Cardiologist Speaks From The Heart About America's Medical System
by Sandeep Jauhar, M.D.
As a young doctor working at a teaching hospital, Sandeep Jauhar was having trouble making ends meet. So, like other academic physicians, he took a job moonlighting at a private practice, the offices of a cardiologist. He noticed that the offices were quick to order expensive tests for their patients — even when they seemed unnecessary.
It was "made very clear from the beginning" that seeing patients alone was not financially rewarding for the business, he says.
"Spending 20-30 minutes with a patient might be reimbursed $80, $90, but sending the patient for a nuclear stress test was much more profitable," Jauhar tells Fresh Air's Terry Gross. "A nuclear stress test, at the time when I started working, was reimbursed roughly $800 to $900."
Jauhar was supervising the tests that had been ordered by a physician — and some physician assistants.
"So even though I wasn't ordering the tests, I was in the office while these tests were being performed — and I felt really dirty about it," Jauhar says.
Jauhar's new memoir, Doctored: The Disillusionment of an American Physician, is about how doctors are growing increasingly discontent with their profession. And they're facing more pressures: As the number of patients they're expected to see increases, so does the amount of paperwork. While some doctors who perform a lot of procedures may be paid too much, he writes, many doctors, such as primary care physicians, aren't paid enough.
And, he adds, "the growing discontent has serious consequences for patients."
(Click on the link to hear the entire interview with Terry Gross)
A Physician With a Troubled Conscience Puts Himself on the Couch
In ‘Doctored,’ Sandeep Jauhar Examines a Broken System
by Susannah Meadows
In Sandeep Jauhar’s arresting memoir about the realities of practicing medicine in America, “Doctored: The Disillusionment of an American Physician,” he describes an interaction he has with a patient at Long Island Jewish Medical Center, where he is the director of the heart failure program. The patient has an abdominal mass and has been transferred to the medical center from another hospital for a preoperative evaluation. Dr. Jauhar tells her that there are some things he needs to figure out before sending her to the operating room.
“Like what is this mass,” he says. “Is it cancer? Has it spread?” Neither her paperwork nor the doctor from the other hospital had provided answers.
“Do you know if it has?” she asks, wondering if the cancer has metastasized. He does not. “No one knows what is going on,” she says, her eyes filling with tears.
And she is right, says Dr. Jauhar, whose writing has appeared in The New York Times and whose first book, “Intern,” chronicled that grueling year of his medical career. “It is hard to imagine such a thing happening in the era of ‘my doctor,’ ” he says, referring to the days when patients primarily had one doctor who knew them well.
It’s not news, of course, that our medical system has become dysfunctional. But Dr. Jauhar’s personal account shows that brokenness on a human scale, starting with the doctor-patient relationship, which is in tatters.
In his telling, being a caring doctor has become practically cost-prohibitive. Insurance companies don’t pay enough for spending time with patients. But they do for CT scans and stress tests — whether they’re warranted or not. While fear of lawsuits drives unnecessary tests, too, Dr. Jauhar sees our fee-for-service model as particularly poisonous.
He describes an internist whose patients tended to have long stays at Long Island Jewish. That doctor admits, evidently without shame, that he keeps them there to make more money. He appears unconcerned about increasing his patients’ risk of picking up a deadly infection. Even Dr. Jauhar’s brother, an interventional cardiologist at the same hospital, doesn’t come off too well, referring to patients as commodities.
by Susannah Meadows
In Sandeep Jauhar’s arresting memoir about the realities of practicing medicine in America, “Doctored: The Disillusionment of an American Physician,” he describes an interaction he has with a patient at Long Island Jewish Medical Center, where he is the director of the heart failure program. The patient has an abdominal mass and has been transferred to the medical center from another hospital for a preoperative evaluation. Dr. Jauhar tells her that there are some things he needs to figure out before sending her to the operating room.
“Like what is this mass,” he says. “Is it cancer? Has it spread?” Neither her paperwork nor the doctor from the other hospital had provided answers.
“Do you know if it has?” she asks, wondering if the cancer has metastasized. He does not. “No one knows what is going on,” she says, her eyes filling with tears.
And she is right, says Dr. Jauhar, whose writing has appeared in The New York Times and whose first book, “Intern,” chronicled that grueling year of his medical career. “It is hard to imagine such a thing happening in the era of ‘my doctor,’ ” he says, referring to the days when patients primarily had one doctor who knew them well.
It’s not news, of course, that our medical system has become dysfunctional. But Dr. Jauhar’s personal account shows that brokenness on a human scale, starting with the doctor-patient relationship, which is in tatters.
In his telling, being a caring doctor has become practically cost-prohibitive. Insurance companies don’t pay enough for spending time with patients. But they do for CT scans and stress tests — whether they’re warranted or not. While fear of lawsuits drives unnecessary tests, too, Dr. Jauhar sees our fee-for-service model as particularly poisonous.
He describes an internist whose patients tended to have long stays at Long Island Jewish. That doctor admits, evidently without shame, that he keeps them there to make more money. He appears unconcerned about increasing his patients’ risk of picking up a deadly infection. Even Dr. Jauhar’s brother, an interventional cardiologist at the same hospital, doesn’t come off too well, referring to patients as commodities.
Dr. Steven Nissen: 'I want to replace the insurance industry'
The following is an unofficial transcript of parts of an interview that Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, gave to Ed “Flash” Ferenc, host of the labor-oriented, Cleveland-based America’s Work Force Radio, on Aug. 15, 2014. In addition to the points he makes below, Dr. Nissen also spoke about pharmaceutical drug safety and other issues. The audio of the entire program is available at awfradio.com/todays-show-8-15-14/. The segments of the show that feature Dr. Nissen are noted at the end of the transcript.
HOST ED ‘FLASH’ FERENC: We’re going to start things off with Steve Nissen. Steve is the chairman of cardiovascular medicine at the Cleveland Clinic. He served nine years as vice-chairman, five years as medical director, of the cardiovascular center that directs multi-center clinical trials. He’s got some national leadership positions, too, which include a term as president of the American College of Cardiology. He also served the Food and Drug Administration as a member of the cardio-renal advisories panel. He spent about five years there and continued as an adviser to several FDA committees. He’s known for public policy discussions regarding drug safety; in fact he testified in the Senate and the House of Representatives on the need for FDA reform. Most recently, he’s been outspoken about the need for a single-payer health system, health insurance, or better known as “Medicare for All.” [Here the host talks at some length about the key features of a single-payer system.] …
Let’s talk about the [health] system as far as paying for it. What are your thoughts on the Affordable Care Act that is underway in America right now?
STEVEN NISSEN: Well, first of all, we had to do something. Having the richest country in human history having 50 million people without health coverage was a shame on our society, and is just not acceptable. And a lot of those 50 million people are working people. They’re people who work in jobs that are often low-paying, maybe the person who hands you your dry cleaning when you go up to the window, or in a fast food restaurant, and we have to be a civil society. We have to provide health care for everybody. Nearly every other developed country does that. They have universal health care systems, and we didn’t. The Affordable Care Act is a compromise that was forged through very difficult political discussions. And it’s far from perfect. I would have gone much further than it went, toward a simpler, universal health care system, but it did move us in the direction of making certain that everybody – or at least most people – have access to health care. To the extent that it did that, I support it, even though I recognize there are flaws in the way the law was designed. The flaws come out of political compromise. It wasn’t written by, necessarily, by a single party. It had to get some bipartisan support to get anywhere.
HOST: Yes. The single-payer system, it’s been, I guess, proven to work in a number of countries – you even referenced that a few minutes ago.
NISSEN: It does. I mean the Canadian system is excellent. They spend about half of what we spend, and a lot of what goes on in America is making us uncompetitive as a country is that we spend so much on health care and we aren’t any healthier than other people. A single-payer system is pretty simple. I mean if you want to think about a single-payer system, there’s one in place in the United States for people over 65. It’s called Medicare. Let me give you a fact about Medicare. The overhead for Medicare is about 3 percent. What that means is that 97 percent of what Medicare spends, it actually spends on for health care for people. The overhead for the private insurance industry is 29 percent, which means that almost one dollar out of every three is going for profit, for who knows what – I mean, trying to figure out who’s going to be covered and who’s not. Medicare is much more efficient, and so you can automatically reduce tens of billions of dollars in expenses just by making certain that you have a system like Medicare. There was a proposal during the health care reform debate to simply allow people to “buy-in” to Medicare, that is, use their own dollars to buy Medicare coverage beginning at age 55. I strongly supported that idea, but I supported it only because it was a bridge toward a true single-payer system. And what I hope would happen is that we’d get people to buy into Medicare at 55, then come back in a few years and say 50, and then we’d say 45, and the next thing we know, everybody could buy into Medicare and they would have had an efficient, high-quality system that worked. We don’t have that. Now what we have is the Affordable Care Act which really is trying to reform the insurance industry, not replace the insurance industry. I want to replace the insurance industry.
HOST: So they’d be out of it altogether.
NISSEN: Get them out of it. Their motives are profit, their motive is not making people healthier, their motive is making money. And the other part about the system that’s really challenging is that physicians, still many physicians, work on what’s called a fee-for-service basis, which means that the more they do to you, the more money they get paid. We work on a different model at the Cleveland Clinic. We’re all salaried. I get exactly the same salary every month, whether I order a cardiac catheterization or some other fancy test for you or not. There’s no incentive. There’s really no incentive to do things that aren’t really needed. Unfortunately, we are in a system where there is an incentive, and it is a perverse incentive. It’s one that says, the more stents you put in, the more money you make. And that is a problem, because it misaligns the needs of the patient and the interests of the patient, and the interests of the physician. In a single-payer system that works, we’d all be on salary. We would be [concerned about] quality care, but not on a fee-for-service basis.
http://www.pnhp.org/print/news/2014/august/dr-steven-nissen-i-want-to-replace-the-insurance-industry
The following is an unofficial transcript of parts of an interview that Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, gave to Ed “Flash” Ferenc, host of the labor-oriented, Cleveland-based America’s Work Force Radio, on Aug. 15, 2014. In addition to the points he makes below, Dr. Nissen also spoke about pharmaceutical drug safety and other issues. The audio of the entire program is available at awfradio.com/todays-show-8-15-14/. The segments of the show that feature Dr. Nissen are noted at the end of the transcript.
HOST ED ‘FLASH’ FERENC: We’re going to start things off with Steve Nissen. Steve is the chairman of cardiovascular medicine at the Cleveland Clinic. He served nine years as vice-chairman, five years as medical director, of the cardiovascular center that directs multi-center clinical trials. He’s got some national leadership positions, too, which include a term as president of the American College of Cardiology. He also served the Food and Drug Administration as a member of the cardio-renal advisories panel. He spent about five years there and continued as an adviser to several FDA committees. He’s known for public policy discussions regarding drug safety; in fact he testified in the Senate and the House of Representatives on the need for FDA reform. Most recently, he’s been outspoken about the need for a single-payer health system, health insurance, or better known as “Medicare for All.” [Here the host talks at some length about the key features of a single-payer system.] …
Let’s talk about the [health] system as far as paying for it. What are your thoughts on the Affordable Care Act that is underway in America right now?
STEVEN NISSEN: Well, first of all, we had to do something. Having the richest country in human history having 50 million people without health coverage was a shame on our society, and is just not acceptable. And a lot of those 50 million people are working people. They’re people who work in jobs that are often low-paying, maybe the person who hands you your dry cleaning when you go up to the window, or in a fast food restaurant, and we have to be a civil society. We have to provide health care for everybody. Nearly every other developed country does that. They have universal health care systems, and we didn’t. The Affordable Care Act is a compromise that was forged through very difficult political discussions. And it’s far from perfect. I would have gone much further than it went, toward a simpler, universal health care system, but it did move us in the direction of making certain that everybody – or at least most people – have access to health care. To the extent that it did that, I support it, even though I recognize there are flaws in the way the law was designed. The flaws come out of political compromise. It wasn’t written by, necessarily, by a single party. It had to get some bipartisan support to get anywhere.
HOST: Yes. The single-payer system, it’s been, I guess, proven to work in a number of countries – you even referenced that a few minutes ago.
NISSEN: It does. I mean the Canadian system is excellent. They spend about half of what we spend, and a lot of what goes on in America is making us uncompetitive as a country is that we spend so much on health care and we aren’t any healthier than other people. A single-payer system is pretty simple. I mean if you want to think about a single-payer system, there’s one in place in the United States for people over 65. It’s called Medicare. Let me give you a fact about Medicare. The overhead for Medicare is about 3 percent. What that means is that 97 percent of what Medicare spends, it actually spends on for health care for people. The overhead for the private insurance industry is 29 percent, which means that almost one dollar out of every three is going for profit, for who knows what – I mean, trying to figure out who’s going to be covered and who’s not. Medicare is much more efficient, and so you can automatically reduce tens of billions of dollars in expenses just by making certain that you have a system like Medicare. There was a proposal during the health care reform debate to simply allow people to “buy-in” to Medicare, that is, use their own dollars to buy Medicare coverage beginning at age 55. I strongly supported that idea, but I supported it only because it was a bridge toward a true single-payer system. And what I hope would happen is that we’d get people to buy into Medicare at 55, then come back in a few years and say 50, and then we’d say 45, and the next thing we know, everybody could buy into Medicare and they would have had an efficient, high-quality system that worked. We don’t have that. Now what we have is the Affordable Care Act which really is trying to reform the insurance industry, not replace the insurance industry. I want to replace the insurance industry.
HOST: So they’d be out of it altogether.
NISSEN: Get them out of it. Their motives are profit, their motive is not making people healthier, their motive is making money. And the other part about the system that’s really challenging is that physicians, still many physicians, work on what’s called a fee-for-service basis, which means that the more they do to you, the more money they get paid. We work on a different model at the Cleveland Clinic. We’re all salaried. I get exactly the same salary every month, whether I order a cardiac catheterization or some other fancy test for you or not. There’s no incentive. There’s really no incentive to do things that aren’t really needed. Unfortunately, we are in a system where there is an incentive, and it is a perverse incentive. It’s one that says, the more stents you put in, the more money you make. And that is a problem, because it misaligns the needs of the patient and the interests of the patient, and the interests of the physician. In a single-payer system that works, we’d all be on salary. We would be [concerned about] quality care, but not on a fee-for-service basis.
http://www.pnhp.org/print/news/2014/august/dr-steven-nissen-i-want-to-replace-the-insurance-industry
Unions Can Lead the Struggle for Single-Payer Health Care
By Kay Tillow
Firedoglake, Aug. 18, 2014
Despite passage of the 2010 health care reform bill, employers continue to push for cuts in benefits and to shift costs to workers in higher monthly payments, co-pays, and deductibles.
Wage increases are always trumped by this costly health care monster. Some employers, in anticipation of the $2,000 annual fine for not offering health insurance, are threatening to drop coverage and instead pay the cheaper fine.
Many companies are dropping benefits for spouses, retirees, and part-timers. Current law does not stop them. Multiemployer plans are disadvantaged by the preferable treatment available to the plans of non-union employers. The 2018 excise tax will cap the ability to bargain better health benefits. Insurance companies continue to decide what doctors and hospitals workers can use.
Unions are playing in a ball park where the odds are stacked against them, a field dominated by private health insurance companies. Unions need a new arena where they can win the battle, improve coverage, and secure it once and for all.
Unions Have a Big Stake in Winning Single-Payer
Currently, nonunion employers undercut union ones by avoiding health care coverage. Ending this unfair advantage will be, like prevailing wage law, a crucial step for progress.
With single payer, unions’ ability to win contract struggles will be enhanced. Now, for many unions, health coverage ends within 30 days of a work stoppage or lockout, placing outrageous pressure on workers to settle for less. With single payer, health coverage never ends.
With single payer in effect, unions, including those with multiemployer plans, can use their health care bargaining power to improve pensions, sick pay, and other benefits as well as wages.
Some union retirees currently have health benefits through VEBA’s. Many of these retirees are in jeopardy of benefit cuts due to rising health costs and limited VEBA funding. With single payer the problem is solved.
Currently, many workers are fearful of organizing because they are afraid to risk losing health insurance coverage. That risk will be gone with single payer.
Labor can win respect and gain support from those who are not in unions by defending not only its own members but by leading the fight for health care for all.
In countries that have a form of single payer universal care, a higher percentage of the workers are in unions. In 2011, rates of unionization were: Sweden 67.5%, Canada 26.8%, United Kingdom 25.6%, U. S. 11.3%.
The Whole Country Wins with Single Payer
Union members are not the only ones in jeopardy now. Our states and cities are strapped by the health insurance burden that siphons public funds from education, jobs, and all the beneficial programs we need.
There’s nothing inevitable about the costly health insurance system we have in the U.S. where private insurance companies dictate what physicians workers can see and what claims to deny.
In fact, the U. S. is the only major industrialized nation that doesn’t have some type of national, universal health care.
Did You Know?
By Kay Tillow
Firedoglake, Aug. 18, 2014
Firedoglake, Aug. 18, 2014
Despite passage of the 2010 health care reform bill, employers continue to push for cuts in benefits and to shift costs to workers in higher monthly payments, co-pays, and deductibles.
Wage increases are always trumped by this costly health care monster. Some employers, in anticipation of the $2,000 annual fine for not offering health insurance, are threatening to drop coverage and instead pay the cheaper fine.
Many companies are dropping benefits for spouses, retirees, and part-timers. Current law does not stop them. Multiemployer plans are disadvantaged by the preferable treatment available to the plans of non-union employers. The 2018 excise tax will cap the ability to bargain better health benefits. Insurance companies continue to decide what doctors and hospitals workers can use.
Unions are playing in a ball park where the odds are stacked against them, a field dominated by private health insurance companies. Unions need a new arena where they can win the battle, improve coverage, and secure it once and for all.
Unions Have a Big Stake in Winning Single-Payer
Currently, nonunion employers undercut union ones by avoiding health care coverage. Ending this unfair advantage will be, like prevailing wage law, a crucial step for progress.
With single payer, unions’ ability to win contract struggles will be enhanced. Now, for many unions, health coverage ends within 30 days of a work stoppage or lockout, placing outrageous pressure on workers to settle for less. With single payer, health coverage never ends.
With single payer in effect, unions, including those with multiemployer plans, can use their health care bargaining power to improve pensions, sick pay, and other benefits as well as wages.
Some union retirees currently have health benefits through VEBA’s. Many of these retirees are in jeopardy of benefit cuts due to rising health costs and limited VEBA funding. With single payer the problem is solved.
Currently, many workers are fearful of organizing because they are afraid to risk losing health insurance coverage. That risk will be gone with single payer.
Labor can win respect and gain support from those who are not in unions by defending not only its own members but by leading the fight for health care for all.
In countries that have a form of single payer universal care, a higher percentage of the workers are in unions. In 2011, rates of unionization were: Sweden 67.5%, Canada 26.8%, United Kingdom 25.6%, U. S. 11.3%.
The Whole Country Wins with Single Payer
Union members are not the only ones in jeopardy now. Our states and cities are strapped by the health insurance burden that siphons public funds from education, jobs, and all the beneficial programs we need.
There’s nothing inevitable about the costly health insurance system we have in the U.S. where private insurance companies dictate what physicians workers can see and what claims to deny.
In fact, the U. S. is the only major industrialized nation that doesn’t have some type of national, universal health care.
Did You Know?
http://www.pnhp.org/print/news/2014/august/unions-can-lead-the-struggle-for-single-payer-health-care
Charges for blood tests vary across California hospitals
UCSF study highlights difficulty of knowing health care prices
New UC San Francisco research shows significant price differences for ten common blood tests in California hospitals, with some patients charged as little as $10 for one test while others were charged $10,169 for the identical test.
The analysis of charges at more than 150 California hospitals looked at blood tests that are often required of patients, such as lipid panel, basic metabolic panel, and complete blood cell count with differential white cell count.
Hospital ownership and teaching status help explain a portion of the variation – prices generally were lower at government and teaching hospitals. Factors such as location, labor costs, patient capacity and percentage of uninsured population generally did not account for the price differences, the authors said, making it difficult for patients to know their costs in advance and to "act as rational consumers."
The report will be published in BMJ Open on August 15, 2014.
Charges for a basic metabolic test ranged from $35 to $7,303, depending on the hospital; the median charge was $214. The most extreme price difference was found in charges for a lipid panel: the median charge was $220, but overall charges ranged from $10 to as much as $10,169.
The results are of particular concern, said the authors, since there isn't much room for variability in blood tests. Moreover, because the tests are identical across providers, consumers might be expected to think that hospital charges would be similar.
"You may hear people say that, 'Charges don't matter' or that 'No one pays full charges,'" said senior author Renee Y. Hsia, MD, an associate professor of emergency medicine at UCSF and director of health policy studies in the Department of Emergency Medicine. She is also an attending physician in the emergency department at San Francisco General Hospital and Trauma Center.
"However, uninsured patients certainly face the full brunt of raw charges, especially if they don't qualify for charity care discounts," Hsia said. "And as employers are switching to more consumer-directed health plans with higher deductibles and co-pays, the out-of-pocket costs of even insured patients can be affected by these charges."
The blood test analysis was based on charges assessed in 2011 by general, acute care medical/surgical hospitals. The majority of the hospitals were not-for-profit, urban, non-teaching facilities. On average, 41 percent of their patient populations were on Medicare and 25 percent were on Medicaid.
The blood test charges were based on hospital full rates before pre-payments or contractual adjustments.
Pervasive Medicare Fraud Proves Hard to Stop
By REED ABELSON and ERIC LICHTBLAU
BALTIMORE — The ordinary looking office building in a suburb of Baltimore gives no hint of the high-tech detective work going on inside. A $100 million system churns through complicated medical claims, searching for suspicious patterns and posting the findings on a giant screen.
Hundreds of miles away in a strip mall north of Miami, more than 60 people — prosecutors, F.B.I. agents, health care investigators, paralegals and even a forensic nurse — sort through documents and telephone logs looking for evidence of fraudulent Medicare billing. A warehouse in the back holds fruits of their efforts: wheelchairs, boxes of knee braces and other medical devices that investigators say amount to props for false claims.
The Obama administration’s declared war on health care fraud, costing some $600 million a year, has a remarkable new look in places like Baltimore and Miami. But even with the fancy computers and expert teams, the government is not close to defeating the fraudsters. And even the effort designed to combat the fraud may be in large part to blame.
Oregon health reforms threatened by new federal directive, officials say
Federal officials have thrown a wrench into the state's high-stakes reforms to the Oregon Health Plan, threatening a program that serves one in four Oregonians.
A new directive could eventually even force the state to return hundreds of millions of dollars received from the federal government – money that's already largely spent.
The federal agency that holds the purse strings for care of nearly 1 million low-income Oregon Health Plan members recently harshly criticized the state's system for distributing money to regional coordinated care organizations under the reforms.
The Aug. 7 letter from the Centers for Medicare and Medicaid Services says the state is employing "high-risk practices" as well as projections that "differ greatly" from those used by the CCOs themselves.
The letter seems to significantly curb the flexibility consideredcrucial to the reforms -- so much so that one CCO executive described it as "a punch to the gut."
In essence, Oregon's reforms give the new regional care organizations broad flexibility to pursue creative programs to improve health and reduce costs.
But after learning of the federal letter in a meeting with the state on Wednesday, CCO executives expressed doomsday pessimism and alarm.
Approved Demonstrations Offer Lessons for States Seeking to Expand Medicaid Through Waivers
By Jesse Cross-Call and Judith Solomon
August 20, 2014
Twenty-six states and the District of Columbia are now implementing health reform’s Medicaid expansion. Arkansas, Iowa, and Michigan have expanded through federally approved Medicaid demonstration projects, or “waivers.” Waivers provide states additional flexibility in how they operate their Medicaid programs.
The programmatic flexibility a waiver can provide, however, is limited. For example, a state cannot use a waiver to impose onerous requirements that make it difficult for eligible individuals to gain and maintain Medicaid coverage. All waivers must serve a demonstration purpose that promotes the objectives of the Medicaid program, which are to deliver health care services to vulnerable populations who can’t afford the health care services and long-term care services and supports that they need. In approving the Arkansas, Iowa, and Michigan expansion waivers, the federal government allowed those states to, for example, enroll some or all of their newly eligible Medicaid beneficiaries in private coverage offered through the health insurance marketplaces, and to charge some beneficiaries modest premiums. At the same time, the federal government scaled back proposals to limit certain health benefits, rejected policies that would condition a beneficiary’s eligibility on participation in work search activities, and did not permit the states to impose cost-sharing charges beyond what Medicaid rules already allow.
The federal government is now considering Medicaid expansion waiver proposals from Pennsylvania and Indiana, and New Hampshire will soon submit its own. As most future state expansions are likely to be implemented through waivers of some kind, the guardrails the federal government has established so far around what is and is not permissible in a Medicaid expansion waiver offer useful lessons for policymakers in states considering whether to expand Medicaid. Future state decisions about the Medicaid expansion will likely be as much about how to expand as about whether to expand.
Patient Advocates Say Insurers Avoiding the Sick
By THE ASSOCIATED PRESS
WASHINGTON — Ending insurance discrimination against the sick was a central goal of the nation's health care overhaul, but leading patient groups say that promise is being undermined by new barriers from insurers.
The insurance industry responds that critics are confusing legitimate cost-control with bias. Some state regulators, however, say there's reason to be concerned about policies that shift costs to patients and narrow their choices of hospitals and doctors.
With open enrollment for 2015 three months away, the Obama administration is being pressed to enforce the Affordable Care Act's anti-discrimination provisions. Some regulations have been issued; others are pending after more than four years.
More than 300 patient advocacy groups recently wrote Health and Human Services Secretary Sylvia Mathews Burwell to complain about some insurer tactics that "are highly discriminatory against patients with chronic health conditions and may ... violate the (law's) nondiscrimination provisions."
Among the groups were the AIDS Institute, the American Lung Association, Easter Seals, the Epilepsy Foundation, the Leukemia & Lymphoma Society, the National Alliance on Mental Illness, the National Kidney Foundation and United Cerebral Palsy. All supported the law.
Coverage of expensive drugs tops their concerns.
The advocates also say they are disappointed by how difficult it's proved for consumers to get a full picture of plans sold on the new insurance exchanges. Digging is often required to learn crucial details such as drugs covered, exact copayments and which doctors and hospitals are in the network.
Washington state's insurance commissioner, Mike Kreidler, said "there is no question" that discrimination is creeping back. "The question is whether we are catching it or not," added Kreidler, a Democrat.
5 reasons health insurance didn't pay your bill
Kevin Flynn, NerdWallet7:30 a.m. EDT August 17, 2014
How many times have you gotten a medical bill for more than you were expecting? Chances are, it's happened before, and you're not the only one who's been shocked at the price tag on a service that your insurance should have covered. Here are five possible reasons why your insurance company didn't pay the entire bill.
1. Your insurance company made an error.
Anyone in the industry can tell you that insurance companies are notorious for inconsistent information, and this unfortunately applies to essentially every part of the insurance process. To protect yourself, get in the habit of documenting the date, time and call reference number every time you contact your insurance company. By doing so, if and when something occurs, you have the leverage to dispute your claim because it was ultimately the fault of representatives of the company. For example, if you call to verify that a provider is in your network, and you end up billed for out-of-network services, you'll be able to reference your original call and get your bill reduced.
If you have a question once you get your bill, always call your insurer to ask how the claim was processed and how the amount covered applied to the service. You will receive varied replies, but often, the person at the insurance company will catch a mistake and have it reprocessed.
2. Your provider "accepts your insurance" — but isn't in your plan's network.
Many people think that it is sufficient to verify that your doctor "accepts your insurance," but this doesn't mean you're totally covered. Many physicians will "accept your insurance," in that they will bill your insurance and accept payment, but this doesn't mean that the doctor is in your network. After your appointment, the doctor's office can "balance bill" you, meaning that you will be charged the difference between what was billed and what your insurance paid.
3. Your free annual examination wasn't billed as a free exam.
The Affordable Care Act mandates that annual exams be free — how can this possibly go wrong? Quite easily, it turns out. If you go to your doctor for your free exam but have something else done that isn't considered part of the free exam, the entire exam is billable. For example, if you go in for an annual exam and ask your doctor to look at your ear because you've had an earache, the exam can be billed as an examination with diagnosis, which is no longer free. Before asking for additional services during your free exam, check with your doctor that it won't be billed as an exam with diagnosis.
4. Your insurance company practices "bundling."
"Bundling" occurs when a secondary procedure is considered to be part of a primary procedure. Think of a carpel tunnel procedure: A surgeon will often consider the incision and the carpel tunnel procedure as separate charges. A problem arises, however, when the insurance company considers the incision as part of the carpel tunnel procedure and "bundles" the two charges. In this case, the insurance company will pay only for the carpel tunnel procedure, leaving you to pay for the incision.
Bundling cases are interesting, because sometimes, the doctor is correct, and sometimes, the insurance company is correct. These cases require research into the billing codes used, what occurred during the procedure, and the specialty's (i.e., orthopedics vs. cardiology) standard billing practices. If you have a complicated bundling issue that has lead to massive bills, you might consider hiring a medical billing advocate for professional help getting your bill resolved.
5. There's missing information.
Often, insurance companies will request additional information from the provider, and for whatever reason, the provider does not give the information or it gets lost in processing at the insurance company. If you are not diligent in following up when you receive an insurance statement indicating that nothing was paid, your claim may never be paid. These cases are easily remedied, but you — the patient — must follow up to ensure that the insurance company receives and processes the requested information.
Paternalism 2.0
The Economist
AMERICAN exceptionalism takes many forms. In the corporate world, one example is particularly odd: companies choose health insurance for their workers. Almost all firms with over 200 employees offer health coverage. Company-sponsored insurance is common for working-age Americans. In no other big and rich country is it the norm. But this form of paternalism is diminishing fast, accelerated by Barack Obama’s health reform. The changes have broad implications for workers and the health industry.
Poll after poll shows that employers are revising their health plans. On August 18th the Federal Reserve Bank of New York reported that more than half of employers were changing insurance in response to Obamacare. The particular reforms may vary but the ailment they are all trying to treat is widespread.
During the second world war, health insurance was used to attract workers made scarce as young men headed off to battle. Tax policy locked in the practice. Corporate health benefits are untaxed, so it is cheaper for firms to pad wage-packets with benefits, rather than to pay more in cash.
This has side effects. Employers who cover spiralling health costs balk at also paying higher wages. Workers are prevented from choosing the right level of health cover. And fear of losing cover may trap them in jobs they want to leave.
Recently firms have shifted more costs on to employees and given them more control over health spending. Obamacare has speeded this up. The law seeks to extend company coverage: all firms with 50 or more workers must offer insurance or pay a penalty. But the scheme’s new exchanges, where individuals can shop for policies, might eventually provide an alternative to company coverage. Meanwhile, companies are rejigging health plans as they deal with Obamacare’s requirements, and prepare for a tax on lavish corporate insurance that looms in 2018.
Employees are shelling out a little more for a rising share of insurance premiums. They paid 28% last year, compared with 26% a decade earlier, according to the Kaiser Family Foundation, a research organisation. The insurance itself is also skimpier. The share of covered workers with deductibles of $1,000 reached 38% last year, more than twice what it was in 2008. Many workers grumble. Yet they also get more control over spending, and new reasons to shop around. Firms have sprung up to help them do that. For example, employers can hire Castlight, a firm based in California, to present data on the cost and quality of different doctors.
More People Going to Switzerland for Assisted Suicide, Study Finds
By PAM BELLUCK
In Redesigned
Room, Hospital Patients May Feel Better Already
PLAINSBORO, N.J. — Can good design help heal the sick?
The University Medical Center of Princeton realized several years ago that it had outgrown its old home and needed a new one. So the management decided to design a mock patient room.
Medical staff members and patients were surveyed. Nurses and doctors spent months moving Post-it notes around a model room set up in the old hospital. It was for just one patient, with a big foldout sofa for guests, a view outdoors, a novel drug dispensary and a bathroom positioned just so.
Equipment was installed, possible situations rehearsed. Then real patients were moved in from the surgical unit — hip and knee replacements, mostly — to compare old and new rooms. After months of testing, patients in the model room rated food and nursing care higher than patients in the old rooms did, although the meals and care were the same.
But the real eye-opener was this: Patients also asked for 30 percent less pain medication.
Reduced pain has a cascade effect, hastening recovery and rehabilitation, leading to shorter stays and diminishing not just costs but also the chances for accidents and infections. When the new $523 million, 636,000-square-foot hospital, on a leafy campus, opened here in 2012, the model room became real.
No, We Still Don’t Have Proof That Private Medicare Plans Are Better
BY THOMAS HUELSKOETTER - GUEST CONTRIBUTOR POSTED ON
A growing debate over the Medicare Advantage program has big ramifications for the future of American seniors’ health coverage. Medicare Advantage, an alternative to the traditional public Medicare program, allows seniors to opt in to private insurance coverage financed by the government. Currently, 16 million of the 54 million Medicare beneficiaries receive coverage through Medicare Advantage plans.
While most discussion of the Medicare Advantage program centers on its higher cost, there’s been some recent focus on the quality of care provided by the private plans, which historically has been worse than traditional Medicare. On Monday, a post in The Upshot atThe New York Times made the case that the quality of Medicare Advantage has not only improved, but actually surpassed that of the public Medicare program. The piece relied in particular on a 2013 Health Affairs study showing seniors on Medicare Advantage to be more likely to receive certain screenings and vaccinations, as well as expressing comparable levels of satisfaction in their doctors and specialists as seniors on Medicare.
However, these findings aren’t as conclusive as they may initially appear. Data limitations make it difficult to directly compare quality between Medicare Advantage plans and traditional Medicare. As a result, this study used only five clinical quality indicators, along with survey results on vaccinations and patient satisfaction, to compare quality of care. All five of these indicators measured clinical processes (i.e., giving preventive screenings to appropriate patient groups) rather than clinical outcomes (i.e., making people healthier). While process measures are important, we shouldn’t draw firm conclusions on quality of care without comparative data on outcomes as well. Notably, the government’s “star rating” quality guides to Medicare Advantage plans for consumers place more than twice as muchweight on outcomes measures as they do on process measures.
What’s more, this study only looked at health maintenance organizations, or HMOs, which account for 64 percent of Medicare Advantage plans. Since some of the other plan types have averaged lower quality “star ratings” to date than the HMOs, this limits the ability of this study to represent how Medicare Advantage plans taken as a whole are performing. And even among HMOs, quality of care varied considerably within this study, with the more established, not-for-profit HMOs performing well, and newer, for-profit HMOs showing more mixed results, performing worse than traditional Medicare on some measures and better on others.
Maine props up ‘two Americas’ with no Medicaid expansion
By Christy Daggett, Special to the BDN
Posted Aug. 19, 2014, at 3:27 p.m.
The Affordable Care Act, as originally passed, holds tremendous promise to decrease health care costs and increase insurance coverage rates across rural states like Maine. But federal court opinions and repeated vetoes of Medicaid expansion are putting all that into jeopardy. Already, data is pointing to widening disparities between the states embracing health reform and those that have resisted — in the numbers of uninsured, in new health care jobs and in the finances of local hospitals.
Historically, the United States has maintained the highest health spending in the world, but it still had lower life expectancies and the highest rates of infant mortality in the developed world. Health costs have sucked up 18 percent of our gross domestic product, leaching out wage gains and damaging America’s global competitiveness.
These factors drove Congress and the president to enact health care reform. Since then, despite the fact that health care utilization typically increases as the economy recovers from recession, health care cost growth has been held in check and health economists increasingly agree that this is due to the structural reforms initiated by the ACA.
And, with federal subsidies and Medicaid expansion to help cover the working poor, the number of people who are uninsured in the country is going down. These are promising trends, but die-hard reform opponents continue to work to reverse them. Every recalcitrant governor, every contentious court decision impedes health reform from realizing its full potential, despite its proven success to date.
There are two Americas. One is prosperous, long-lived and healthy. The second comprises the working poor who are short-lived, disabled early and beset by chronic illnesses that could have been prevented — diabetes, heart failure, pulmonary disease. Those in this second America are people who have a job — maybe two — but do not earn enough to make ends meet.
We make special provisions for some of the most vulnerable in this group — children, the elderly and disabled — but millions of hard-working Americans fall through the gaps. And unfortunately, the ranks of America’s working poor are increasing, not shrinking.
An American born in one of our rural counties is likely to live a shorter life than a person in Algeria or Bangladesh. Meanwhile, Americans who live in prosperous urban regions have life expectancies that rival the healthiest places in the world. This disparity exists, and it takes money. It costs our economy, through lost worker productivity and the high price of treating people in emergency rooms when they cannot afford less expensive preventive care.
As designed, health reform aimed to erase health disparities. It pumped money into making affordable health care available to Americans in poorer, more rural states like Maine. It offered good jobs and billions in economic impact while improving the quality of care to all Americans wherever they live, whatever their income. It directed money to cost-effective primary care and dedicated scholarship funds to increase the number of doctors in rural and underserved areas, like much of Maine.
The New York Times recently reported that state-level refusal to expand Medicaid combined with the recent court ruling jeopardizing subsidies to residents of states on the federal exchange threaten to undo the national reform and create a state-by-state patchwork. This would effectively maintain the two Americas. The states that declined to expand Medicaid or design state exchanges are mostly the poorer, less healthy states. Right now, Maine is on this list.
Gov. Paul LePage has vetoed majority votes to expand Medicaid five times. If we continue in this direction, 12 percent of Mainers will continue to be uninsured while 96 percent of residents in nearby Massachusetts are insured.
Politics threaten to block health reform from fulfilling its promise: to bridge the yawning gap in health and economic potential between the two Americas. Partisan politics shouldn’t block Maine from reaping the benefits of health reform — both in better health outcomes and in expanded economic opportunity.
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