Of Patients and Prices
By A.W. Gaffney, M.D.
Truthout, March 26, 2014
There are many good reasons to impatiently anticipate the end of one's medical training, which not infrequently lasts upwards of five years following medical school. But counterpoised to the oft-cited benefits -- greater autonomy, reliably increased remuneration, less reliably improved hours, and so forth -- there is also, unfortunately, an almost entirely unrecognized drawback: a largely unavoidable entanglement in the business of health care.
Now for some, such an entanglement might make the transition from training seem all the more attractive. But clearly, one need only hear about patients (or their surviving family members) being chased by collections agencies for medical bills, or about the growing problem of "medical bankruptcies" among the insured, or even about the bizarre unaffordability of asthma inhalers to see that something is seriously askew with the way the price of health care can adversely impact the circumstances of the ill. As my own clinical training now winds down, I frequently reflect on how to navigate today's highly problematic health care terrain - in which patients are increasingly exposed to the cost of care provided.
I think it's only fair to begin, however, by recognizing that unlike ethical issues revolving around artificial hearts or organ transplants, the problem of the cost of health care isn't entirely new. Hippocrates (or whoever it was that wrote the Precepts) generally saw nothing wrong in doctors looking after their pecuniary interests, though he also opined that they mustn't "extort money from those who are at death's door." The problem of US national health spending has likewise been recognized for some time: in 1971, as health care expenditures rapidly outstripped inflation, Richard Nixon proclaimed that the nation faced a "deepening crisis," which has been more or less the conventional wisdom ever since (if not without reason).
However, an awareness that something might be awry with what prices patients were being charged by hospitals, physicians, pharmaceutical companies, ambulance companies and more or less everyone in the health care industry seems to have surged into the spotlight in more recent years. The journalist Steven Brill, for instance, in an important issue-length article "Bitter Pill" in Time last year, investigated the stories of patients who received massive itemized bills for health care, which, in several instances, might very well be termed "money from those who are at death's door."
He discussed one person, for instance, who between diagnosis with metastatic lung cancer and death a mere 11 months later had accumulated some $900,000 in medical bills, debt that was then dumped onto his devastated wife. Additionally jarring, however, was Brill's exploration of the extremely high prices being charged for individual services or items to such patients (e.g. $77 for each tiny square of cotton gauze), which originated from a confidential list of hospital prices dubbed the "chargemaster."
Elizabeth Rosenthal of the New York Times has explored the issue further in an ongoing and highly revealing series. Like Brill, she finds instances of absurd prices (e.g. $3,355.96 for five stitches in the ER), though in most cases, these prices are frequently several times higher than what insurance companies - which directly negotiate reimbursements with hospitals and providers - actually pay. However, for the uninsured, the "underinsured" (i.e. those who have insurance, but with high deductibles, coinsurance or copays), those who are out-of-network, or those who have limits on coverage, the "chargemaster" is real enough. For these individuals and families, massive and arbitrary medical bills - for conditions ranging from the trivial to the deadly - can be tantamount to financial ruin.
Why is this issue coming to the spotlight now? Partially, it's a reflection of ongoing trends in the health care system that predated Obamacare but that are also not ended by it. Insured patients increasingly have more financial liability, or as the saying goes, "skin in the game," when they receive health care. High-deductible employer plans are more and more common, "four-tier" prescription drug plans are the norm, and themost commonly purchased "silver" plans on the Obamacare exchanges have an actuarial value of only 70%. All of this equates to increased "cost sharing," or out-of-pocket money paid for health care, on top of annual premiums (which are also rising). Between uninsurance and underinsurance, it's not all that surprising that unpaid medical bills apparently constitute half of accounts reported to collection agencies, compromising the credit scores and the financial opportunities of those affected. Along similar lines, 62% of US bankruptcies, according to one study, are caused by medical illnesses - even though most of these bankrupt individuals actually had health insurance at the time of their illness.
http://www.pnhp.org/print/news/2014/march/of-patients-and-prices
Truthout, March 26, 2014
There are many good reasons to impatiently anticipate the end of one's medical training, which not infrequently lasts upwards of five years following medical school. But counterpoised to the oft-cited benefits -- greater autonomy, reliably increased remuneration, less reliably improved hours, and so forth -- there is also, unfortunately, an almost entirely unrecognized drawback: a largely unavoidable entanglement in the business of health care.
Now for some, such an entanglement might make the transition from training seem all the more attractive. But clearly, one need only hear about patients (or their surviving family members) being chased by collections agencies for medical bills, or about the growing problem of "medical bankruptcies" among the insured, or even about the bizarre unaffordability of asthma inhalers to see that something is seriously askew with the way the price of health care can adversely impact the circumstances of the ill. As my own clinical training now winds down, I frequently reflect on how to navigate today's highly problematic health care terrain - in which patients are increasingly exposed to the cost of care provided.
I think it's only fair to begin, however, by recognizing that unlike ethical issues revolving around artificial hearts or organ transplants, the problem of the cost of health care isn't entirely new. Hippocrates (or whoever it was that wrote the Precepts) generally saw nothing wrong in doctors looking after their pecuniary interests, though he also opined that they mustn't "extort money from those who are at death's door." The problem of US national health spending has likewise been recognized for some time: in 1971, as health care expenditures rapidly outstripped inflation, Richard Nixon proclaimed that the nation faced a "deepening crisis," which has been more or less the conventional wisdom ever since (if not without reason).
However, an awareness that something might be awry with what prices patients were being charged by hospitals, physicians, pharmaceutical companies, ambulance companies and more or less everyone in the health care industry seems to have surged into the spotlight in more recent years. The journalist Steven Brill, for instance, in an important issue-length article "Bitter Pill" in Time last year, investigated the stories of patients who received massive itemized bills for health care, which, in several instances, might very well be termed "money from those who are at death's door."
He discussed one person, for instance, who between diagnosis with metastatic lung cancer and death a mere 11 months later had accumulated some $900,000 in medical bills, debt that was then dumped onto his devastated wife. Additionally jarring, however, was Brill's exploration of the extremely high prices being charged for individual services or items to such patients (e.g. $77 for each tiny square of cotton gauze), which originated from a confidential list of hospital prices dubbed the "chargemaster."
Elizabeth Rosenthal of the New York Times has explored the issue further in an ongoing and highly revealing series. Like Brill, she finds instances of absurd prices (e.g. $3,355.96 for five stitches in the ER), though in most cases, these prices are frequently several times higher than what insurance companies - which directly negotiate reimbursements with hospitals and providers - actually pay. However, for the uninsured, the "underinsured" (i.e. those who have insurance, but with high deductibles, coinsurance or copays), those who are out-of-network, or those who have limits on coverage, the "chargemaster" is real enough. For these individuals and families, massive and arbitrary medical bills - for conditions ranging from the trivial to the deadly - can be tantamount to financial ruin.
Why is this issue coming to the spotlight now? Partially, it's a reflection of ongoing trends in the health care system that predated Obamacare but that are also not ended by it. Insured patients increasingly have more financial liability, or as the saying goes, "skin in the game," when they receive health care. High-deductible employer plans are more and more common, "four-tier" prescription drug plans are the norm, and themost commonly purchased "silver" plans on the Obamacare exchanges have an actuarial value of only 70%. All of this equates to increased "cost sharing," or out-of-pocket money paid for health care, on top of annual premiums (which are also rising). Between uninsurance and underinsurance, it's not all that surprising that unpaid medical bills apparently constitute half of accounts reported to collection agencies, compromising the credit scores and the financial opportunities of those affected. Along similar lines, 62% of US bankruptcies, according to one study, are caused by medical illnesses - even though most of these bankrupt individuals actually had health insurance at the time of their illness.
http://www.pnhp.org/print/news/2014/march/of-patients-and-prices
Most states fail on health price transparency, but not Maine
Maine doctors, here’s what your patients think of you
Survey: Mainers struggle to pay medical bills — even those with insurance
Posted March 26, 2014, at 5:12 p.m.
Many Maine residents, even those with health insurance, struggle to afford their medical bills, a new statewide survey has found.
While the poorest Mainers reported the most difficulty affording health services, more than a quarter of residents with health coverage ran into trouble paying medical bills, according to the survey released Wednesday by the Maine Health Access Foundation.
Designed to track the impact of the Affordable Care Act in Maine, the survey polled nearly 1,000 residents in December 2013, just before new private policies purchased on Healthcare.gov took effect on Jan. 1, 2014. The research will provide a snapshot of the burden of health costs in Maine to serve as a benchmark in future years, said Dr. Wendy Wolf, president and CEO of the private nonprofit foundation.
“One of the most important questions that policymakers are going to want to know is what is happening in the wake of the Affordable Care Act with actually lowering the rate of uninsurance, and also helping people with the issue of both affordability and the types of benefits that are offered in insurance plans,” she said.
The foundation, which is leading the effort to sign Mainers up for health insurance under the ACA, partnered with market research firm GfK to conduct the survey. The poll piggybacked on a national health reform survey developed by the Urban Institute and funded by the Robert Wood Johnson Foundation and the Ford Foundation.
Bucking the national trend, Maine adults in the middle income range actually struggled more than their low-income counterparts to pay medical bills. About 35 percent of mid-range earners — with incomes between about $33,000 and $93,000 a year for a family of four — faced problems or were unable to afford their bills during the prior year, compared to 32 percent of those earning less. Many middle-income Mainers receive no government aid and don’t earn enough to buy a health policy with sufficient coverage, the survey results noted.
The Maine survey polled 992 adults between the ages of 18 and 64 across a range of incomes. Included were the uninsured; people who buy their own coverage in the individual market; those who get coverage through work; and Mainers with government-sponsored insurance, with the exception of Medicare.
The growth of bare bones, high-deductible health plans in the individual market likely contributed to many Mainers’ difficulty affording medical bills, Wolf said. Those plans will be phased out under the Affordable Care Act, except for those under age 30.
A chief goal of the law, also known as Obamacare, is to expand access to more robust and affordable health insurance, with free preventive care and a cap on out-of-pocket costs. Healthcare.gov, the federal government’s gateway for insurance marketplaces in Maine and 35 other states, targets private policies for individuals and small businesses, but also allows users to determine if they’re eligible for Medicaid.
Posted March 26, 2014, at 5:12 p.m.
Many Maine residents, even those with health insurance, struggle to afford their medical bills, a new statewide survey has found.
While the poorest Mainers reported the most difficulty affording health services, more than a quarter of residents with health coverage ran into trouble paying medical bills, according to the survey released Wednesday by the Maine Health Access Foundation.
Designed to track the impact of the Affordable Care Act in Maine, the survey polled nearly 1,000 residents in December 2013, just before new private policies purchased on Healthcare.gov took effect on Jan. 1, 2014. The research will provide a snapshot of the burden of health costs in Maine to serve as a benchmark in future years, said Dr. Wendy Wolf, president and CEO of the private nonprofit foundation.
“One of the most important questions that policymakers are going to want to know is what is happening in the wake of the Affordable Care Act with actually lowering the rate of uninsurance, and also helping people with the issue of both affordability and the types of benefits that are offered in insurance plans,” she said.
The foundation, which is leading the effort to sign Mainers up for health insurance under the ACA, partnered with market research firm GfK to conduct the survey. The poll piggybacked on a national health reform survey developed by the Urban Institute and funded by the Robert Wood Johnson Foundation and the Ford Foundation.
Bucking the national trend, Maine adults in the middle income range actually struggled more than their low-income counterparts to pay medical bills. About 35 percent of mid-range earners — with incomes between about $33,000 and $93,000 a year for a family of four — faced problems or were unable to afford their bills during the prior year, compared to 32 percent of those earning less. Many middle-income Mainers receive no government aid and don’t earn enough to buy a health policy with sufficient coverage, the survey results noted.
The Maine survey polled 992 adults between the ages of 18 and 64 across a range of incomes. Included were the uninsured; people who buy their own coverage in the individual market; those who get coverage through work; and Mainers with government-sponsored insurance, with the exception of Medicare.
The growth of bare bones, high-deductible health plans in the individual market likely contributed to many Mainers’ difficulty affording medical bills, Wolf said. Those plans will be phased out under the Affordable Care Act, except for those under age 30.
A chief goal of the law, also known as Obamacare, is to expand access to more robust and affordable health insurance, with free preventive care and a cap on out-of-pocket costs. Healthcare.gov, the federal government’s gateway for insurance marketplaces in Maine and 35 other states, targets private policies for individuals and small businesses, but also allows users to determine if they’re eligible for Medicaid.
Anti-Anxiety Drugs Tied to Higher Mortality
A large study has linked several common anti-anxiety drugs and sleeping pills to an increased risk of death, although it’s not certain the drugs were the cause.
For more than seven years, researchers followed 34,727 people who filled prescriptions for anti-anxiety medications like Valium and Xanax, or sleep aids like Ambien, Sonata and Lunesta, comparing them with 69,418 controls who did not.
After adjusting for a wide variety of factors, the researchers found that people who took the drugs had more than double the risk of death. The study appears online in BMJ.
The researchers tried to account for the use of other prescribed drugs, age, smoking, alcohol use, socioeconomic status, and other health and behavioral characteristics. Most important, the investigators also controlled for sleep disorders, anxiety disorders and other psychiatric illnesses, all of which are risk factors for mortality.
The lead author, Dr. Scott Weich, a professor of psychiatry at the University of Warwick, said that while he and his colleagues were careful to account for as many potential risks as possible, they were not able to control for the severity of the illnesses suffered by the study participants.
Still, he said, the research “adds to an accumulating body of evidence that these drugs are dangerous.” He added: “I prescribe these drugs, and they are difficult to come off. The less time you spend on them the better.”
Deadline Near, Health Signups Show Disparity
WASHINGTON — The online insurance marketplace in Oregon is such a technological mess that residents have been signing up for health coverage by hand. In Texas, political opposition to President Obama’s health law is so strong that some residents believe, erroneously, that the program is banned in their state.
But in Connecticut, a smoothly functioning website, run by competent managers, has successfully enrolled so many patients that officials are offering to sell their expertise to states like Maryland, which is struggling to sign people up for coverage.
The disparities reveal a stark truth about the Affordable Care Act: With the first open enrollment period set to end Monday, six months after its troubled online exchanges opened for business, the program widely known as Obamacare looks less like a sweeping federal overhaul than a collection of individual ventures playing out unevenly, state to state, in the laboratories of democracy.
The White House said on Thursday that more than six million people have signed up for private plans, a significant political milestone for the Obama administration. Independent analysts estimate that an additional 3.5 million Americans are newly insured under Medicaid — figures the law’s backers hail as a success.
But those numbers may not reveal much. Federal officials do not know how many of those who selected plans were previously uninsured, or how many actually paid their premiums. Independent experts warn that the intense focus on national numbers is misguided, and that it will take years to fully assess the law’s impact, much less deem it a success or a failure.
“The whole narrative about Obamacare — ‘Will they get to six million? What is the percentage of young adults going to be?’ — has almost nothing to do with whether the law is working or not, whether the premiums are affordable or not, whether people think they are getting a good deal or not,” said Drew Altman, president of the Kaiser Family Foundation, whose analysts are closely tracking the measure.
“It’s almost like trying to predict the local weather from national averages,” Mr. Altman said. “This is really now a state and local game, not a national one.”
Doctor Priorities vs. Patient Priorities
Not so long ago, a middle-aged patient came to my office for a checkup. He cheerfully admitted that he hadn’t been paying attention to his diabetes for the last few years. He’d stopped taking his medicine, stopped seeing his doctors, stopped thinking about the disease altogether. When I checked his blood sugar in the office, it wasn’t just a little elevated — it was four times the normal level.
For doctors, it is always a shocker to hear a case like this. How can a patient completely ignore a disease for so long? How can a life-threatening illness just disappear from someone’s consciousness?
The patient was not in denial; he knew he had diabetes. It just wasn’t on his priority list at this point in his life. For me, it was flashing neon at the top of my list with seven exclamation points.
Don’t quit before you start
By Ellen Oxfeld
Rutland Herald, March 27, 2014
Rutland Herald, March 27, 2014
This week in a VPR interview, Senate President Pro Tem John Campbell backed away from an unwavering commitment to the historic task set out in Act 48 — creating a publicly funded guaranteed health care system for all Vermonters.
Campbell’s stated reason for this is disappointing. He demurred that he was not sure that a single-payer financing plan would be “politically viable” in the Legislature because of the “costs” of single payer.
Senator Campbell needs to reconsider. It’s true that financing a single-payer plan will cost about $2 billion; but that is actually less than we Vermonters are already paying. (In fact, in 2011, we Vermonters paid $2.5 billion in private premiums and out-of-pockets for our health care.)
It is also odd to see a Senate leader shrinking from his delegated role of doing just what he has been selected to do, lead. In the past, Senator Campbell has been a leader on many issues, such as marriage equality and in passing Act 48, the 2011 road map legislation for single-payer. Yes, successfully enacting an equitable and viable single-payer financing package will not be easy. It will take political courage.
But the facts support moving forward, not giving up before even trying. After all, in five official studies commissioned since 2001 by the state of Vermont, the conclusion has always been the same — there is no other way to guarantee health care for all Vermonters while containing costs other than a publicly financed (“single-payer”) system.
The Senate president stated that he would like an “alternate” plan in case single-payer financing does not work out. But we already have an alternate plan in place — the Affordable Care Act. And although that act has certainly helped some individuals to purchase private insurance, it still leaves in place our multi-tiered system of different private plans, with different levels of coverage and the expenses created by the complex administration of such a system.
Furthermore, a situation in which there are multiple levels of private plans can never guarantee access to health care for all. It can still leave people with inadequate financial protection, or even without health care coverage at all, in the event that they change jobs, lose jobs, or experience changes in their financial status.
Act 48 was not passed on a fanciful whim. It passed because it built upon two decades of experience and numerous studies. Alternatives to a publicly financed health care plan for all were studied and tried, but none offered the possibility of both universality and cost control. Publicly financed systems throughout the world surpass our present system by guaranteeing access to health care for all while simplifying administration and containing costs effectively.
The vision of guaranteed health care and an affordable health care system can be reached in Vermont. Vermonters will be ill served if our political leaders step away from the road map laid out in Act 48, which they voted for and passed.
Obamacare is not universal health care [Commentary]
The Affordable Care Act leaves some of our neediest citizens without insurance or a reliable source of care
Mary is single, in her late 50s, widowed and earning about $2,000 a month cleaning bathrooms downtown. She's had no health insurance for the last decade, but she's received medical care when she needed it at free clinics and emergency rooms.
But now it's the era of Obamacare, and Mary hears that she has to buy health insurance. We check her options on Maryland Health Connection, the state's online health insurance exchange:
The cheapest "bronze plan" is only $2.20 per month, which will avoid a year-end fine for being uninsured, but it pays for little up until the $6,000 deductible. The "silver plans" cost $130 to $360 per month with a $900 annual deductible, but for those she'd have to choose between a health savings account, a limited HMO provider network, a 40 percent or a $40 co-pay, and many other confusing options.
None of it sounds like straightforward "affordable care" to her.
This isn't a story about error messages or frozen screens. Website crashes make news; they don't make history. This is about the real implications of Obamacare, about which ideas work in real life and which just sound good on paper.
Mary was just one of dozens of low-income Baltimoreans I met as a health insurance enrollment volunteer in a Baltimore free clinic over the past six months, but she shares the experience of thousands of Marylanders this season. Once the website glitches subsided, the reality set in that the government was telling uninsured people to spend a significant portion of their incomes on health insurance. I have seen how many low-income Marylanders will remain uninsured because of the cost and complexity of buying insurance.
If we really want universal health care, we need a public system that actually includes all people, such as extending Medicare to all Americans. Obamacare's individual mandate to buy health insurance does not reach everyone because many uninsured individuals will not "buy-in" to an expensive and overly complex insurance system.
Unlike some critics, I do not think the Affordable Care Act (a.k.a. Obamacare) got everything wrong: It has made health insurance for individuals cheaper and better. Obamacare expands Medicaid to cover more low-income people, creates tax credits to make insurance cheaper for individuals, makes it illegal for insurance companies to deny coverage based on preexisting conditions and stops insurers from rescinding coverage when beneficiaries get sick.
But while Obamacare patches some of the gaping holes in the health insurance market, it also fails to create access for many of the people who never budgeted for insurance before. The bottom line is that Obamacare will insure millions, but it will also leave tens of millions of Americans still uninsured.
http://www.baltimoresun.com/news/opinion/bs-ed-obamacare-medicare-20140326,0,5129108.story#ixzz2x5adCqZw
 | |
The Obamacare report card
| |
| Time’s up, Obamacare. Ready for your grades? After six months, the first enrollment season is coming to an end. So it’s time to take stock, with POLITICO’s report card that covers the highs and lows of the rollout. If you’re a supporter of the law, you might be cringing right now — you know the areas where the grade is not going to be good. It’s pretty obvious that the Obama administration wasn’t ready for the launch, despite three and a half years to prepare. The political messaging hasn’t impressed anyone; Democrats are scampering away from what was supposed to be a legacy achievement. No one’s going to forget that notion that everyone could keep their plans. (Also on POLITICO: Full health care policy coverage) But the critics will have to round out their picture of the law, too. The signups have now hit 6 million — a feat that seemed impossible in the worst days of the website failures — and the administration’s outreach efforts are better than they used to be. And although there are lots of complaints about the prices, some low-income customers seem to be genuinely happy with the rates and subsidies they’re getting. It’s also important to judge the rollout against the political headwinds the law has faced. White House officials argue that the battles against Obamacare have been stronger and longer lasting than even the fights against breakthroughs like Social Security and civil rights laws. “There’s no other law that has had to overcome all the obstacles that have been thrown at this law by its opponents,” said White House health care adviser Phil Schiliro. But this is also a program that will affect millions of Americans, and Republicans say it’s such a bad student it should repeat a grade. “For gross incompetence, the thing should be held back a year,” said Brendan Buck, a spokesman for House Speaker John Boehner. “The law is clearly not ready for prime time — not that it ever will be — and that’s why the House has voted to delay it.” Here’s where Obamacare was a good student and where it needs to show more effort, based on the latest research and interviews with health care experts across the board: Enrollment At this point, it’s all about expectations — and after months of lowering the bar, the White House has finally cleared it. (PHOTOS: Obamacare in the Mississippi Delta) Thanks to the fumbled launch and an unspectacular February, health care experts had been convinced that the total enrollment would be roughly five and a half million people. That turned around quickly once the enrollment websites became flooded with last-minute signups, as the White House had predicted. And on Thursday, President Barack Obama had his best day in months when the total hit 6 million, earlier than even optimistic experts thought it would. That’s not nothing. It’s a big recovery from October, and it’s enough to avoid a financial disaster for the insurers. It’s certainly enough to give Democrats the talking point they want against Republicans: “Do you really want to take health insurance away from millions of people?” It’s just not the original 7 million goal, as declared by Health and Human Services Secretary Kathleen Sebelius, and Republicans won’t ever let the administration forget it. (There was even a time when CBO was predicting 8 million, right when the law passed.) http://dyn.politico.com/printstory.cfm?uuid=461C2104-AF06-4F58-8D43-E6A86666716E |
No comments:
Post a Comment