Month: April 2017

Let’s Restore Common Sense to Medical Care Charges!

 - 

As I was doing my usual scoping of Twitter posts the other day, and I came across one person I follow on Twitter (@StikNtheMud) whose Twitter feed has generally been dedicated to people expressing their disdain for their Obamacare insurance policies. I had actually not been on her Twitter feed for some time, so I figured it was high time to hang out there awhile.

There I found a veritable bevy of comments about the ravages of Obamacare on the average person. Here are a couple of quotes from commenters on this Twitter feed. The names have been withheld to protect the innocent victims of Obamacare.

  • “I don’t want Obama Care. It sucks for me. I lost my doctors, the cost for health care with it is so high. I don’t even go to the doctor anymore.”
  • “In Anchorage, premiums for a silver ACA (Affordable Care Act) plan for a 64-year-old couple making $82K a year =  $50,930 a year. That’s not a misprint.”

Believe me, these are only a couple of the many, many posts decrying the miseries of Obamacare.

So once again, I am beating the drum about so called “coverage” not equaling access to health care.

Wasn’t Obamacare enacted to make health care more affordable?

In the first post mentioned, the person wrote that health care costs are so high that she doesn’t even see a doctor now. Also, in looking closely at the second comment, this 64-year-old couple’s insurance premiums cost more than half their annual income. Clearly, with this annual income, this couple did not qualify for any premium subsidies, and they most likely have a deductible and co-insurance to pay in addition to that annual premium. A mortgage should not even be that much of a percentage of one’s income, much less health care costs.

The ultimate irony here is the name of the law that was supposed to bend down the cost curve for health care is the “Affordable Care Act.”

Posts like the ones above are a strong indication that our current health care environment remains generally Unaffordable, and has become even more Unaffordable each year since the implementation of Obamacare. I do understand that there are those who embraced Obamacare and its subsidies to reduce their premiums. However, if they have deductibles of $5,000 or more, how much use are those plans if they are not the kind of people who see the doctor more than once or twice each year?

Many people have been deceived into believing that if they are in a narrow Preferred Provider network, the contractual agreements between their health care providers and the insurance companies that “cover” them will result in less health care costs for them. NOT!

According to an editorial to which I often refer entitled, “Have PPO Networks Perpetrated the Greatest Heist in American History,” author Dave Chase (1) states that hospitals often charge 550 percent of the standard reimbursement by Medicare. Then the BUCA (Blue Cross Anthem, United Healthcare, Cigna, and Aetna) PPOs will discount such charges by about 50 percent. Well, a quick calculation reveals that 50 percent of 550 percent is 275 percent. Those are still very high charges, and I do not believe such charges actually reflect the cost of providing care.

I could not help but wonder why Medicare reimbursement is the benchmark for reasonable payments of medical costs because I often see complaints from doctors about how the low reimbursement rates by Medicare do not cover the costs of care. I do not think that a payment practice by insurers of reimbursing providers 275 percent of Medicare rates (regardless of whether those rates totally cover the cost of care) is reasonable either. Whatever happened to hospitals and other providers determining their costs (I’m sure they have some brains that can figure that out) and charging an amount with a reasonable profit margin over their costs?

In his editorial, Chase’s interviewee Mike Dendy makes the following statement: “A well-run hospital can make money from Medicare payment schedules. The problem is that most hospitals are not financially well managed and have no reason to be when they can pretty much charge for services at will.” So I guess that is the explanation for Chase using Medicare reimbursement as a benchmark for reasonable payment.

There are so many nonsensical factors that go into heath care pricing, mainly by the large health care systems that also try hard to eliminate the competition posed by independent doctors. These doctors generally have reasonable charges for their services,  but large health care systems (including “non-profit” ones) often either employ them or buy them out. My guess for the motivation of the “health care” systems is that they want to continue unfettered with their ridiculous prices for medical services. (Please see my Expert Posts category for more information on this one.)

So what use is “coverage” when all these ridiculous games are being played by “health care” systems and insurance companies? This has to be stopped!

Further reading:

  1. https://www.forbes.com/sites/davechase/2016/09/05/have-ppo-networks-perpetrated-the-greatest-heist-in-american-history/#2e8cfdfa3330

Image courtesy of canstockphoto.com


Expert Post by Dr. Niran Al-Agba

 - 

I follow pediatrician Dr. Niran Al-Agba, pictured here, on Twitter (Twitter handle – MommyDoc, @silverdalepeds), and I also receive email notifications whenever she adds a new post to her blog. I believe that the post I am linking to here on my blog is VERY important for people (and our national leaders) to know because it explains one of several drivers of high costs for health care, so I decided to go ahead and do something that was already suggested to me for my blog – establish an “Expert Posts” category where I will post links to blog posts and articles I feel strongly moved to share outside of the customary source linking I do for my posts.

https://peds-mommydoc.blogspot.com/2017/04/youve-got-facility-fees.html?showComment=1492017458996#c6483269634879565256


Here We Go … Another Round of Numbers!

 - 

I wrote a blog post more than a month ago about the way numbers can be manipulated by government, media, or anyone else who wants to get in on the act to promote a particular point of view, and nowhere has that been more evident than with the Patient Protection and Affordable Care Act of 2010, especially in the midst of efforts by the Republicans to repeal and replace the sputtering law.

In my previous post, I dealt with how many people had been touting the “success” of the ACA because it had supposedly provided insurance coverage for an additional 20 million people, which gave President Barack Obama’s administration the opportunity to pat themselves on the back. However, my post also pointed out that the coverage of  20 million more people was inaccurate, according to most counts, and in fact, no counts on people covered by the ACA reached the 20- million mark as far as I could see. Although one estimate by the Rand Corporation of the people “newly covered” by the law placed the original number at 22.8 million, but then had also calculated that approximately 5.9 million people had also lost their “coverage” as a result of the law. This brought the grand total of newly covered people under Obamacare to approximately 16.9 million, quite a bit under the touted 20 million.

Where is the logic here?

The newest twist in numbers totally mystifies me, but if you read its details it is not as dramatic as one would think.

As Congress and President Donald Trump unsuccessfully attempted to pass the American Health Care Act last month, the Congressional Budget Office, which is supposed to be non-partisan, released some interesting figures regarding the anticipated effects of repealing and replacing Obamacare.

An article entitled “The GOP’s Obamacare Replacement Is Going to Disproportionately Affect One Group,” by Lydia Ramsey and Andy Kiersz (1), reported that when the CBO released its report on the effects of the American Health Care Act, the agency estimated that “24 million more people could be uninsured.”

I had an immediate question – 24 million MORE than what? More than the number of people who remain uninsured despite of or because of Obamacare? The article simply does provide any details on that.

Then a CNN report entitled “CBO Report: 24 Million Fewer Insured by 2026 under GOP Health Care Bill.” by M.J. Lee and Tami Luhby (2), stated that there would be 24 million fewer insured people in the United States by the year 2026, which is less than nine years from now. This article also said that as many as 14 million fewer people could be insured by next year if Obamacare is repealed and replaced by the AHCA.

As I mentioned earlier, none of the counts for the number of people who were actually “covered” by insurance under Obamacare ever reached as many as 20 million, much less 24 million. Now this is only the fourth year that Obamacare has been in place, and maybe many more people would have enrolled in the years to come, but maybe NOT because several large insurance companies were pulling out of the exchanges as the result of large losses blamed on the ACA.

There are too many unknown factors to make any real predictions.

One crucial point in all these rather bizarre estimations sticks out in my mind. How can the CBO, or anyone else, accurately predict what may happen in both the individual and employer-sponsored insurance markets over the course of 9-10 years? There are just too many unknown factors. For instance there are several policy areas that could change drastically over that time period that would allow for people to get different insurance plans that fit their needs better.

Here are a few policies that, if enacted, might cause the loss of insurance coverage under our customary insurance models for the last 30 years or so, but may result in a much wider variety of insurance plans being offered, as well as more individualized methods of providing for health care needs such as larger amounts in Health Savings Accounts.

  • The formation of high risk pools in every state that enable the chronically ill to buy insurance for their needs at affordable rates.
  • Making tax credits that have only been available to employers available to all citizens so people can decide whether they want to buy insurance through their employer or buy an insurance policy more suitable to their own needs in the individual market – either way the tax advantages would be roughly the same.
  • The removal of all mandates to buy insurance, including the essential benefit mandates that only served to drive up the costs of premiums for many people because a number of benefits had to be covered. This flexibility could enable people to buy truly catastrophic plans that they feel would meet their needs.
  • Increasing the annual amount allowable, by tax law, to add to health savings accounts as well as not requiring that they be tied to a high-deductible insurance plan.
  • Removing the tax-exempt status of most “non-profit” hospitals. This is one that I have not read or heard about anyone proposing yet, but it would go a long way in making health care providers (especially hospitals) actually have to compete for patients by lowering costs and improving the quality of care with real quality measures rather than useless government-mandated measures.

So while many people wave various and assorted numbers around to catastrophize anything our current national leadership does to restore a functioning health/medical care system, there are opportunities for people to come out of the whole mess with a much better deal than they have now, especially with the continued proliferation of innovative free market practice models designed to lower overall health costs.

Further reading:

  1. http://www.businessinsider.com/cbo-chart-on-how-healthcare-costs-could-change-under-ahca-2017-3
  2. http://www.cnn.com/2017/03/13/politics/cbo-report-health-care/

Perspective From Those in the Trenches

 - 

Introduction

As I have educated myself about a lot of the issues with health care delivery and payment in the course of my employment with Dr. Randy Delcore and my own blogging efforts, I owe a lot of what I have learned to connecting with doctors and health policy experts on several of the social media platforms. I feel that many of those blogs and articles I have come across in that process, especially those written by doctors who work in the trenches of our health care system daily, lend even more insight than I can provide from my perspective as an average non-medical citizen observing the many dysfunctions AND innovative models present in our current health care environment. I will use these “expert posts”  to provide links to those blogs and articles with the purpose of providing an even richer understanding of how to improve the U.S. system of health care delivery with that great American pioneer spirit.


How Can the U.S. Really Make Health Care Truly Affordable?

 - 

In many of my posts, I complain about the way our Congress and President (not to mention the Congressional Budget Office and media) harp about how people will or will not be “covered” for receiving medical care. This outlook ASSUMES that it is just too darn expensive for the “average Joe” to just pay cash for his visit to the doctor or surgery. The ultimate irony is that plans within the Obamacare exchanges require quite a bit of out-of-pocket expense anyway – high premiums, deductibles, plus co-insurance, etc. Forking out all this money does not constitute my idea of “coverage.”

What if health (or should I  say medical care) wasn’t generally that expensive?

When someone proposes that thought, many others express incredulity at such an idea. It’s as if people asking the question, “Does health care have to be outrageously expensive?” could be compared to someone asking “Is the Pope Catholic?” While there are situations in which the provision of medical care can become very expensive as in the case of heart attacks, strokes, critical injuries, etc., those are situations in which huge amounts of resources are required to save a person’s life and help them recover. That is what catastrophic medical insurance was always intended to do.

Then there are surgical procedures that can be quite expensive, but they do not necessarily have to be. Let’s just use the example of a hip or knee replacement. These procedures are often needed when someone’s arthritic condition has deteriorated to being “bone on bone.” I know personally how painful this can be because I experienced it with both my hips and needed to have them both replaced. Fortunately, medical science has made great inroads to replacing the bad joints and giving those with that condition a new lease on mobility and life.

However, joint replacements are not known to be cheap, and costs vary wildly.

I recently read an article that was published in February of 2013, but not much as changed since then. The article is entitled, “How Much Will Your Surgery Cost? Finding Out Cost of Hip Replacement Surgery is a Confusing Uphill Battle: Study,” which was credited to the Associated Press (1). The study the article discussed was published in the Journal of the American Medical Association Internal Medicine.

According to this article, researchers conducted a study of 122 hospitals in every state to find out how much a hip replacement would cost if performed on a healthy 62-year-old woman who was not covered by any insurance, but could pay out-of-pocket. According to this study, 15 percent of the hospitals contacted never provided even an estimate of a price, even after as many as five calls. The article reported that researchers were able to obtain cost information from approximately half of the hospitals contacted that included both the physician and hospital charges.

The study found that costs for hip replacement surgery could be as little as $11,000 or as much as $126,000.

The Associated Press wrote that American Hospital Association spokeswoman Marie Watteau commented on the study published in JAMA. She is quoted as saying, “hospitals have a uniform set of charges. Sharing meaningful information, however, is challenging because hospital care is unique and based on each individual patient’s needs.”

Really? It seems as if, especially in these times when patients even face high deductibles along with a responsibility for what is known as co-insurance, if they are insured, that hospitals could look at typical charges on a hospital bill for a total hip replacement and at least provide a ballpark figure with a disclaimer that complications could increase that cost.

It is interesting that a number of ambulatory surgery centers have begun to post transparent bundled pricing for many non-emergent surgeries. For example, at Cedar Orthopaedic Surgery Center, the cash price for the replacement of one hip joint is $17,500 (including the surgeon’s, facility, and anesthesiologist’s fees as well as the cost of the hip implant, initial consultation, and in-surgery radiology). This price is posted on COSC’s website. At Surgery Center of Oklahoma, the cost of a hip replacement is posted as $25,000 (which also includes the surgeon’s, facility, and anesthesiologist fees as well as the initial consultation). Each facility has a clear pricing disclaimer that enumerates any possible charges that are not included as part of the cash package as well as what is included, so there should be very little in the way of surprises. And yes, both of these facilities treats each patient as a unique individual.

So why is it so difficult for hospitals to provide at least a reasonable ballpark figure for costs? Well, I’ve given you quite enough to digest for today so I will cover that subject in my next post on health care issues.

Further reading:

  1.  http://www.nydailynews.com/life-style/health/surgery-cost-article-1.1261818

And The Beat Goes On …

 - 

Congress and President Trump are both apparently revisiting the issue of repealing and replacing Obamacare. And I say, “Good!”

I was very disappointed when the last effort by the House of Representatives failed to get a bill passed that could go on to the Senate and get passed there. To their credit, our congressional representatives did not totally abandon the effort to repeal and replace Obamacare with something that permits a (hopefully)  more free market approach to “health care” and just jump over to tax reform, although that certainly remains on their agenda.

As the discussions continue between moderately conservative Republicans and ultra-conservative Republicans (who are identified as the Freedom Caucus), I worry that they are just in too big of a hurry to get some kind of a bill passed. I have one question:

Where’s the fire?

As I listened to Fox News late last week and throughout this week, the news coverage seems to center around how soon this can be done. In the end, from everything I have heard regarding the timetable for passing an Obamacare repeal and replacement bill, nothing is likely to happen until after Easter. And once again – I say “Good!”

Hopefully it doesn’t even happen too closely on the heels of Easter.

Yes, I do want to see Congress take action on enabling free market medical care as expeditiously as possible. However, I do not want them to hurry through this process and do a bad job at it. It seems like there is an obsession in news stories and in Congress (not to mention the Congressional Budget Office) with gauging how many people will end up with insurance “coverage” and how many people could end up losing it as a result of any repeal action of Obamacare.

I say Congress, and the media that reports on what Congress is up to, is too obsessed with this issue of insurance “coverage.” However, very few people are addressing the real reason that health costs are so high and people fear going into bankruptcy if they are not “covered” by insurance for medical needs. A lot of it has to do with the ways the insurance industry has deceived many people into believing that its contract negotiations with its “participating providers” (especially hospitals) are beneficial to them as patients and coverage holders. Not only that, but many of the deductibles in Obamacare exchange plans are HUGE!

Case in Point

Let me provide you with one example I recently read about in an editorial, “ObamaCare Subsidies Rob the Middle Class” by Alieta Eck, MD (1).

Dr. Eck wrote that most insurance companies have networks of “preferred providers” that most people assume are doctors, labs, hospitals, etc. that provide better rates for care. However, the opposite appears to be the case.

She wrote about one patient who had to spend a day in the emergency room. The grand total for the “billed charges” was $12,000. Because the hospital he/she went to was a one of those “preferred providers,” the actual charges came to $10,000. Coincidentally, the patient’s deductible was $10,000.

Here is the real kicker. A hospital “patient advocate”” informed this patient with the $10,000 deductible that he/she was responsible for paying this entire amount because he/she had not yet met the plan’s deductible. Because the patient had insurance “coverage,” there was no option to take part in any cash pay discounts the hospital might offer to patients not covered by insurance.

Dr. Eck also wrote that the total charge of laboratory work performed during the patient’s day in the emergency room totaled $3,500, and those labs would have cost less than $100 if done by a lab outside the hospital.

So did this patient’s insurance “coverage” in a “preferred provider” network do him/her any good? Anyone with a grain of sense would have to answer, “No way!”

So why is everyone obsessed with “coverage?” It could be a much better deal to get a basic catastrophic insurance plan that would pay for expenses for which few people can really plan. I believe that giving people the freedom (in terms of tax credits/deductions) to save for medical care expenses with Health Savings Accounts, find doctors with reasonable and up-front pricing (most likely outside the insurance networks), and buy insurance plans that fit their individual needs and budget is far superior to the insurance mandates in the Obamacare plans. All the “essential benefits” required to make insurance plans compliant to the Obamacare law are driving costs UP, not DOWN.

A memo to Congress – don’t just do it; do it right!

Congress and the president really do need to “get this.” They also need to slow down and really listen to doctors, nurses, other providers and patients who live the misery of government mandated coverage and interference in medical decision-making every day.

Further reading:

(1) http://aapsonline.org/obamacare-subsidies-rob-middle-class/

Image courtesy of canstockphotos.com