Report Faults High Fees for Out-of-Network Care
By RONI CARYN RABIN
Just over a year ago, Angel Gonzalez, 36, awoke with searing chest pain at 2 a.m. A friend drove him to the closest emergency room.
Though he was living on $18,000 a year as a graduate student, Mr. Gonzalez had good insurance and the hospital, St. Charles in Port Jefferson, N.Y., was in his network. But the surgeon who came in to remove Mr. Gonzalez’s gallbladder that Sunday night was not.
He billed Mr. Gonzalez $30,000, and an assistant billed an additional $30,000. Mr. Gonzalez’s policy covered out-of-network providers, but at a rate it considered appropriate: $2,000. “I was on the hook for more than I made in a year,” Mr. Gonzalez said.
A health insurance industry report to be released on Friday highlights the exorbitant fees charged by some doctors to out-of-network patients like Mr. Gonzalez. The report, by America’s Health Insurance Plans, or AHIP, contrasts some of the highest bills charged by non-network providers in 30 states with Medicare rates for the same services. Some of the charges, the insurers assert, are 30, 40 or nearly 100 times greater than Medicare rates.
Insurers hope to spotlight a vexing problem that they say the Affordable Care Act does little to address. “When you’re out of network, it’s a blank check,” said Karen Ignagni, president and chief executive of AHIP. “The consumer is vulnerable to ‘anything goes.’ ”
“Unless we deal with cost, we won’t have affordability,” she added. “And unless we have affordability, we won’t have people participating” under the Affordable Care Act.
Among the fees on the report’s list are a $6,205 outpatient office visit to a doctor in Massachusetts for which Medicare would have paid $152; a $12,000 bill for examining a tissue specimen in New York for which Medicare would have paid $128; and a $48,983 surgeon’s fee for a total hip replacement in New Jersey that Medicare would have reimbursed at $1,543. Many of the highest billers were in New York, Texas, Florida and New Jersey.
Elisabeth R. Benjamin, co-founder of the Health Care for All New York coalition, who is often at odds with the insurance industry, said that “is one area we totally agree on.” She continued, “Out-of-network billing is just out of control.”
Europe Says Drug Makers Paid to Delay a Generic
By JAMES KANTER and KATIE THOMAS
BRUSSELS — European antitrust officials on Thursday accused the drug giants Johnson & Johnson and Novartis of colluding to delay the availability of a less expensive generic version of a powerful medication often used to ease severe pain in cancer patients.
The case focuses on monthly payments that a Netherlands-based subsidiary of Johnson & Johnson made to Sandoz, a unit of the Swiss company Novartis. While the companies have said the payments were legitimate, the European Union’s antitrust chief said on Thursday that the money probably changed hands to keep lower-cost versions of the drug, called fentanyl, off the market in the Netherlands.
European authorities are “determined to fight undue delays in the market entry of generic medicines,” Joaquín Almunia, the European competition commissioner, said in a statement on Thursday.
Agreements to delay the introduction of generic drugs have come under heightened scrutiny in both Europe and the United States in recent years, with regulators on both sides of the Atlantic concluding that such deals are anticompetitive. In the United States, the Supreme Court is scheduled to take up the issue in March. Typically, such arrangements are a result of patent disputes between brand-name and generic drug makers, although no such dispute was mentioned in the most recent case involving Johnson & Johnson and Novartis.
“From our perspective in the United States, we hope to have a real resolution of this issue with the Supreme Court this term,” said Jay Lefkowitz, a lawyer who has represented several drug companies in such cases. But because many companies sell their products around the world, “this is something that people are taking note of, for sure.”
Fentanyl is widely used in Europe and the United States, typically paid for by government-provided health plans or, in many cases in the United States, by private insurance. Although the pricing of such drugs is usually negotiated behind closed doors, generic versions are typically much cheaper.
Mr. Almunia warned pharmaceutical companies against practices that raised costs for European governments, squeezed by austerity and an economic slowdown, which must buy medicines for state-supported health care plans. It is “important to make sure that pharmaceutical companies do not free-ride our welfare state and health insurance systems, especially in this period of constraints on public spending,” he said.
LePage's budget would cut off patients with special needs
Hard-to-find dental care for 3,000 of the mentally ill and disabled would vanish under the governor's budget.
PORTLAND – Rick Hagan counts on the specialized dental care offered at Clinical Services to keep his teeth clean and healthy.
Hagan, who lives in Bath and has bipolar disorder, is one of more than 3,000 people with mental illnesses or intellectual disabilities across southern Maine who visit the state-funded dental clinic at 63 Preble St.
Now, because Gov. Paul LePage's proposed state budget would close the clinic in June, Hagan and other patients fear they will no longer have access to regular dental care. Hagan, 45, said he barely survives on Social Security disability payments andMaineCare, the state's form of Medicaid.
"If I had to pay for dental care, it would pretty much clean me out," Hagan said Thursday, while he was at the clinic to have his teeth cleaned. "I'm worried that LePage is hellbent on hurting people and getting rid of anyone who isn't up to his standards."
LePage's office did not respond to a request for comment.
Leave my prostate alone
Posted Oct. 26, 2011, at 1:34 p.m.
Dear Guys (and the women who love us),
I’ve recently decided to let the little lobe (my prostate) do the thinking for the big lobe (my brain). As a result, I am not going to get a popular blood test for prostate cancer called Prostate Specific Antigen.
My brain, of course, thinks my prostate is an idiot not to get the PSA test. If we have a test for a cancer that kills 45,000 men each year why on earth would we not use it? My prostate, however, is happy to heed recent draft recommendations from the U.S. Preventive Services Task Force that men over 50 years of age do not routinely get PSA prostate cancer screening.
The reason this news has my prostate sighing with relief and telling my brain to smarten up or butt out of the issue, is because aggressive prostate cancer treatment is unnecessary for most men, and the treatment for prostate cancer is often worse than the disease.
If prostates could emerge into the sunshine and read, this is what they should peruse to help their brains distinguish fact from fiction in the Great Prostate Debate:
• The USPSTF draft report at uspreventiveservicestaskforce.org/draftrec3.htm, the most comprehensive review available of the whole issue, will point out that of 100 men diagnosed with prostate cancer, 97 will die of something else. For most men, prostate cancer is kind of a lazy, slowly progressive disease that will develop in almost all men who live to the age of 80. Aggressive prostate cancer is much less common, and there is little evidence that diagnosing it early with PSA testing improves the chance of survival.
It will also point out the problems with treating the more benign form of prostate cancer. Between 1986 and 2005 one million American men had surgery or radiation treatment for prostate cancer that would not have been diagnosed early without a screening PSA test. Of those, according to the USPSTF analysis, 5,000 died soon after from treatment complications, 200,000-300,000 suffered permanent impotence, incontinence or both as a result of treatment and 10,000-70,000 suffered other serious treatment complications.
• The credentials of the USPSTF members (uspreventiveservicestaskforce.org/members.htm), so you can ignore those — Sarah Palin, Newt Gingrich, etc — who say the USPSTF is just a government “death panel.” The membership of the panel, which makes preventive health screening recommendations on a wide range of important health issues, is made up of some of the best physicians from universities all over America. It is the same panel that has recommended in favor of screening some men for the potentially life-threatening condition abdominal aortic aneurysm (uspreventiveservicestaskforce.org/uspstf/uspsaneu.htm). Its work is aimed at helping us be smart about our preventive care, not at helping “big government” deny us necessary medical care.
• The New York Times column by the physician who invented the PSA test (nytimes.com/2010/03/10/opinion/10Ablin.html), in which he calls PSA screening “a public health disaster” and urges the medical community to “confront this reality and stop the inappropriate use of PSA screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.”
What’s best care — now available to all
Posted Jan. 31, 2013, at 12:03 p.m.
The power of knowledge in the practice medicine used to be given only to us physician wizards of the medical Land of Oz. You novices had to stay on your ignorant side of the green curtain with Dorothy and her witless sidekicks. Those days are gone; any Dorothy, Toto, or Scarecrow with access to the Internet can get access to good information about what’s best care in medical practice.
In fact, a smart traveler on this new Yellow Brick Road of better, evidence-driven health care can not only help themselves get better care, but save lots of money in their out-of-pocket medical expenses and reduce chances of a complication from an unnecessary test. As important, the powers that be in health care — politicians, insurance companies, employers, physicians and hospitals, etc. — can all help us and each other use it to reduce health care costs and improve care.
A great example of this is the Choosing Wisely Campaign, about which I have written previously. In it, a number of physician experts have banded together to identify wasteful tests in their areas of specialty. Want to know what relevant experts think about when you do and don’t need allergy tests, bone density tests, EKGs and stress tests for heart disease, chest x-rays before surgery, or what five tests and treatments in cancer care that cancer specialists think you should question? Go to the website at choosingwisely.org/?page_id=13.
Want to know how frequently you need a pap smear, or that most women don’t need them every year, or that women under the age of 21 don’t need to start having them as soon as they start having sex? Visit cancer.gov/cancertopics/factsheet/detection/Pap-HPV-testing. Want to know the most up-to-date, scientifically supported medical thinking on an array of topics from cranberry juice for urinary infections to whether taking zinc actually helps prevent the common cold? Visit the Cochrane Collaborative at cochrane.org.
One powerful application of this kind of knowledge is in an emerging concept called shared decision making. SDM is the old risk-benefit discussion with your physician on steroids. In the SDM process, a patient and-or family works through a data-driven, patient-centered decision making process about a proposed treatment. The process is supported by good, evidence-based statistical information about the risks and benefits of the treatment. Content language is patient-friendly, and the process usually takes place outside the pressures of the physician office visit. Dartmouth Hitchcock Medical Center in New Hampshire has a small library of SDM decision support tools available to patients online at patients.dartmouth-hitchcock.org/shared_decision_making/decision_aid_library.html.
What this all means is that patients can now often find out for themselves “What is the evidence for that test or treatment?” When they get a recommendation for a test or treatment, they can ask their health care provider whether they really need it. And then, before making a decision, and therefore often before paying out of pocket for it, the patient or family can start comparing what they are told with the growing body of evidence-based testing and treatment recommendations that are available to anyone with internet or library access.
The real potential of evidence-based information from credible sources to change health care, however, can only be realized when those same powers that be noted above start supporting patients in its use, start consistently using it themselves, and start pushing each other to do both of those things.
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