Pay, Pride, and Public Purpose: Why America's Doctors Should Support Universal Healthcare
Abstract
Discussion of universal healthcare is nothing new for US politicians or among reform advocates, policy experts, or the general public. Physicians, however, have been minor voices in the discussion. Their relative silence has been detrimental both to the public and to physicians themselves. We pose 3 arguments as to why physicians should support universal access grounded in medicine's own self-interest, arguments that are largely ignored in the current debate. These are: (1) the need for paying patients, (2) the need for a sense of self-esteem rooted in professionalism rather than commercialism, and (3) the urgency to affirm a public purpose for medicine by promoting the nation's health through universal care.
Who has a stake in universal healthcare? Some groups, such as those lacking insurance, are obviously at risk and have a keen interest. Others, such as insured workers, have a less obvious but demonstrable concern. Arguments that urge adoption of an inclusive system typically focus on "healthcare horror stories" designed to evoke sympathy for the unfortunate persons whose lives are forever changed by unmet health needs or unpaid health bills.[1] Our focus is different. We ask, regarding universal healthcare, "What's in it for physicians?" While the active support of doctors may not be a sufficient force to change the US system, it is probably a necessary one. At a minimum, universal coverage will be far less likely if physicians are opposed to it. Our aim here is to explore and discuss some of the reasons that should motivate active physician involvement in a more just and equitable system. We will discuss 3 reasons in particular. They are: (1) the need for paying patients; (2) the need to take pride in what one does -- that is, the need to be nurtured by recognition of skillful professional performance in medical work, and not just rewarded monetarily; and (3) the importance of embracing a public purpose for medicine and thus engaging the trust and esteem of the population. We will examine each of these in turn, but first we will discuss briefly the other constituencies for universal coverage, since their reasons for supporting an inclusive system are often shared by doctors.
Paying Patients
Even those who entered medicine for altruistic reasons and continue to be sustained by that motivation need to be compensated for their work. So one obvious answer to the question "What's in it for doctors?" is that they will have patients who have an assured way to deal with the bill. Whatever else their motivation, physicians have a powerful self-interest in being paid for the care they provide. Only the very wealthy can afford to routinely see physicians if they are uninsured.
Yet this reason may not be widely recognized or appreciated among physicians themselves. Here American history provides an exemplary tale. In 1965, the Medicare program was created, providing health benefits for all citizens aged 65 and over. The impact on the health of the elderly, and on their social status, was dramatic. Prior to the advent of Medicare, 35% of the elderly lived in poverty; in 2003 that number was at 9%.[7] Medicare is also credited with desegregating US hospitals, being the largest funder of graduate medical education and creating the field of geriatrics. But for our purposes here, the critical change was creating millions of newly insured patients. In spite of the potential boon to physician incomes, organized medicine strenuously opposed Medicare, a situation in which a misidentified fear of socialism triumphed over common sense and economic self-interest.
The American Medical Association (AMA)'s well-organized campaign of lobbying and advertising against Medicare was dubbed "Operation Coffee Cup." The name bespeaks a strategy of building grass-roots opposition, and one feature of the campaign involved sending physicians' wives anti-Medicare phonograph records and tapes to play for their neighbors. One of the speeches on the records and tapes was given by Ronald Reagan and intoned that Medicare would mean that one day "we will awake to find we have socialism."[8] The socialism charge was nothing new at the time, and has remained a staple ingredient of opposition to reform, including the defeat of Clinton's Health Security Act in 1994. Medicare was passed in spite of organized medicine's massive campaign of opposition. Yet our main point is less about the erroneous ideological charges that fueled the opposition of the AMA in 1965, and more about the great irony of organized medicine lobbying fiercely against the economic self-interest of its members. In retrospect, it is clear that Medicare has had a profound, beneficial effect on physician incomes, as well as on the health status of the elderly.
It could be objected that some of the government regulations that were feared by the AMA during Medicare's passage have come to pass, such that reimbursements are currently below what many physicians believe is appropriate. There is no question that regulatory changes since 1965, such as the introduction of the Resource Based Relative Value Scale (RBRVS) in 1989 and other adjustments in rates, have diminished the dollar value of Medicare reimbursements. Yet it remains clear that Medicare as a whole has been and remains an important component of medicine's economic well-being.
Imagine if the 46 million currently uninsured were provided with the insurance coverage similar to that provided by Medicare, as advocated by one of the most frequently proposed reforms. The reduction of costs involved in record keeping, filing, and negotiating claims would be substantial and immediate. Perhaps equally important, the vexing issue of finding a sustainable mix of insured-to-uninsured patients would be greatly lessened or eliminated. Because medical practices must now be run as small businesses, physicians are distracted from clinical care by worries about costs and profit margins, either their own or those of the health maintenance organizations (HMOs) for which they work. So long as reimbursements for the newly insured were adequate, physicians could spend more time actually doing what they were trained to do, rather than functioning as business managers or chafing under the control of MBAs.
Professional Pride: Commercialism and the Erosion of Physician Self-Esteem
A second answer to the question of why physicians should support universal coverage is to reduce commercialism in healthcare and the damaging effects of commercial forces on professional self-esteem.
Several years ago, one of us (LRC) was talking to a surgeon who was host for a visiting lecture at his institution. Arriving in the early afternoon for an after-dinner talk, we went to the construction site of his new home and we walked together through the emerging shell of beams and girders. It was to be a grand house, roughly 15,000 square feet, with rooms for every possible activity, multiple garages, and every amenity imaginable for a private residence -- and all for 2 people. Clearly it represented the fulfillment of his and his wife's aspirations. His comment about the opulent new residence, half in apology, was: "It gives me a reason to keep working."
We tell this story not because we begrudge physicians, or anyone for that matter, wealth or fulfillment of their material aspirations. Rather, what was striking was that "conspicuous consumption" had become the rationale for continuing a medical practice beyond the point of engagement for intrinsic rewards.[9] Such values might not be worrisome in a corporate CEO or an NBA star, but they are in a physician. They signal the usurpation of the altruistic rewards of medicine by monetary gain. We are not concerned with whether this physician and his spouse should have settled for less opulence, but with how professionalism could be maintained when the motivation that impels the scalpel is the price of the procedure.
Commercial forces have always been a force in medicine, but it is only recently that they have come to dominate. While physicians have consistently sought to portray themselves as purveyors of a social service, until recently in the United States they have functioned as small-business owners. For the greater part of the 20th century, American medicine was a cottage industry with a professional service ethos, populated by solo or group practices, run on fee-for-service, indemnity insurance or out-of-pocket patient financing, providing adequate to good returns for most generalists and handsome pecuniary rewards for specialists. Those who received care were largely those who could pay, either through insurance or out-of-pocket, while the uninsured were the sporadic recipients of charity. So the conduct of medical practice as a business and the use of market forces as the chief mechanism for the distribution of medical goods and services are nothing new in the United States.
What is new is the pervasive presence of large corporations as owners and providers of health services, and the loss of physician autonomy in decision-making that goes with that change. While there were some healthcare corporations in the past, they were typically businesses owned by medical groups or nonprofit organizations that were governed by boards of local citizens and were community oriented. While not always altruistic in their aims, these organizations were often responsive to local needs. The new healthcare corporation has a Wall Street orientation and is responsive to markets and mergers. The new corporate providers are also far more skilled than the cottage industry entrepreneurs at advertising and selling their services, cutting costs, and shaping the way their customers think not only about the services they offer but also about the economic arrangements that undergird their profitability. The healthcare insurance industry's derailing of the Clinton healthcare reforms in 1994 is vivid testimony to their power.
The muscle of the new corporate health entrepreneurs can be documented by looking at the portion of healthcare services they now control, but our interest here is less in the size of their market share and more in the subtle but pervasive ways we have all been encouraged to talk and think about healthcare as a marketable product. For example, physicians are now "providers," while patients have become "consumers." The logic of these terminology changes is reinforced by the methods managed care organizations (MCOs) use to assure their members that quality is being maintained or enhanced -- through "consumer satisfaction surveys." The idea that consumer satisfaction is a good measure of quality means that patients now have the role of customers who, to be effective in this exchange, must be knowledgeable and shrewd in comparisons of price and quality. Health services are now "commodities," in which the cardinal defect is the absence of choice. The absence of choice prohibits the chief means of consumer assurances of value, viz., comparison shopping. In brief, commercialism means that going to see a doctor is increasingly portrayed as purchasing a product or claiming a service -- largely prepaid if one is insured -- rather than seeking help from a trusted professional.
Within the logic of the market, the goal of commercializing health services is to capture a market niche, to enlarge it, and to maximize profits. This, too, is reflected in changes in the idioms that describe the activity. Services to patients by physicians are registered in accountants' ledgers as "medical losses," precisely because these services reduce the fraction of income that can be counted as profit. Advertising is undertaken to attract and sustain the loyalty of carefully selected, low-risk groups, known as "revenue bodies," to whom the cheaper premiums are offered. Most physicians currently function under a variety of incentive systems designed to reduce utilization -- and thus costs -- in keeping with the aims of corporate profitability. If efficiency targets are not met, whatever portion of physicians' incomes that are "at risk" is lost. Thus, clinical choices about how much time to spend with a patient, or what services to provide or recommend, have substantial implications for physicians' incomes. Just how direct and severe these implications are depends on the model being used, and they range from those that simply produce a prudent cost-consciousness to those that are morally perverse because they create a conflict of interest for the physician.
The impact of corporate commercialization of medicine on physicians would be hard to overestimate. The literature of the past 15 years has been filled with carping, complaints, and other signs of demoralization. And this is entirely understandable. The experience of many practitioners has changed from patient care to patient and revenue management. Time spent in clinical activities is routinely cut short by conversations with benefit managers to gain approval for recommended diagnostic procedures or therapies, and the burdens of documentation are far greater as the consequences of nonconformity to insurance guidelines increase. The application of industrial, assembly-line management techniques to medical care has done perhaps more than anything else to reduce the self-esteem of physicians. Seeing more patients for shorter periods of time to meet a managerial quota has led, predictably, to less satisfying relationships for both physicians and patients.
Although we are painting a sobering picture, it is not a surprising one. It would be very strange if the logic of commercialism so pervasive in the rest of society had not invaded the medical sensibility. Physicians are subject to the same pressures as all Americans, increasingly measuring in dollars how they rank as good professionals, good family providers, and more generally as successful persons. In American society, these indices of merit and honor are all thought to be related, directly or indirectly, to the monetary resources one can muster. The result is that physicians are systematically encouraged to think about their most basic stewardship as one of protecting investor resources -- rather than, or at best in addition to, their stewardship of patients. But beyond patient vulnerability, management's claim to physician loyalty marks a profound shift in the sources of professional pride and self-esteem. In the past, this sense of worth was more firmly anchored in helping people, in developing and sustaining therapeutic relationships, and in a general altruism of purpose. The industrial-managerial model of care makes these sources of reward secondary and less available.
We are painting a portrait here of professionalism under siege, not to decry the evils of money or markets, but to note with some concern the diminishment of the traditional sources of professional self-esteem -- patient devotion and pride in skillful practice. What is so troubling about the waning of professional pride in the face of commercial forces is the way that physicians are cut off from the sustaining motivations that make the hard work of medical care rewarding, and sometimes just bearable. The cruelty in this waning of professionalism lies in the way money overpowers all other values and thereby uproots physicians from the deep rewards of recognizing themselves as part of a healing process. Money (and the considerable list of things it can buy) becomes the chief standard against which doctors are encouraged to judge themselves and to be judged. But for professionals, the only god worthy of solemn devotion is signified in the etymology of 'profession,' viz., an avowal of service beyond self.[10] Without this piety technical proficiency may remain intact, and financial rewards may remain plentiful, but professional identity cannot be sustained. As Arthur Okun has remarked, "everybody (but an economist) knows that that money shouldn't buy some things."[11] Yet to be accurate we need to go beyond the moral realm indicated by "should." One of the things money can't buy is a professional identity; this means that every encroachment of commercialism into medicine makes professionalism more fragile.
Would coverage for all Americans eliminate commercial forces from medical practice? That outcome, however desirable, seems unlikely. But it is reasonable to assume that commercial forces would be substantially reduced. No conceivable system of inclusive care could exist with the pervasive commercialism that now characterizes US healthcare. Commercialism exists at all because there are profits to be made, because there are corporate and individual bottom lines to be protected, because physicians must be financially disciplined against their instincts to provide more patient time and more complete care, and because persons with complex and expensive health problems represent financial liabilities to insurers in a system fragmented by health status and money. Universal care would eliminate most or all of these commercializing forces since it would require a clear and vigorous regulatory framework to be feasible. Commercial insurers in medicine make much of their money by shifting costs to others. In any well-conceived and well-managed universal system, such cost shifting would not be possible. Universal systems do not risk-rate insurance premiums, do not contain preexisting condition clauses, do not permit providers and insurers to enroll only the healthiest and lowest-cost patient groups. And universal systems, eschewing profitability and industrial models of physician work and rewards, together with accountability to the public for quality, lessen the tendency to tie physician compensation to denials of needed care. The availability of medical services in a universal system is a policy issue, not an individual decision made at the bedside by a provider with a conflict of interest.
Whatever else it brings, universal access, even in a system with multiple tiers, is a great equalizing force. Commercialism plays upon, and profits from, disparities in health status and income, and as noted above, makes physicians active players in that collusion against the poor and the sick. It is very likely that any system of universal care, whatever the organization and delivery mechanisms, will promote an environment in which physicians can again take pride in recognizing the skillful execution of their unique abilities in serving, healing, and alleviating suffering. For most doctors, a rise in professional self-esteem will be the result.
Public Purpose
William Sullivan has asserted: "It is hard to see how medicine can resolve its crisis of legitimacy without simultaneously seeking to redefine its identity around a public mission."[12] We concur with this assessment. Our stress in the previous section was on how commercialism threatens the traditional professional self-definition and erodes the intrinsic rewards of medical work. Our focus in this section -- our third reason why physicians should support universal coverage -- is that it would clearly and forcefully unite physicians with the larger population in a fundamental concern for the nation's health.
Whatever else can be said about the virtues of physicians -- and a great deal can be said about individual physicians' commitments to their patients' well-being -- organized medicine in the United States rarely embraces a larger social purpose for itself as a professional body. For example, one would look in vain for anything resembling a public commitment in most of medicine's ethical codes and principles. An examination of the major ethical obligations of medical professional associations published in 2004 indicated that while there is often a robust and well-defined set of obligations toward individual patients, little is said about medicine's role in promoting the public good. Advocacy for the uninsured, or for vulnerable populations of patients, or even for public health more generally, were mentioned in only 11% of the medical codes examined, and in almost all these cases, it amounted to no more than a mention, not a developed or fully articulated commitment.[13]
It might be argued that medicine should only be concerned with the way individual doctors relate to individual patients, and not with health policy, financing, and the larger questions of the health of society. But such an argument would be deleterious, both to the profession and to society. Physicians are among those best equipped to speak about matters of public health, and to be absent from policy making and political participation about health matters will only make the valuable expertise and experience of physicians irrelevant. More important, there is a long but largely unrecognized tradition of social activism and public purpose in medicine that serves as a model for an expanded professional identity in early 21st century America.
The idea that medicine takes its identity less from its scientific prowess or its professional sovereignty and more from a commitment to the public good was definitively articulated in the modern period by Jules Guerin.[14] Guerin was a French physician-journalist who practiced and wrote during the time revolutionary urban changes were sweeping Europe in the mid-19th century. Guerin and other politically active leaders expressed both a hope and an expectation that medicine would be a force for social justice and rapid social improvement. This meant applying medicine's knowledge and skills to address the problems of growing urban industrialization and the many health problems it created: long hours in unsanitary working conditions, child labor, poor worker housing, and the general environmental filth of crowded, ill-managed factory life. The better-known contemporary of Guerin, Rudolph Virchow, put it this way: "Only an intimate knowledge of individual living conditions and the life of the people can transform the laws of medicine. . . into general laws for the human race." He continued: "Certain it is that medicine will suffer no loss of dignity when it mingles with the people, for among the people it will find new strength."[15] Or, more pointedly, "Doctors are the natural advocates of the poor and social problems are very largely within their jurisdiction."[16] In sum, Virchow, Guerin, and other activist physicians of their time recognized that medicine has a clear public purpose, and that in embracing it, medicine will find new strength.
This is essentially our argument here. The issue in early 21st century US society that most calls for organized medicine's attention is the suffering and second-class medical treatment of the uninsured. Physicians as a group are intimately acquainted with the problems created by the increasingly fragmented and brutal system in which they practice. They are thereby, paraphrasing Virchow, natural advocates of the uninsured. The insistence of organized medicine for a change in policy to a universal system would be a powerful force, one that political leaders could ignore only at their peril. But more to the point, such advocacy would be a way for medicine to side with patients rather than profiteers and rise above the professional indifference and political passivity that have often characterized its recent past. What is at stake is the health of millions of Americans, but also medicine's soul.
Opinion: It’s liberals who are the tough-minded realists about policy
by E. J. Dionne, Jr. - The Washington Post - August 16. 2021
Over the decades, conservatives have been enormously successful at selling a parody of liberalism. Liberals are cast as dreamy idealists who think “throwing money at problems” is the way to solve them. They’re painted as hostile to a tough-minded examination of their programs and indifferent to whether they work.
This parody has things exactly backward. In 2021, it’s liberals who want citizens, politicians included, to look rigorously at the evidence. It shows how many public programs make a substantial, positive difference in the lives of Americans, especially kids from low-income families. It’s conservatives who prefer ideology and moralism to the facts.
The spending that liberals favor these days — much of it included in President Biden’s American Families Plan that Democrats are pushing through Congress — is for government interventions that have been tested and proved.
The phrase “laboratories of democracy” refers to how state governments are free to try different policy approaches, giving all of us a chance to see which are successful and which aren’t.
The idea is often misused by opponents of federal action to argue that we should leave as much as possible to the states. Thinking of the states as “laboratories” points in a different direction. If states — red and blue — show that certain policies plainly improve people’s opportunities and circumstances, doesn’t it make sense to apply them to the whole country? Key programs, starting with Social Security and Medicare, are national for a reason.
This underscores the importance of a report released this month by the Center on Budget and Policy Priorities (CBPP), a think tank devoted to careful policy analysis aimed at lifting up those who have been left out. Citing study after study, the report concludes that “a large body of research” demonstrates the policies in Biden’s package and other forms of assistance to the needy “would make a substantial difference in the lives of children and youth.”
Just a few particulars from the report written by Arloc Sherman, Ali Safawi, Zoë Neuberger and Will Fischer:
“When children grew up in a household receiving additional cash benefits, their academic achievement increased on a lasting basis.”
“When elementary and middle school students received access to free school lunches, their academic performance improved.”
“When children had access to quality pre-kindergarten at age 4, they were likelier to enter college on time.”
“When high school students were guaranteed grants to pay for community college, they were likelier to complete community college.”
“When parents had access to paid family leave, rates of early births and low birthweights declined.”
There’s much more about what works. Footnoting proves nothing by itself, but this document’s 108 footnotes are a measure of how many high-quality, nonpartisan studies have tested the effect of various policies.
Sharon Parrott, president of the CBPP, said in an interview that the research pulled together underscores that programs Biden and other progressives are proposing are bold but not radical. (It’s one reason the polls show them to be popular.)
“Many of them are building on successful but underfunded programs” nationally and in the states, she said, or programs that work well in other well-off democracies. Without intending an ideological pun, she added that Biden’s proposals are not “out of left field.”
Parrott offered a common-sense point, often overlooked, about why a society that says it cares about “family values” should want to help parents with young children through programs such as the child tax credit.
On the whole, earnings rise as people get older, but they tend to have children when they are younger. “We ask people to spend a lot of money” on child-rearing “at the time when they’re earning the least,” she noted. Smoothing out the imperatives of the life cycle for middle-class and poor families is good for parents and children alike.
There is no rational reason the child poverty rate needs to be as high as it is in the United States. The percentage of children living in poverty in this country based on market incomes is not all that different from the share in most of 18 other rich countries. But an analysis of pre-pandemic data from the Organization for Economic Cooperation and Development — that is, from before the covid-fueled surge of social spending — found that when public policies relating to taxes and benefits were taken into account, the United States ranked dead last.
We should do better. With smart policies, we can.
A major obstacle to more energetic efforts to help the least advantaged, Parrott said, is “the cynicism that it doesn’t matter what we do.” But it does matter. When it comes to public programs, the antithesis of cynicism is reality itself: We know a great deal about what works. Let’s do it.
Hospitals and Insurers Didn’t Want You to See These Prices. Here’s Why.
by Sarah Kliff and Josh Katz - NYT - August 22, 2021
This year, the federal government ordered hospitals to begin publishing a prized secret: a complete list of the prices they negotiate with private insurers.
The insurers’ trade association had called the rule unconstitutional and said it would “undermine competitive negotiations.” Four hospital associations jointly sued the government to block it, and appealed when they lost.
They lost again, and seven months later, many hospitals are simply ignoring the requirement and posting nothing.
But data from the hospitals that have complied hints at why the powerful industries wanted this information to remain hidden.
It shows hospitals are charging patients wildly different amounts for the same basic services: procedures as simple as an X-ray or a pregnancy test.
And it provides numerous examples of major health insurers — some of the world’s largest companies, with billions in annual profits — negotiating surprisingly unfavorable rates for their customers. In many cases, insured patients are getting prices that are higher than they would if they pretended to have no coverage at all.
At the University of Mississippi Medical Center, a colonoscopy costs ...
$1,463
with a Cigna plan.
$2,144
with an Aetna plan.
$782
with no insurance at all.
Until now, consumers had no way to know before they got the bill what prices they and their insurers would be paying. Some insurance companies have refused to provide the information when asked by patients and the employers that hired the companies to provide coverage.
This secrecy has allowed hospitals to tell patients that they are getting “steep” discounts, while still charging them many times what a public program like Medicare is willing to pay.
And it has left insurers with little incentive to negotiate well.
The peculiar economics of health insurance also help keep prices high.
How to look up prices at your hospital (if they’re there) ›
Customers judge insurance plans based on whether their preferred doctors and hospitals are covered, making it hard for an insurer to walk away from a bad deal. The insurer also may not have a strong motivation to, given that the more that is spent on care, the more an insurance company can earn.
Federal regulations limit insurers’ profits to a percentage of the amount they spend on care. And in some plans involving large employers, insurers are not even using their own money. The employers pay the medical bills, and give insurers a cut of the costs in exchange for administering the plan.
A growing number of patients have reason to care when their insurer negotiates a bad deal. More Americans than ever are enrolled in high-deductible plans that leave them responsible for thousands of dollars in costs before coverage kicks in.
Patients often struggle to afford those bills. Sixteen percent of insured families currently have medical debt, with a median amount of $2,000.
Even when workers reach their deductible, they may have to pay a percentage of the cost. And in the long run, the high prices trickle down in the form of higher premiums, which across the nation are rising every year.
At the Hospital of the University of Pennsylvania, a pregnancy test costs ...
$18
for Blue Cross patients in Pennsylvania.
$58
for Blue Cross HMO patients
in New Jersey.
$93
for Blue Cross PPO patients
in New Jersey.
$10
with no insurance at all.
Insurers and hospitals say that looking at a handful of services doesn’t provide a full picture of their negotiations, and that the published data files don’t account for important aspects of their contracts, like bonuses for providing high-quality care.
“ These rate sheets are not helpful to anyone,” said Molly Smith, vice president for public policy at the American Hospital Association. “It’s really hard to say that when a lot of hospitals are putting in a lot of effort to comply with the rule, but I would set them aside and avoid them.”
The trade association for insurers said it was “an anomaly” that some insured patients got worse prices than those paying cash.
“ Insurers want to make sure they are negotiating the best deals they can for their members, to make sure their products have competitive premiums,” said Matt Eyles, chief executive of America’s Health Insurance Plans.
The five largest insurers — Aetna, Cigna, Humana, United and the Blue Cross Blue Shield Association — all declined requests for on-the-record interviews. Cigna, Humana and Blue Cross provided statements that said they support price transparency.
The requirement to publish prices is a rare bipartisan effort: a Trump-era initiative that the Biden administration supports. But the data has been difficult to draw meaning from, especially for consumers.
The New York Times partnered with two University of Maryland-Baltimore County researchers, Morgan Henderson and Morgane Mouslim, to turn the files into a database that showed how much basic medical care costs at 60 major hospitals.
The data doesn’t yet show any insurer always getting the best or worst prices. Small health plans with seemingly little leverage are sometimes out-negotiating the five insurers that dominate the U.S. market. And a single insurer can have a half-dozen different prices within the same facility, based on which plan was chosen at open enrollment, and whether it was bought as an individual or through work.
But the disclosures already upend the basic math that employers and customers have been using when they try to get a good deal.
People carefully weighing two plans — choosing a higher monthly cost or a larger deductible — have no idea that they may also be picking a much worse price when they later need care.
Even for simple procedures, the difference can be thousands of dollars, enough to erase any potential savings.
At Aurora St. Luke’s in Milwaukee, an M.R.I. costs United enrollees ...
$1,093
if they have United’s HMO plan.
$4,029
if they have United’s PPO plan.
It’s not as if employers can share that information at open enrollment: They generally don’t know either.
“ It’s not just individual patients who are in the dark,” said Martin Gaynor, a Carnegie Mellon economist who studies health pricing. “Employers are in the dark. Governments are in the dark. It’s just astonishing how deeply ignorant we are about these prices.”
A vital drug, a secret price
Take the problem Caroline Eichelberger faced after a stray dog bit her son Nathan at a Utah campsite last July.
Nathan’s pediatrician examined the wound and found it wasn’t serious. But within a week, Nathan needed a shot to prevent rabies that was available only in emergency rooms.
Ms. Eichelberger took Nathan to Layton Hospital in Layton, Utah, near her house. It hasn’t published price data for an emergency rabies vaccine, but the largest hospital in the same health system, Intermountain Medical Center, has.
Nathan, then 7 years old, received a child’s dose of two drugs to prevent rabies. The bill also included two drug administration fees and a charge for using the emergency room.
Intermountain owns a regional insurer called SelectHealth. It is currently paying the lowest price for those services: $1,284.
In the same emergency room, Regence BlueCross BlueShield pays $3,457.
Ms. Eichelberger’s insurer, Cigna, pays the most: $4,198.
For patients who pay cash, the charge is $3,704. Half of the insurers at Intermountain are paying rates higher than the “cash price” paid by people who either don’t have or aren’t using insurance.
This pattern occurs at other hospitals, sometimes with more drastic consequences for adults, who require a higher dosage.
Prices for a drug that prevents rabies
Charts include private insurers only. Prices reflect the typical dose for a 160-pound person.
Prices were still secret when Brian Daugherty went to an emergency room near Orlando, Fla., for a rabies shot after a cat bite last summer.
“ I tried to get some pricing information, but they made it seem like such a rare thing they couldn’t figure out for me,” he said.
He went to AdventHealth Orlando because it was close to his house. That was an expensive decision: It has the highest price for rabies shots among 24 hospitals that included the service in their newly released data sets.
The price there for an adult dose of the drug that prevents rabies varies from $16,953 to $37,214 — not including the emergency-room fee that typically goes with it.
Mr. Daugherty’s total bill was $18,357. After his insurer’s contribution, he owed $6,351.
“ It was a total shock when I saw they wanted me to pay that much,” said Mr. Daugherty, who ultimately negotiated the bill down to $1,692.
In a statement, AdventHealth said it was working to make “consumer charges more consistent and predictable.”
If Mr. Daugherty had driven two hours to the University of Florida’s flagship hospital, the total price — between him and his insurer — would have been about half as much.
Similar disparities show up across all sorts of basic care.
One way to look at the costs is to compare them with rates paid by Medicare, the government program that covers older people. In general, Medicare covers 87 percent of the cost of care, according to hospital association estimates.
At multiple hospitals, major health plans pay more than four times the Medicare rate for a routine colonoscopy.
Prices for a colonoscopy
Charts include private insurers only.
And for an M.R.I. scan, some are paying more than 10 times what the federal government is willing to pay.
Prices for a knee M.R.I.
Charts include private insurers only.
Health economists think of insurers as essentially buying in bulk, using their large membership to get better deals. Some were startled to see numerous instances in which insurers pay more than the cash rate.
Whether those cash rates are available to insured patients varies from hospital to hospital, and even when they are, those payments wouldn’t count toward a patient’s deductible. But the fact that insurers are paying more than them raises questions about how well they’re negotiating, experts said.
“ The worrying thing is that the third party you’re paying to negotiate on your behalf isn’t doing as well as you would on your own,” said Zack Cooper, an economist at Yale who studies health care pricing.
‘ They don’t want their secrets out there’
Employers are the largest purchasers of health insurance and would benefit the most from lower prices. But most select plans without knowing what they and their workers will pay.
To find out what the prices are, they would need to solicit bids for a new plan, which can frustrate employees who don’t want to switch providers.
It also requires the employers to hire lawyers and consultants, at a cost of about $50,000, estimated Nathan Cooper, who manages health benefits for a union chapter that represents Colorado sheet metal and air-conditioning workers.
“ If you want the prices, you have to spend to get them,” he said.
At hospitals in the Erlanger Health System in Tennessee, administration of a flu vaccine costs ...
$104
with a Blue Cross plan.
Employers who do sometimes come up empty-handed.
Larimer County, in Colorado, covers 3,500 workers and their families in its health plan. In 2018, county officials asked their insurer to share its negotiated rates. It refused.
“ We pushed the issue all the way to the C.E.O. level,” said Jennifer Whitener, the county’s human resources director. “They said it was confidential.”
Ms. Whitener, who previously managed employer insurance contracts for a major health insurer, decided to rebid the contract. She put out a request for new proposals that included a question about insurers’ rates at local hospitals.
A half dozen insurers placed bids on the contract. All but one skipped the question entirely.
“ They don’t want their secrets out there,” Ms. Whitener said. “They want to be able to tout that they’ve got the best deal in town, even if they don’t.”
Hospitals and insurers can also hide behind the contracts they’ve signed, which often prohibit them from revealing their rates.
“ We had gag orders in all our contracts,” said Richard Stephenson, who worked for the Blue Cross Blue Shield Association from 2006 until 2017 and now runs a medical price transparency start-up, Redu Health. (The association says those clauses have become less common.)
At Memorial Regional Hospital, in Florida, an M.R.I. costs ...
$1,827
with a Cigna plan.
$2,148
with a Humana plan.
$2,455
with a Blue Cross plan.
$262
with a Medicare plan.
Mr. Stephenson oversaw a team that made sure the gag orders were being followed. He said he thought insurers were “scared to death” that if the data came out, angry hospitals or doctors might leave their networks.
Warnings, but no fines
The Eichelberger family at home. Last summer Nathan, second from right, was bitten by a stray dog and needed a rabies shot. The family originally received an estimate that it would cost about $800 paying cash, but later received a surprise bill for over $2,000 more.Lindsay D’Addato for The New York Times
Ms. Eichelberger’s plan had a $3,500 deductible, so she worked hard to find the best price for her son’s care.
But neither the hospitals she called nor her insurer would give her answers.
She made her decision based on the little information she could get: a hospital, Layton, that said it would charge her $787 if she paid cash. The price for paying with insurance wouldn’t be available for another week or two, she was told.
But even the cash price didn’t turn out to be right: A few weeks after the visit, the hospital billed her an additional $2,260.
Itemized costs
It turns out that the original estimate left out a drug her son would need.
“ It was the most convoluted, useless process,” said Ms. Eichelberger, who was able to get the bill waived after five months of negotiations with the hospital.
Daron Cowley, a spokesman for Layton’s health system, Intermountain, said Ms. Eichelberger received the additional bill because “a new employee provided incomplete information with a price estimate that was not accurate.”
The health system declined to comment on prices at its hospitals, saying its contracts with insurers forbid discussing negotiations.
It’s not clear how much better the Eichelbergers would do today.
The new price data is often published in hard-to-use formats designed for data scientists and professional researchers. Many are larger than the full text of the Encyclopaedia Britannica.
And most hospitals haven’t posted all of it. The potential penalty from the federal government is minimal, with a maximum of $109,500 per year. Big hospitals make tens of thousands of times as much as that; N.Y.U. Langone, a system of five inpatient hospitals that have not complied, reported $5 billion in revenue in 2019, according to its tax forms.
As of July, the Centers for Medicare and Medicaid Services had sent nearly 170 warning letters to noncompliant hospitals but had not yet levied any fines.
Catherine Howden, a spokeswoman for the agency, said it expected “hospitals to comply with these legal requirements, and will enforce these rules.”
She added that hospitals that do not post prices within 90 days of a warning letter “may be sent a second warning letter.”
The agency plans to increase the fines next year to as much as $2 million annually for large hospitals, it announced in July.
The hospital that treated Ms. Eichelberger’s son has begun posting some information. But it has spread its prices across 269 web pages. To look for rabies, you have to check them all. It isn’t there.
At the Biggest U.S. Hospitals, Few Prices Are Available
Six months after the new rules took effect, The Times reached out to the 10 highest-revenue hospitals that had posted little or no data about their negotiated rates or cash prices. Here’s what they had to say:
“We will not be providing a statement or comment.”
N.Y.U. Langone has not published its negotiated rates or cash prices.
“Services that do not have a fixed payer-specific rate are shown as variable.”
Stanford Health Care has not published its cash prices. Of more than 300,000 possible combinations of insurance and medical treatment in its data file, it includes prices for 479.
“We do not post standard cash rates, which typically will not reflect the price of care for uninsured patients.”
Cedars-Sinai Medical Center, in Los Angeles, has not published its cash prices. The hospital initially posted a 2.5 GB data file composed almost entirely of more than one million lines that contained no data. After The Times inquired about the large file size, the hospital reduced it to a 1.4 MB file.
“We have listed the fixed rates where possible and, where that is not possible, have listed them as ‘variable.’”
U.C.S.F. Medical Center has not published its cash prices. Of more than eight million possible combinations of insurance and medical treatment in its data file, U.C.S.F. includes negotiated rates for 346. (U.C. Davis, which is part of the same system and has also not published its cash prices, sent an identical statement.)
“The resources we provide ensure that our patients know what kind of assistance is available to them and, ultimately, what a procedure will cost them — not us.”
Montefiore Medical Center, in the Bronx, has not published its negotiated rates or cash prices.
“Penn Medicine is committed to transparency about potential costs.”
The Hospital of the University of Pennsylvania added cash prices to its price transparency file after The Times inquired about why that data was missing.
“V.U.M.C. offers a toll-free number which consumers can call if they have questions about what they may be charged for services.”
Vanderbilt University Medical Center, in Nashville, has not published its negotiated rates or cash prices.
“Orlando Health has worked hard over the past several years to deliver helpful pricing information to its patients.”
Orlando Health has not published its negotiated rates or cash prices.
“”
Methodist Hospital (San Antonio) did not respond to multiple requests for comment. The hospital has not published its negotiated rates or cash prices.
“We are continuing to work on the machine-readable file that includes payer-negotiated rates. … It involves analyzing a daunting number of data points.”
Long Island Jewish Medical Center has not published its negotiated rates or cash prices.
The largest hospitals were chosen based on gross revenue reported to the Centers for Medicare and Medicaid Services in 2018, the most recent year with full data available.
Do you have a medical bill we should investigate? Share it with us.
The New York Times is exploring the wide variation in health care prices that patients face in the United States. Medical bills help us see the prices that hospitals and insurers often keep secret. If you have a medical bill that surprised you — maybe because of a high price, or an unexpected charge — we’d love to review it.
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https://www.nytimes.com/interactive/2021/08/22/upshot/hospital-prices.html
How to Avoid a Surprise Bill for Your Coronavirus Test
Get tested at a public facility. Question what services are being provided. And know your rights under federal law.
by Sarah Kliff - NYT - August 18, 2021
The Delta-variant-driven wave of coronavirus infections is driving a new surge in testing — and that could mean more surprise medical bills.
Congress wrote rules last spring to make most coronavirus testing free for all Americans. But patients, with or without insurance, have found holes in those coverage programs.
Federal law does not, for example, require insurers to cover the routine testing that a growing number of workplaces and schools are mandating. Some doctors and hospitals have tacked unexpected fees onto coronavirus testing bills, leaving patients with surprise charges ranging from a few dollars to over $1,000.
In the past year, I’ve collected patients’ bills related to coronavirus. As part of that project, I’ve read through more than 100 patient stories about coronavirus tests. Many patients are happy to report no charge at all, while others have been billed large unexpected fees or denied claims related to coronavirus tests.
[Have a bill you want to share? Submit it here.]
The surprise bills have hit uninsured Americans as well as those with robust coverage. The health data firm Castlight estimates that 2.4 percent of coronavirus test bills leave some share of the charge to consumers, which means there could be millions of patients facing fees they did not expect.
These are some simple steps you can take to lower your chances of becoming one of them.
If you can, get tested at a public site
Many states, counties and cities/towns now have public testing facilities. Very few patients have reported surprise medical bills from those testing sites (although it’s not impossible). You can typically use your state health department website to find public testing options.
If a public test site isn’t an option where you live, you might consider your primary care doctor or a federally qualified health clinic. The largest surprise coronavirus test bills I’ve reviewed tend to come from patients who are tested in hospitals and free-standing emergency rooms. Those places often bill patients for something called a facility fee, which is the charge for stepping into the room and seeking service.
Patients are finding that these fees can pop up even when they don’t actually set foot in the facility. Multiple patients at one Texas emergency room had $1,684 facility fees tacked onto their drive-through coronavirus tests. A patient in New York faced a $1,394 charge for her test at a tent outside a hospital. The majority of the bill was the facility fee. The investigative news site ProPublica has reported on how facility fees can sometimes cost as much as 10 times the coronavirus test itself.
If you get your test at a primary care provider, or at a public test site, you shouldn’t have to worry about that type of billing. They typically do not charge facility fees for coronavirus tests or any other types of care.
Ask your provider what they’ll bill you for
When patients receive a surprise medical bill related to a coronavirus test, often the charges they face are not for the test itself, but for other services that the patient may not have known about.
Some of these make sense: Many bills for coronavirus tests have fees for the doctor visit that went along with it. Others make less sense, like the bills that include screenings for sexually transmitted diseases. Those extra fees appear to be a bit more common in emergency rooms, or when health providers send their samples to outside laboratories. But they can happen at public testing sites, too: One Connecticut doctor regularly tested patients for dozens of illnesses at a town drive-through. The patients thought they were simply getting coronavirus tests.
To avoid those extra charges, ask your provider what diseases they will screen for. It can be as simple as saying: “I understand I’m having a coronavirus test. Are there any other services you’ll bill me for?” Having a better understanding of that up front can save you a headache later, and you can make an informed decision about what care is actually needed. If your providers can’t tell you what they’ll bill for, that may be a signal you want to seek care elsewhere.
Uninsured? Ask your doctor to bill the government, not you.
Uninsured patients have faced coronavirus bills upward of $1,000, according to billing documents reviewed by The New York Times.
That type of billing is legal: Health care providers are not required to provide free coronavirus tests to Americans who lack health insurance. But they do not necessarily have to bill patients directly. The federal government has set up a provider relief fund: Health providers can seek reimbursement for coronavirus testing and treatment provided to those without coverage. Once again, it pays to ask ahead of time how providers handle uninsured patients and whether they submit to the fund. Unfortunately, they are not required to do so — and could continue to pursue the debt.
You should also be aware that 17 states have authorized their state Medicaid plans to cover coronavirus test costs for uninsured Americans. This means your state government can pay the bill instead of you. You can find out if you live in one of these states here.
To challenge a surprise bill, know your rights under federal law
New federal laws regulate how health providers and insurers can bill patients for coronavirus tests. Understanding how they work can help you push back on charges that may not be allowed.
The new laws state that health insurers must cover coronavirus tests ordered by a doctor without any cost to the patients. This means that standard deductibles and co-payments you’d face for other services do not apply.
There is one important exception in those laws: Insurers do not have to cover routine coronavirus testing ordered by a school or workplace. If your job mandates that you get tested each week, for example, it is up to your health plan whether it wants to pay those bills.
For that type of testing, you’ll want to be especially careful about where you get tested, and ask more questions about the fees you may have to pay. Some employers are already directing their workers to be tested at public sites, in part to reduce the possibility of surprise charges.
For the coronavirus tests that insurers do have to cover, there is still a bit of a gray area. The law requires insurers to cover any other services that are necessary to get the coronavirus test, but doesn’t define what makes the cut. Most experts agree that a doctor visit fee is a pretty clear example of a service that ought to qualify, and that patients facing those types of bills ought to appeal to their insurer for coverage. Other services, like a flu test or even an X-ray conducted alongside a coronavirus test, present a murkier situation. If you’re facing fees like those, you might want to enlist your doctor to tell the insurer why the additional care was needed.
One last thing to know about the federal laws is that they require insurers to fully cover out-of-network coronavirus tests. This can be especially important for patients who go to an in-network doctor but unknowingly have their sample sent to an out-of-network laboratory, a situation I’ve seen many times. Your health plan’s typical rules for out-of-network care should not apply to the coronavirus test. They can, however, be applied to other parts of the test experience (the doctor visit fee, for example), so it is safer to stick with in-network providers whenever possible.
Receive an unexpected bill? Medical codes could be the culprit.
One other issue to look for is what billing codes your doctor used for the test visit. Many of the surprise bills I’ve reviewed involve doctors who charge a visit fee, then send the test to an outside laboratory that submits its own claim. The health plan might apply a co-pay to the doctor’s visit because it’s not clearly linked in billing records to the coronavirus test. In this case, you may need to work with your health provider to get your visit recoded to show a coronavirus test occurred.
Tell us what happened to you. It helps our journalism.
Nearly everything I know about coronavirus test billing comes from reading the bills that hundreds of Times readers have sent describing their experiences. If you receive a bill related to coronavirus testing and treatment, we ask that you take a moment to submit it here. It will help me continue to report on the types of fees patients face, and can help identify areas of the country where patients are facing unusually high fees.
