back, he learned the cost exceeded the limit for automatic approvals, and the order wouldn’t be processed until he personally approved the charge. No one had told him there was a limit. So much time had passed that he had only a two-day of supply of insulin left.  “The delay created a potential emergency,” he said.

Often patient engagement has come to mean selling things, particularly tools and devices, that purport to help patients manage their care. During the man’s many calls with the supplier the company tried to sell him knee and back braces, advising that Medicare would pay if he got a doctor’s prescription.

Last year I was invited to attend a panel discussion about innovations in patient engagement.  The room was full of young marketers eager to sell their products and share the best ways to reach patients. Since the term patient engagement is so slippery, it wasn’t surprising the program began with a discussion of what it actually meant. 

One panelist offered this definition: “It really has to do with how can you get patients to do more or become more active in the ecosystem about their health.” Another said, “Let’s think of patient engagement as a marketplace. How are they engaged in the marketplace? 

Perhaps he meant that people like the man who needed an insulin pen pronto would be “engaged” enough to buy a brace he did not need.

Another panelist noted, “People’s engagement with health is quite low. There’s a gap we’re seeing between technology and tools and the patients and doctors involved in using them.”  A fellow panelist said patients “don’t want just excellent care. They want an experience.”

Most experts would argue that patients too often are not getting excellent care. Postponing medical treatment because of schedulers’ errors and nearly running out of insulin because a company’s procedures are inefficient hardly qualify as excellent care.  “Experiences” like those are all too common.

That’s not to say patients shouldn’t be active in their care. Growing evidence suggests that patients who are more actively involved have better health outcomes. But that doesn’t mean profit-seeking providers should be pushing unnecessary care, pills, or devices onto patients.

I recently got a letter called a Care Consideration from Aetna, my supplemental insurer. It said, “This information was identified to support you in working with your doctor to improve your health.” The letter was a not-so-subtle push to take a statin for heart disease.  There was just one problem. At my last physical less than a year ago my cholesterol was “excellent,” as it always has been. No medication required. 

Pushing a drug and trying to overrule my doctor does not qualify as patient engagement.  

What does patient engagement mean to you?  Write to Trudy at trudy.lieberman@gmail.com.      

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 trudy.lieberman@gmail.com.  

Hospitals Are Penalized for Harming Patients

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 trudy.lieberman@gmail.com. 

Non-network ER docs may charge big bucks

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 trudy.lieberman@gmail.com.

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What you need to know about choosing health insurance

By Trudy Lieberman
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 trudy.lieberman@gmail.com.   

Obesity Rates Fall in a Few States but Are Still Far Higher Than in 1990

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.

Trudy Lieberman

Obesity is a disease, and for the last 13 years the Trust and the Robert Wood Johnson Foundation have monitored obesity rates in the country, focusing on the proportion of a state’s population that is obese. The study designates someone as obese whose body mass index (a measure based on height and weight) is 30 or higher.

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.

Other reasons?

• 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. 

Eating habits are different, too, with families eating more often in restaurants, including fast food establishments, and consuming more added sugars and fats. Many families eat at McDonalds or Burger King a few times a week, but even if they cooked at home, they might not be eating “healthy” because they don’t have access to fresh fruits and vegetables.

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 trudy.lieberman@gmail.com.