Health Insight: Don’t be blindsided by doctors’ ‘facility fees’
by Felice Freyer
Providence Journal
Early last year, a friend of mine consulted a highly recommended doctor in Providence. She liked the doctor and got the care she needed. But she canceled a follow-up appointment and says she will never return to that practice — because she’s furious about what showed up on her bill.
Listed beneath the expected charge for physician services ($162), she found an item labeled “Clinic Visits” with a $370 price tag. When my friend called to find out what the $370 was for, she was told it was a “facility fee,” a sum charged simply because the medical group is owned by a hospital. No one had warned her, and this makes no sense.
But she’s not the only one being blindsided by this practice — which is legal and tolerated by the insurance companies and Medicare. Around the country hospitals have been acquiring medical groups and hiring community-based doctors as employees. In this way, the high cost of running a hospital leaks into the outpatient world.
“It’s paying for the infrastructure that the entire hospital represents … and it’s helping to subsidize where we’re not getting paid,” says Mark Montella, a senior vice president at the Lifespan hospital group. Montella says Lifespan doesn’t like these fees either and hopes to eventually get rid of them. Contrary to my friend’s experience, he said, most people pay only $15 or $20 extra, but he could not provide a range because fees vary depending on the services obtained.
At least two groups owned by the Lifespan hospital group — the Women’s Medicine Collaborative (where my friend went) and the Cardiovascular Institute — charge facility fees, but another Lifespan-owned group, Ob-Gyn Associates, does not.
The Care New England hospital group has affiliated doctors’ groups that are not hospital-owned and don’t charge facility fees. It also has many hospital-employed physicians who do charge these fees — but only to Medicare patients.
South County Hospital has been actively hiring physician groups but decided against charging facility fees. “That practice does not fit the philosophy of the hospital,” says Dr. Frederick Browne, chief medical officer.
As Montella explains it, the community depends on the Lifespan hospitals — especially Rhode Island Hospital — to care for those who can’t pay, to train future doctors and to maintain a complex, specialized facility ready 24/7 for any calamity — expensive burdens that hospitals like South County don’t bear. Hospitals have always depended on paying customers to subsidize those who can’t pay. But now this cost-shifting is getting harder, with new reductions in both the amount hospitals are paid and the number of people needing inpatient care. Lifespan lost $19 million in 2013. The hospitals are struggling to adapt, Montella says, and until all these changes are sorted out, it still needs those facility fees.
Rapid Price Increases for Some Generic Drugs Catch Users by Surprise
The
first sign of trouble came when Dr. Barry Lindenberg, a cardiologist,
received a three-page insurance form in January, demanding he get
preapproval to prescribe one of the oldest known heart medicines.
His
patient had been on the drug, digoxin, for many years. A mainstay of
treating older patients with rapid rhythm disturbances, it was first
described in the medical literature in 1785. Millions of Americans still
use it every day, and many had long paid just pennies a pill.
“I wrote on the form: ‘ARE YOU KIDDING ME?’ ” said Dr. Lindenberg, who practices in Schenectady, N.Y.
What
the cardiologist did not know then was that the price of generic
digoxin was rapidly rising. The three companies selling the drug in the
United States had increased the price they charge pharmacies, at least
nearly doubling it since late last year, according to EvaluatePharma, a
London-based consulting firm.
For
patients, that meant the prices at pharmacies often tripled from last
October to this June, according to Doug Hirsch, chief executive of GoodRx.com,
a website that tracks drug pricing to help consumers find good deals.
And while the average price tag at the pharmacy for a month of digoxin
this year is still relatively cheap, about $50, he said, some patients
are now encountering costs of more than $1,000. That can translate into
co-pays of hundreds of dollars.
No
wonder, Dr. Lindenberg said, that he began hearing from patients
requesting a drug change because they could not afford digoxin. He noted
that one patient did not fill her prescription because it would have
cost her $1.60 per pill, and that she ended up in intensive care.
Large price increases in the United States for vital medicines for the young, such as vaccines,
have been mirrored by similar rises in some of the most basic
treatments for older patients, like digoxin. Though there are many newer
types of drugs to treat heart disease, for some patients there are no
effective substitutes; digoxin is on the World Health Organization’s
list of essential medicines.
In
recent years, generics have curbed the rise of drug prices, saving the
American health care system billions of dollars. After the patents for
Lipitor, the cholesterol drug, and Ambien, the sleeping pill, expired in
the last few years, for example, generics entered the market and prices
plummeted.
But
increasingly, experts say, the costs of some generic drugs are going
the other way. The prices paid by pharmacies for some generic versions
of Fiorinal with codeine (for migraines) and Synthroid (a thyroid
medicine) as well as the generic steroid prednisolone have all more than
doubled since last year, EvaluatePharma found. In January, the National
Community Pharmacists Association called for a congressional hearing
on generic drug prices, complaining that those for many essential
medicines grew as much as “600, 1,000 percent or more” in recent years.
The price jumps especially affected smaller pharmacies, which do not
have the clout of big chains to bargain for discounts.
http://www.nytimes.com/2014/07/09/health/some-generic-drug-prices-are-soaring.html?hpw&action=click&pgtype=Homepage&version=HpHedThumbWell&module=well-region®ion=bottom-well&WT.nav=bottom-wellhttp://www.nytimes.com/2014/07/09/health/some-generic-drug-prices-are-soaring.html?hpw&action=click&pgtype=Homepage&version=HpHedThumbWell&module=well-region®ion=bottom-well&WT.nav=bottom-well
'Private option' won't help poor
By Adam Gaffney, MDUSA Today, July 7, 2014
By expanding Medicaid to all earning less than 138% of the poverty level, the Affordable Care Act will help many avoid this outcome. Unfortunately, the Supreme Court ruled that states can opt out of the expansion, and 24 states have done that. Arkansas and Iowa, on the other hand, have won federal waivers to pursue a "private option" as a compromise, and other states may follow.
Private option Medicaid would give low-income families vouchers to purchase private insurance, instead of enrolling them in traditional Medicaid.
Why is that a problem?
Medicaid is far from perfect, but the private option won't be an improvement. Medicaid patients, for instance, often have trouble finding doctors. But private option Medicaid plans, like many plans on the health exchanges, have very narrow doctor and hospital networks.
"Churning" is another problem: Families must often change providers as they move in and out of Medicaid eligibility. But churning will persist under the private option as people change jobs or plans change provider networks.
To truly address Medicaid's problems, we need a universal single-payer system. But until that is achieved, traditional Medicaid will remain a crucial safety net. We must fight to expand it, but also to protect it.
Adam Gaffney is a physician and writer in Massachusetts who blogs at theprogressivephysician.org.
http://www.pnhp.org/print/news/2014/july/private-option-wont-help-poor
Traditional Medicaid will remain a crucial safety net
Living in poverty is hard enough; having to face sickness without insurance while doing so is a fate no one should bear.By expanding Medicaid to all earning less than 138% of the poverty level, the Affordable Care Act will help many avoid this outcome. Unfortunately, the Supreme Court ruled that states can opt out of the expansion, and 24 states have done that. Arkansas and Iowa, on the other hand, have won federal waivers to pursue a "private option" as a compromise, and other states may follow.
Private option Medicaid would give low-income families vouchers to purchase private insurance, instead of enrolling them in traditional Medicaid.
Why is that a problem?
- First, private option plans impose new co-pays for doctor visits and medications on the dubious premise that patients need more "skin in the game." But co-pays often deter vital care: Heart attack victims delay coming to the ER, or children forgo asthma medicines. And co-pays are especially hard on low-income families.
- Second, the private option is inefficient. Insurers have much higher overhead than public programs such as Medicaid or Medicare. Privatized "Medicare Advantage" plans take more than 13% for overhead (traditional Medicare is closer to 2%), gaining large profits at taxpayer expense.
Medicaid is far from perfect, but the private option won't be an improvement. Medicaid patients, for instance, often have trouble finding doctors. But private option Medicaid plans, like many plans on the health exchanges, have very narrow doctor and hospital networks.
"Churning" is another problem: Families must often change providers as they move in and out of Medicaid eligibility. But churning will persist under the private option as people change jobs or plans change provider networks.
To truly address Medicaid's problems, we need a universal single-payer system. But until that is achieved, traditional Medicaid will remain a crucial safety net. We must fight to expand it, but also to protect it.
Adam Gaffney is a physician and writer in Massachusetts who blogs at theprogressivephysician.org.
http://www.pnhp.org/print/news/2014/july/private-option-wont-help-poor
Health-care expenditure and health policy in the USA versus other high-spending OECD countries
Luca Lorenzoni MSc a 
,
, Summary
The USA has exceptional levels of health-care expenditure, but growth has slowed dramatically in recent years, amidst major efforts to close the coverage gap with other countries of the Organisation for Economic Co-operation and Development (OECD). We reviewed expenditure trends and key policies since 2000 in the USA and five other high-spending OECD countries. Higher health-sector prices explain much of the difference between the USA and other high-spending countries, and price dynamics are largely responsible for the slowdown in expenditure growth. Other high-spending countries did not face the same coverage challenges, and could draw from a broader set of policies to keep expenditure under control, but expenditure growth was similar to the USA. Tightening Medicare and Medicaid price controls on plans and providers, and leveraging the scale of the public programmes to increase efficiency in financing and care delivery, might prevent a future economic recovery from offsetting the slowdown in health sector prices and expenditure growth.
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