What Ails America
I was in Germany when I got sick. Late at night in Munich on December 3, 2019, I was admitted to a hospital with abdominal pain and then released the next morning. In Connecticut, on December 15, I was admitted to the hospital for an appendectomy and released after less than twenty-four hours. In Florida on vacation, on December 23, I was admitted to the hospital for tingling and numbness in my hands and feet but released the following day. Then I began to feel worse, with a headache and growing fatigue.
On December 27, we decided to return to New Haven. I had not been satisfied with treatment in Florida, and I wanted to be home. But it was my wife, Marci, who had to make the decisions and do the work. On the morning of the twenty-eighth, she packed everything up and got our two kids ready to go. I was a burden. I had to lie down to rest after brushing my teeth and after putting on each article of clothing. Marci arranged for wheelchairs at the airports and got us where we needed to be.
At the Fort Myers airport I sat in a wheelchair with the children on a curb while she returned the rental car. As she remembers the journey, “You were fading from life on the flight.” At the Hartford airport she wheeled me from the plane straight to a friend’s car and then stayed with the kids to wait for the luggage. Our friend had not known what was happening; she looked at me in the wheelchair, said “What have they done?” in Polish, shook her head, and got me into the front seat. I lay down flat as she sped to New Haven, because my head hurt less that way.
I struggled to get admitted to the emergency room in New Haven. I had to use a wheelchair to get from the parking lot to the lobby of the emergency department. Another friend, a doctor, was waiting for me there. When I was admitted to the emergency room at midnight, I used the word malaise to describe my condition to the doctor. My head ached, my hands and feet tingled, I was coughing, and I could barely move. Every so often I was seized by tremors.
Although I did not understand this then, I had a severe infection in my liver, which was leaking into my bloodstream. I had an abscess the size of a baseball in my liver, and the infection had spilled into my blood. I was in a condition known as sepsis; death was close.
The nurses guarding the entrance to the emergency room did not seem to take me seriously, perhaps because I did not complain, perhaps because the friend who advocated for me, though a physician, was a black woman. She had called ahead to say that I needed immediate treatment. That had no effect.
After the better part of an hour sprawled between a wheelchair and a table in the lobby, I finally got into the emergency department. Nothing much happened then, so I reflected on what I had seen as I stumbled from the lobby to an emergency room bed. I have been in emergency rooms in six countries, and have a feel for them. Like most American emergency departments, this one was overflowing, with beds lining the hallways. In Florida six days before, the overcrowding had been even more severe. I felt lucky in New Haven that night to get a small area to myself: not a room, but a sort of alcove separated by a yellow curtain from the dozens of other beds outside.
After a while, the curtain started to bother me. Getting attention in emergency rooms is a matter of figuring out who staff are and catching someone’s eye. I couldn’t see people passing when the curtain was closed, and so it was hard to decipher the uniform colors and the name badges and ask for help. The first doctor who opened the curtain decided that I was tired, or perhaps had the flu, and gave me fluids. My disconcerted doctor friend tried to suggest that my condition was something more serious.
“This is someone who was running races,” she said. “And now he cannot stand up.”
My friend told the resident that this was my second emergency room visit within a few days, so extra attention was warranted. The resident left unconvinced, and with the curtain partway open behind her, I caught a glimpse then of the two nurses who had admitted me and heard what they said as they passed: “Who was she?” “She said she was a doctor.” They were talking about my friend. They laughed. I couldn’t write this down then but did later in the diary I kept while I was in the hospital: racism hurt my life chances that night; it hurts others’ every moment of their lives.
I was tested, slowly, for flu, for this and that, with little result. I had undergone my appendectomy in the same hospital two weeks earlier, but no one in the emergency department seemed inclined to look at my electronic record. I had brought a folder with the printouts and a CD from the Florida hospital, and I had just enough presence of mind to offer it to the doctors. They were not interested. “We do things our own way,” said the resident. The doctors and nurses seemed unable to complete a sentence, let alone think about my case as something with a history.
I could see, or rather hear, why they were distracted.
A drunk beyond the curtain to the right, an older lady from the sound of her voice, kept crying out “Doctor!” or “Nurse!” A second alcoholic, to the left, was a loquacious homeless man. When asked for his belt, he riffed on the idea of the “Belt of Orion,” comparing himself to the hunter and rapist of Greek mythology. Whenever approached by a female doctor or nurse, he said, “You belong to me; don’t try to fight it.” One of the nurses declared that she didn’t belong to anyone.
Two policemen sat just beyond the curtain, observing two wounded young men. With nothing much to do, the cops moved closer together, just in front of my curtain, and loudly talked the night away. I learned how the police department organizes its shifts. I heard stories of drunk driving, abandoned vehicles, domestic assault, and, the favorite theme, rumbles in the open air that the police were powerless to stop. Some of the stories were funny, like the one about the woman who was caught, shovel in hand and dirt on her knees, undoing the gardening work of her neighbor.
The two police officers preferred different topics: the one bureaucracy, the other criminality. The one who liked to talk about crimes used the terms unperson and unpeople. In George Orwell’s novel 1984, an unperson is someone who has been expunged by the state, someone of whom all trace has been erased. It seemed, though, that the policeman had in mind African Americans he regarded as criminals. I wanted to speak to him about that but lacked the strength.
I was fading. After three hours in my alcove, my fever reached 104. My blood pressure crashed: 90/50, 80/40, 75/30, 70/30. I was hanging somewhere in between. Sepsis kills people, and mine was not being treated.
*
Malaise means weakness and weariness, a sense that nothing works and nothing can be done. Malaise is what we feel when we have a malady. Malaise and malady are good old words, from French and Latin, used in English for hundreds of years; in American Revolutionary times they meant both illness and tyranny. After the Boston Massacre, a letter from prominent Bostonians called for an end to “the National and Collonial Malady.” The Founding Fathers wrote of malaise and malady when discussing their own health and that of the republic they founded.
In America today, malady is physical illness and the political evil that surrounds it. We are ill in a way that costs us freedom, and unfree in a way that costs us health. Our politics are too much about the curse of pain and too little about the blessings of liberty.
When I got sick, freedom was on my mind. As a historian, I had spent twenty years writing about the atrocities of the twentieth century. Recently I have been thinking about how history defends against tyranny in the present and safeguards freedom for the future. The last time I stood before an audience, I was giving a lecture about how America could become a free country. I hurt that evening, but I did my job, and then I went to the hospital. What followed has helped me to think more deeply about freedom, and about America.
When I stood before the lectern in Munich on December 3, I had appendicitis. That condition was overlooked by German doctors. My appendix burst, and my liver became infected. At the time of my appendectomy, the doctors in New Haven had noted a lesion in my liver but had neglected to treat it, or examine it again, or order another test, or even mention it to me. I was discharged from the hospital the day after that surgery, December 16, with too few antibiotics and no information about that second infection. When I was admitted to the hospital in Florida on December 23 with tingling and numbness in my limbs, I had not known to tell the doctors about my liver. Again, I was discharged after a day.
In the emergency room in New Haven on December 29, everyone dismissed the possibility that my condition had to do with my appendix or my recent surgery. It seemed unthinkable to the doctors in New Haven that their colleagues had done something wrong. This sort of clan thinking is an elementary error, the kind we all make under stress.
The doctors in New Haven did think that the doctors in Florida might have made a mistake. As it became clear that I had some kind of bacterial infection, they suspected meningitis arising from a spinal tap performed in Florida. The New Haven doctors therefore performed a second spinal tap but were distracted even as they punctured my back and searched for the spinal fluid. The resident made an obvious mistake, penetrating my spine through the wound of the previous puncture, which is to say at the putative site of infection. The attending physician had to tell her to pull the needle back out.
People are much poorer at almost every task when they are close to a cell phone; both physicians had kept theirs turned on and close by. I was hunched over a bed with my face against a wall; I know that their phones were present because they rang three times during the procedure. The first was the most memorable. After reinserting the long needle in my spine at a second point, the resident jumped in reaction to her ringtone. Bent over the railing of my bed, I did my best not to move.
My body was at the mercy of the doctors’ permanent distraction. My friend had called the surgeon who performed my appendectomy; she did not remember the liver finding and did not, at this or any other time, mention that it was in the record. If the attending physician and the resident in the emergency department hadn’t been distracted, they could have taken a moment to look up the record of my previous surgery themselves, noted the liver problem, and spared me the second spinal tap. If they had been able to talk to me for a moment longer, I could have shown them my Florida record, which indicated elevated liver enzymes, a clue as to what was happening. I had even circled those results on the paper, but I couldn’t get anyone to pay attention to them. If the two doctors had silenced their cell phones before the spinal tap, they could have done what they thought they needed to without shaking a needle in my spine.
Like everything that happened, this wasn’t my bad luck or the doctors’ bad intentions. It is the nature of the system that doctors are harried and make mistakes.
On December 29, after seventeen hours in the emergency room, I had an operation on my liver. Lying on my back in a hospital bed early the next morning, tubes in my arms and chest, I couldn’t ball my fists, but I imagined that I was balling my fists. I couldn’t raise my body from my bed on my forearms, but I had a vision of myself doing so. I was one more patient in one more hospital ward, one more set of failing organs, one more vessel of infected blood. But I didn’t feel that way. I felt like an immobilized, infuriated me.
When I look now at the pages of my hospital journal, stained by saline, alcohol, and blood, I see that the New Haven sections, from the last days of the year, concern the powerful emotions that rescued me when I was near death. The first words I wrote in New Haven were “only rage lonely rage.” I have felt nothing cleaner and more intense than rage amid deathly illness. It came to me in the hospital at night, giving me a torch that ignited amid kinds of darkness I hadn’t before known.
Had I died, my death would have been all too typical, a passing into sad statistics. Far too many Americans have needlessly departed life this year. Far too many Americans are too close to death all the time. Although we have been promised ever-longer lives, life expectancy in our country peaked six years ago, in 2014.
The beginning of life in this country is frightening and uncertain. Care of expectant mothers is wildly uneven and grossly inadequate. Black women often die in childbirth, and so do their babies. The mortality rate of babies borne by African-American women is higher than in seventy other countries. America as a whole does worse than forty countries in infant mortality. Young adulthood has lost its charm. Unless something changes, millennials will live shorter lives while spending more money on health care than Gen-X parents or boomer grandparents. The prime of life is not what it once was. Middle-aged white men are committing suicide and drugging themselves to death in astonishing numbers. Middle-aged white women in the South are dying before their time.
Our system of commercial medicine, dominated by private insurance, regional groups of private hospitals, and other powerful interests, looks more and more like a numbers racket. We would like to think we have health care that incidentally involves some wealth transfer; what we actually have is wealth transfer that incidentally involves some health care. If birth is not safe, and is less safe for some than for others, then something is wrong. If more money is extracted from young adults for health care, but they are less well than older generations, something is wrong. If the people who used to believe in the country are killing themselves, something is wrong. The purpose of medicine is not to squeeze maximum profits from sick bodies during short lives but to enable health and freedom during long ones.
Our malady is particular to America. We die younger than people in twenty-three European countries; we die younger than people in Asia (Japan, South Korea, Hong Kong, Singapore, Israel, and Lebanon); we die younger than people in our own hemisphere (Barbados, Costa Rica, Chile); we die younger than people in other countries with histories of British settlement (Canada, Australia, New Zealand). Other places keep passing us in the longevity charts. In 1980, when I was ten, Americans lived on average about a year less than inhabitants of countries of comparable wealth. By 2020, when I was fifty, the difference in life expectancy had grown to nearly four years. It is not that other countries have more knowledge or better doctors. It is that they have better systems.
The gap between the United States and other countries grew in 2020, since no democracy mishandled the coronavirus pandemic as we have done. People in Japan and Germany, in South Korea and Austria, and indeed in all rich democracies, were at less risk than we were, because their governments treated them better, and because they had better access to information and care. It was already far too easy to die in this country before the novel coronavirus arrived in the United States. Our botching of a pandemic is the latest symptom of our malady, of a politics that deals out pain and death rather than security and health, profit for a few rather than prosperity for the many.
The new coronavirus ought to have been taken seriously from the time of my hospitalization, which is when it was documented. In January 2020, we should have acquired a test for the novel coronavirus, tracked the new disease down, and limited its reach. This could easily have been done. Far poorer countries did it. Americans infected with the coronavirus should all have had access to hospital beds and ventilators, and the doctors and nurses who treated them should have had enough masks and gowns. A virus is not human, but it is a measure of humanity. We have not measured up well. Some two hundred thousand Americans are dead for no reason at all.
Our malady makes pollution deaths, opioid deaths, prison deaths, suicides, newborn deaths, and now mass graves for the elderly all too familiar. Our malady goes deeper than any statistic, deeper even than a pandemic. There are reasons why we are living shorter, unhappier lives. There are reasons why a president thinks he can keep Americans ignorant during a pandemic and exploit our confusion and pain. Our malady leaves us isolated, uncertain where to turn when we hurt.
America is supposed to be about freedom, but illness and fear render us less free. To be free is to become ourselves, to move through the world following our values and desires. Each of us has a right to pursue happiness and to leave a trace. Freedom is impossible when we are too ill to conceive of happiness and too weak to pursue it. It is unattainable when we lack the knowledge we need to make meaningful choices, especially about health.
The word freedom is hypocritical when spoken by the people who create the conditions that leave us sick and powerless. If our federal government and our commercial medicine make us unhealthy, they are making us unfree.
“The whole history of the progress of human liberty,” as Frederick Douglass reminds us, “shows that all concessions yet made to her august claims have been born of earnest struggle.” It will be a struggle to heal our malady. The struggle begins when we claim health care as a human right.
*
My body was not well cared for during the early hours of December 29. Fluids brought my blood pressure up some, but no meaningful treatment took place. The doctors and nurses could not spend more than a few seconds at a time with me and rarely made eye contact. They ran their blood work, forgot the results, misreported them, ran off. The permanent distraction of doctors and nurses is a symptom of our malady. Each patient has a story, but no one is following the story.
For five hours, from about one to about six in the morning, I had trouble remaining conscious. While I was in this suspended state, the sounds from beyond the curtain never ceased. My brain formed the words uttered by everyone around me, but I was no longer mediating the stimuli. I was not in charge, or there was not enough left of me to be in charge. The policemen’s conversation kept coming through, as did the drunken shouts, the squeak of shoes on the floor, the wheeze of an automatic door, the slap of a hand on the button that opened it, the knock of a bed against it. The curtain to my alcove followed the bodies of people passing by or danced with a draft from beyond.
When I closed my eyes in the early morning hours, I could still see the moving curtain. The rippling became hypnotically regular, from right to left, like an invertebrate sea creature undulating with the waves. The color of the curtain deepened from yellow to ochre. An inky black around the edges replaced the fluorescent white of the lights outside.
Each time I closed my eyes, the rippling ochre curtain beckoned. I tried to keep them open. The blood pressure reading behind me provided a point of focus. Each time I turned back from my vital signs toward the curtain, though, I would eventually have to close my eyes. Then the color of the curtain would change to ochre, its movements would become darkly voluptuous, and I would remember.
My whole life did not rush before my eyes. It was rather that my ability to suppress memories dissolved. A few images of childhood came on heavy, with punching force. I could no longer induce them to make way for other memories or for new thoughts. It was strange to be a spectator of the real, rather than a referee.
The memories of adulthood were less about what befell me and more about what I learned from others. When I concentrate on what I read, I have a very good memory. Much of my thirties and forties I spent reading first-person accounts of the Holocaust and other German crimes, Stalinist mass shootings and famine, ethnic cleansings, and other atrocities. These came now, too, unbidden, a thousand jabs: one after the other, book after book, document after document, photograph after photograph.
Something in me paused over a Jewish orphan taken in by childless Ukrainian peasants: “You will be like a daughter to us,” they said, she remembered, I remembered. Something in me hesitated over the story of a woman whose special gift, as she hid Jews in her apartment, was to behave as if nothing extraordinary were taking place. Poise. Existential poise. A certain photograph I had looked at regularly for twenty-five years appeared before my eyes again: a Polish Jew named Wanda, full of self-possession. Wanda had refused the German command to go to the Warsaw ghetto in 1940 and kept her two boys safe throughout the war. Her husband, their father, was murdered.
It went on, the black and white of remembered words and images, the ochre curtain rippling in the background, neither near nor far, neither on this side nor that. I was with others. At first I was uneasy with the society of the dead, but this passed. I had learned from them. In some way I remembered what they remembered. Wanda’s younger son grew up to become a historian, who approved my dissertation fifty-five years after his mother had saved him from the ghetto. Twenty years after that, I found the record of what his mother had done and wrote about it myself. Life is not just inside people; it passes through people.
It was the ochre curtain I didn’t like; it was the passage into death, repulsive and seductive, that I feared. I never drew it in my diary; I remember it too well.
I was in sepsis for a long time. Britain’s National Health Service recommends that antibiotics be administered to a septic patient no later than one hour after admission to a hospital. My father-in-law, a physician, was trained that the doctor should see to this personally. In my case I had to wait eight hours, until after that surreal second spinal tap. Nine hours after that test’s negative result, the curtain was drawn, and my bed was pulled from the alcove into an operating room. Someone had finally looked at my scans from the time of the appendectomy and noticed the neglected liver problem. A new scan then showed that the abscess in my liver had grown very large during the two weeks it was ignored. After an urgent procedure to drain my liver, I was wheeled to a hospital room, the one where I would spend the last two days of 2019 and the early part of 2020. After my postoperative care was mishandled, I underwent another procedure on my liver, to add two more drains.
I was released weeks later with nine new holes in me: three from the appendectomy, three for liver drains, two from spinal taps, and one in my arm for the tube that channeled the antibiotics I inject. My hands and feet are still tingling, from what my neurologist now believes is nerve damage caused by my immune system when it reacted to an overwhelming threat.
As I write, I am still in treatment: taking medication, undergoing tests, and seeing doctors. For me, writing is part of the treatment. My own malaise has meaning only insofar as it helps me understand our broader malady. I remember places where I should not have been, things that should not have happened, not to me nor to anyone else, and I want to make sense of them.
After I was discharged from the hospital in New Haven, I heard that colleagues were astounded that my wife and I hadn’t called in powerful patrons to protect me when I was in the emergency room. That had not occurred to us. If the system does work that way, it should not. If some Americans have access to health care thanks to wealth or connections, they will feel pleased because they are included and others are not. Such a feeling turns our human concern about health into a silent yet profound inequality that undermines democracy. When everyone has access to decent care at minimal cost, as is true for almost all of the developed world, it is easier to see fellow citizens as equal.
Part of our malady is that there is nothing in our country, not even life and not even death, where we take the proposition that “all men are created equal” seriously. If health care were available to everyone, we would be healthier not only physically but also mentally. Our lives would be less anxious and lonely because we would not be thinking that our survival depended on our relative economic and social position. We would be profoundly more free.
Since health is so elemental to existence, confidence about care is an important part of freedom. If everyone can assume that treatment will be available when necessary, they can turn their minds and their resources to other matters, make freer choices, pursue greater happiness. If, on the other hand, people think that care is preferential, then those who are on the inside start to take pleasure from the suffering of those who are on the outside. If health care is a privilege rather than a right, it demoralizes those who get it and kills those who do not. Everyone is drawn into a sadistic system that comes to seem natural. Rather than pursuing happiness as individuals, we are together creating a collective of pain.
And so our malady concerns us all. We all take part in the collective of pain. Those of us who are doing better are harming those who are less well-off. When health care is competitive the winners do wrong to others, but they also get worse care themselves. Distracted by their relative advantage, they do not see that by harming others they are also harming themselves. If health care were a right, we would all have better access to treatment and would all be liberated from the collective of pain. Health care should be a right, not a privilege, for the sake of our bodies, and for the sake of our souls.
A Doctor Went to His Own Employer for a COVID-19 Antibody Test. It Cost $10,984.
Physicians Premier ER charged Dr. Zachary Sussman’s insurance $10,984 for his COVID-19 antibody test even though Sussman worked for the chain and knows the testing materials only cost about $8. Even more surprising: The insurer paid in full.
by Marshall Allen - ProPublica - September 5, 2020
When Dr. Zachary Sussman went to Physicians Premier ER in Austin for a COVID-19 antibody test, he assumed he would get a freebie because he was a doctor for the chain. Instead, the free-standing emergency room charged his insurance company an astonishing $10,984 for the visit — and got paid every penny, with no pushback.
The bill left him so dismayed he quit his job. And now, after ProPublica’s questions, the parent company of his insurer said the case is being investigated and could lead to repayment or a referral to law enforcement.
The case is the latest to show how providers have sometimes charged exorbitant prices for visits for simple and inexpensive COVID-19 tests. ProPublica recently reported how a $175 COVID-19 test resulted in charges of $2,479 at a different free-standing ER in Texas. In that situation, the health plan said the payment for the visit would be reduced and the facility said the family would not receive a bill. In Sussman’s case, the insurer paid it all. But those dollars come from people who pay insurance premiums, and health experts say high prices are a major reason why Americans pay so much for health care.
Sussman, a 44-year-old pathologist, was working under contract as a part-time medical director at four of Physicians Premier’s other locations. He said he made $4,000 a month to oversee the antibody tests, which can detect signs of a previous COVID-19 infection. It was a temporary position holding him over between hospital gigs in Austin and New Mexico, where he now lives and works.
In May, before visiting his family in Scottsdale, Arizona, Sussman wanted the test because he had recently had a headache, which can be a symptom of COVID-19. He decided to go to one of his own company’s locations because he was curious to see how the process played out from a patient’s point of view. He knew the materials for each antibody test only amounted to about $8, and it gets read on the spot — similar to an at-home pregnancy test.
He could even do the reading himself. So he assumed Physicians Premier would comp him and administer it on the house. But the staff went ahead and took down his insurance details, while promising him he would not be responsible for any portion of the bill. He had a short-term plan through Golden Rule Insurance Company, which is owned by UnitedHealthcare, the largest insurer in the country. (The insurance was not provided through his work.)
During the brief visit, Sussman said he chatted with the emergency room doctor, whom he didn’t know. He said there was no physical examination. “Never laid a hand on me,” he said. His vitals were checked and his blood was drawn. He tested negative. He said the whole encounter took about 30 minutes.
About a month later, Golden Rule sent Sussman his explanation of benefits for the physician portion of the bill. The charges came to $2,100. Sussman was surprised by the expense but he said he was familiar with the Physicians Premier high-dollar business model, in which the convenience of a free-standing ER with no wait comes at a cost.
“It may as well say Gucci on the outside,” he said of the facility. Physicians Premier says on its website that it bills private insurance plans, but that it is out-of-network with them, meaning it does not have agreed-upon prices. That often leads to higher charges, which then get negotiated down by the insurers, or result in medical bills getting passed on to patients.
Sussman felt more puzzled to see the insurance document say, “Payable at: 100%.” So apparently Golden Rule hadn’t fought for a better deal and had paid more than two grand for a quick, walk-in visit for a test. He was happy not to get hit with a bill, but it also didn’t feel right.
He said he let the issue slide until a few weeks later when a second explanation of benefits arrived from Golden Rule, for the Physicians Premier facility charges. This time, an entity listed as USA Emergency sought $8,884.16. Again, the insurer said, “Payable at: 100%.”
USA Emergency Centers says on its website that it licenses the Physicians Premier ER name for some of its locations.
Now Sussman said he felt spooked. He knew Physicians Premier provided top-notch care and testing on the medical side of things. But somehow his employer had charged his health plan $10,984.16 for a quick visit for a COVID-19 test. And even more troubling to Sussman: Golden Rule paid the whole thing.
Sussman was so shaken he resigned. “I have decided I can no longer ethically provide Medical directorship services to the company,” he wrote in his July 13 resignation email. “If not outright fraudulent, these charges are at least exorbitant and seek to take advantage of payers in the midst of the COVID19 pandemic.”
Sussman agreed to waive his patient privacy so officials from the company could speak to ProPublica. USA Emergency Centers declined interview requests and provided a statement, saying “the allegations are false,” though it did not say which ones.
The statement also said the company “takes all complaints seriously and will continue to work directly with patients to resolve issues pertaining to their emergency room care or bill. …The allegations received pertain to a former contracted employee, and we cannot provide details or further comment at this time.”
Physicians Premier advertises itself as a COVID-19 testing facility on its website, with “results in an hour.” According to the claims submitted by Physicians Premier to Golden Rule, obtained by Sussman, the physician fee and facility fees were coded as emergency room visits of moderate complexity. That would mean his visit included an expanded, problem-focused history and examination. But Sussman said the staff only took down a cursory medical history that took a few minutes related to his possible exposure to COVID-19. And he said no one examined him.
The claims also included codes for a nasal swab coronavirus test. But that test was not performed, Sussman said. The physician’s orders documented in the facility’s medical record also do not mention the nasal swab test. Those charges came to $4,989.
The claims show two charges totaling $1,600 for the antibody test Sussman received. In a spreadsheet available on its website on Friday, Physicians Premier lists a price of $75 for the antibody test.
For comparison, Medicare lists its payment at $42.13 for COVID-19 antibody tests. That’s because Medicare, the government’s insurance plan for the disabled and people over 65, sets prices.
Complicating matters, Texas is the nation’s epicenter for free-standing emergency rooms that are not connected to hospitals. Vivian Ho, an economist at Rice University who studies the facilities, said their business model is based on “trying to mislead the consumer.” They set up in locations where a high proportion of people have health insurance, but they don’t have contracted rates with the insurers, Ho said. They are designed to look like lower-priced urgent care centers or walk-in clinics, Ho said, but charge much higher emergency room rates. (The centers have defended their practices, saying that they clearly identify as emergency rooms and are equipped to handle serious emergencies, and that patients value the convenience.)
The day after he resigned, Sussman texted an acquaintance who works as a doctor at Physicians Premier. The acquaintance said the facility typically only collects a small percentage of what gets billed. “I just don’t want to be part of the game,” Sussman texted to him.
Shelley Safian, a Florida health care coding expert who has written four books on medical coding, reviewed Sussman’s medical records and claims at ProPublica’s request. The records do not document a case of a complex patient that would justify the bills used to code the patient visit, she said. For example, the chief complaint is listed as: “A generic problem (COVID TESTING).” Under “final acuity,” the medical record says, “less urgent.” Under the medical history it says, “NO SYMPTOMS.”
Safian described the charges as “obscene” and said she was shocked the insurer paid them in full. “This is the exact opposite of an employee discount,” she said. “Obviously nobody is minding the store.”
Congress opened the door to profiteering during the pandemic when it passed the CARES Act. The legislation, signed into law in March, says health insurers must pay for out-of-network testing at the cash price a facility posts on its website, or less. But there may be other charges associated with the tests, and insurers generally have tried to avoid making patients pay any portion of costs related to COVID-19 testing or treatment.
The charges for Sussman’s COVID-19 test visit are “ridiculous,” said Niall Brennan, president and CEO of the Health Care Cost Institute, a nonprofit organization that studies health care prices. Brennan wondered whether the CARES Act has made insurers feel legally obligated to cover COVID-19 costs. He called it “well intentioned” public policy that allows for “unscrupulous behavior” by some providers. “Insurance companies and patients are reliant on the good will and honesty of providers,” Brennan said. “But this whole pandemic, combined with the CARES Act provision, seems designed for unscrupulous medical providers to exploit.”
It’s illegal for medical providers to charge for services they did not provide. But ProPublica has previously reported how little insurers, including UnitedHealthcare, do to prevent fraud in their commercial health plans, even though experts estimate it consumes about 10% of all health care costs. For-profit insurance companies don’t want to spend the time and money it takes to hold fraudulent medical providers accountable, former fraud investigators have told ProPublica. Also, the insurance companies want to keep providers in their networks, so they easily cave.
In mid-July, Sussman used the messenger system on Golden Rule’s website to report his concerns about the case. Short-term health plans are typically less expensive because they offer less comprehensive coverage. Sussman said he appreciated that his plan covered the charges, and felt compelled to tell the company what had happened.
That led to a phone conversation with a fraud investigator. They went line by line through the charges and Sussman told him many of the services had not been provided. “His attitude was kind of passive,” Sussman said of the fraud investigator. “There was no indignation. He took in stride, like, ‘Yep, that’s what happens.’” The investigator said he would escalate the case and see if the facility had submitted any other suspect claims. But Sussman never heard back.
Maria Gordon-Shydlo, a spokeswoman for UnitedHealthcare, which owns Golden Rule, would not provide anyone to be interviewed. She said in an emailed statement that the company’s first priority during the pandemic “has been to ensure our members get the care they need and are not billed for COVID testing and treatment. Unfortunately, there are some providers who are trying to take advantage of this and are inappropriately or even fraudulently billing.”
“Golden Rule has put processes in place to address excessive COVID-related billing,” the statement said. “We are currently investigating this matter and, if appropriate, will seek to recoup any overpayment and potentially refer this case to law enforcement.”
Golden Rule’s 100% payment of the charges may simply come down to “incompetence,” said Dr. Eric Bricker, a Texas internist who spent years running a company that advised employers who self-fund their insurance. Insurance companies auto-adjudicate millions of claims on software that may be decades old, said Bricker, who produces videos to help consumers and employers understand health care. If bills are under a certain threshold, like $15,000, they may sail through and get paid without a second look, he said.
UnitedHealth Group reported net earnings of $6.6 billion in the second quarter of 2020. Bricker said the company may be paying bills without questioning them because it doesn’t “want to create any noise” by saying no at a time its own earnings are so high, Bricker said.
Texas has a consumer protection law that’s designed to prevent businesses from exploiting the public during a disaster. The attorney general’s office has received and processed 52 complaints about health care businesses and billing or price gouging related to the pandemic, a spokeswoman from the office said in an email. The agency does not comment on the existence of any investigations, but has not filed any cases related to overpriced COVID-19 tests.
Sussman said he got one voicemail from a billing person at Physicians Premier, saying she wanted to explain the charges, but he did not call back. He said he spoke out about it to ProPublica because he opposes Medicare-for-all health care reform proposals. Bad actors in the profession could cause doctors to lose their privilege to bill and be reimbursed independently, he said. Most physicians are fair with their billing, or even conservative, he said. “If instances like these go unchecked it will provide more ammo for advocates of a single-payer system.”
Choosing the Wrong Health Insurance Could Kill You
By examining what happens to outcomes when Medicare Advantage beneficiaries switch from one privately managed health insurance plan to another, Yale SOM’s Jason Abaluck and his co-authors calculated that the plans appreciably influence the survival rates of their enrollees. Shutting down the plans with the highest mortality rates could save thousands of lives per year.
Choosing a health insurance plan is among the most important consumer decisions we make—and, for many of us, among the most bewildering. Do you pick the plan with the lowest out-of-pocket cost, or the one that allows you to see the primary care physician you trust?
Do you care more about prescription drug benefits or mental health coverage? One thing that doesn’t end up on most pro/con lists is whether a particular plan is likely to prolong your life. But new research co-authored by Yale SOM’s Jason Abaluck shows that insurance plans appreciably influence the survival rates of their enrollees.
Despite the variation in mortality effects, consumers aren’t flocking to the plans most likely to benefit their health—not necessarily because they don’t care, but because they aren’t well informed about how plans affect health outcomes, the researchers found.To Abaluck, the research reveals not only a policy failure to guide consumers toward the best choices, but also a “fundamental breakdown in current private [insurance] markets: they have way too little incentive to invest in things that will actually make people healthier.”
Studying how insurance plans affect mortality has long vexed policy makers and economists—Abaluck included. It’s hard to disentangle the people from the plan, he explains: “If you see that a plan has a low mortality rate, it might just be that younger, healthier nonsmokers with fewer medical conditions chose that plan.” Researchers can control for some of those factors, such as age, but others, such as diet, exercise, and stress, resist statistical analysis.
To understand health plan mortality effects, Abaluck and his co-authors focused on the Medicare Advantage market, which covers about a third of all Medicare beneficiaries and allows them to pick from a variety of privately managed plans subsidized by the government. Participants have lots of options: in 2010, for example, 33 different Medicare Advantage plans operated in a typical U.S. county. The researchers’ data set included more than 15 million Medicare Advantage enrollees and the plans offered to them between 2006 and 2011.
With the wealth of choices on the Medicare Advantage market comes a large variation in mortality rates, the researchers discovered. Within the same county, even controlling for basic demographic factors, plans’ mortality rates were “super different,” Abaluck says. “There are some plans where 2% of people die in a year, and some plans where 8% of people die. Of course, that raises the question: is that because those plans enroll healthier people, or because those plans are actually making people healthier?”
The ideal way to answer this question would be to randomly assign people to different Medicare Advantage plans. But since that’s not possible, Abaluck and his co-authors looked for a creative way to approximate a randomized controlled trial. Plan terminations, they realized, offered just such an opportunity. Sometimes Medicare Advantage plans are terminated, forcing enrollees to pick a new option, creating “a kind of experiment,” Abaluck says.
Of particular interest to the researchers was the fate of people forced to leave plans with especially low and especially high mortality rates. These individuals tended to end up in plans with more middle-of-the-road mortality rates.
If the terminated plans had low mortality rates because they happened to have healthy enrollees, you’d expect to see those individuals’ mortality rates stay the same when they moved into new plans. But if the plans themselves were affecting health outcomes, then you’d expect to see mortality rates change as patients switched plans.
And that’s exactly what Abaluck and his co-authors found: “If people are reassigned from a good plan to an average plan, they get much sicker. If they are reassigned from a bad plan, they get much healthier,” Abaluck says.
So why aren’t consumers all opting for the most life-prolonging plans? While mortality rates aren’t publicly available, there is other information to guide consumers in their choices—most notably, star ratings from the Centers for Medicare and Medicaid Services (CMS), a measure of quality you might expect would correlate with mortality.
But it turns out that CMS star ratings, which are calculated based on factors including customer satisfaction, have no relationship to mortality rates. “Whether a plan has five stars or two stars tells you nothing about whether that plan is likely to make you live longer,” Abaluck says. In other words, one of the few pieces of information consumers have when making their choice doesn’t help them select plans with low mortality rates.
In fact, the researchers found only one easily accessible piece of information that corresponded with plan mortality rates: price. Plans with higher premiums and more generous prescription drug coverage “do appear to have better outcomes,” Abaluck notes, though most of the variation in whether plans extend your life is not explained by these factors.
Ultimately, it’s not surprising that Medicare Advantage participants aren’t picking the best plans: “They don’t have the information they need,” Abaluck says. As a result, they are “way, way less sensitive to mortality effects than they would be if they fully understood the differences across these plans.”
To Abaluck, the research suggests several ways to make the Medicare Advantage work better for Americans. For example, regulators could simply remove the plans with the highest mortality rates from the market. Eliminating the worst 5% of plans, the researchers estimate, could save around 10,000 elderly lives each year. The government could also require plans to provide life insurance—creating a strong financial incentive to meaningfully improve the health of enrollees.
And CMS could change how it calculates star ratings to include mortality rates. This is important not just because it would better inform consumers, but also because star ratings also affect the rate at which plans are reimbursed by the government.
Hospitals wrangle over need for Topsham surgery center
Presidents of Lewiston-based Central Maine Healthcare, which is proposing an ambulatory surgery center, and Brunswick-based Mid Coast-Parkview Health, which opposes the proposal, have made their cases before Topsham selectmen in recent weeks.
by Darcie Moore - Times Record - September 8, 2020
TOPSHAM — Two Maine hospitals have locked horns over a proposed Topsham health care facility and are trying to sway public opinion to their side.
Lewiston-based Central Maine Healthcare’s proposed ambulatory surgery center at the Topsham Fair Mall would have two operating rooms and four procedure rooms. It would offer specialties including ear, nose and throat, urology, general surgery, sports medicine, plastic surgery and other basic outpatient services.
Brunswick-based Mid Coast-Parkview Heath has argued the facility isn’t needed.
Topsham Selectman David Douglass said Central Maine Healthcare reached out and asked to present project plans to selectmen. When that presentation appeared on selectmen’s Aug. 20 meeting agenda, it prompted about 20 emails from residents urging selectmen to oppose the proposal. One email was in favor, Douglass said.
Douglass said Lois Skillings, the CEO and president of Mid Coast-Parkview, have asked to make a rebuttal.
Douglass has said selectmen are not taking a position on the project or voting on it in any way. He said the center would be reviewed by the planning board.
“Our plans are to continue to make presentations to educate the general public about what we’re trying to do to extend our mission; to extend our capabilities to provide care locally at high quality and affordable costs in a convenient manner,” Central Maine Healthcare President and CEO Jeffrey Brickman told selectmen on Aug. 20.
On Thursday, Skillings told selectmen that the proposed surgery center duplicate services already available in the Midcoast, and that it would disrupt health care delivery in the region. It would also deliver a significant financial blow to Mid Coast-Parkview Health that would raise local health care costs, she said.
Surgery and X-ray are the only parts of health care that make any contribution margin at all, “and when that is taken away from the comprehensive health care system, it leaves the health care system with only the parts of the system that are not paid,” Skillings said.
Before opening the center, Central Maine Healthcare must receive approval for a certificate of need from the Maine Department of Health and Human Services. The public hearing for that application closed on Aug. 21.
Jackie Farwell, spokesperson for the Maine Department of Health and Human Services, said Central Maine Healthcare’s proposal drew 150 comments from the public. The department will prepare a preliminary analysis that will be released to the public for another 10-day comment period.
“We would expect further comments during that period, then, barring any action on the part of either party, the Commissioner would reach a decision,” Farwell said Friday. “There is no set timeline for that decision.”
This is not the first time Mid Coast-Parkview Health, formerly Mid Coast Health Services, has squared off against Central Maine Healthcare during such a review. In 2012 both submitted applications for a certificate of need from DHHS to assume operations at Parkview Adventist Medical Center in Brunswick.
Ultimately, Mid Coast Health won that battle and merged with Parkview in 2015.
https://www.pressherald.com/2020/09/07/hospitals-wrangle-over-need-for-topsham-surgery-center/
