When big money floods into health care, the results can be crazy and corrosive

medpricehikes-210x300With Americans spending more than $3 trillion annually on health care, the corrosive and crazy effects of all that big money can become almost common place. Even still, hospitals, doctors, and Big Pharma still manage to come up with plenty of, Aw, really, c’mon kinds of financial situations.

Recent news reports, for example, have focused on such dubious dollars and cents concerns like: bedside loans, disparities (price gouging) in cancer care, and, of course, skimpy health insurance plans.

Caveat emptor? Not already infuriated by some recent visual depictions of the upside-down state of costs in the U.S. health care system (see figures*) Read on:

Money lenders invade the ER

medglance-300x96Reporter Shefali Luthra deserves credit for her story for the independent, nonpartisan Kaiser Health News Service on the questionable increased cooperation between hospitals, banks, and other lenders to provide new “patient financing” options, aka offering them loans to guarantee at admission that they will pay medical bills.

Cut through the fiscal jargon and what’s on offer are, potentially, arm-twisting bed-side loans. Yes, they typically come with no- or low-interest, and in at least some ways, the aim may seem well-intentioned — to help poorer patients cope with the skyrocketing cost of medical services.

The devil’s in the details, of course, in this case the execution. As Luthra’s story illustrates, at least some hospitals are pushing these loans when patients are ill-disposed to give any financial matter due consideration: Hospital billing staff are pushing loan papers at emergency room patients, including a scared, expectant mom awaiting treatment after a fall.

Yes, medicine is a business and bills need to be paid or arrangements must be made. But, really, c’mon: If patients are in bad enough shape to turn up in an ER, is that the place to badger them and their families about money?

And if this isn’t unacceptable already, the KHN story goes on to provide financial details of the loans. It turns out that they may allow poorer or needier patients an alternative to trying to max out credit cards or to deplete savings to provide guarantees they can cover their care.

But the loans come at a less than clear cost: They’re typically estimated to help cover what a patient may pay for care based on hospitals’ “charge masters” — the list, often legally required, of prices for common procedures. But those prices may be among the highest that institutions will seek, and they’re certainly not, say, what an insured patient might pay. One expert told Luthra these are not “rack” but “whack rates” for care, meaning patients taking out loans based on these costs will be charged to the max, even if they pay lesser interest for their borrowing.

Price gouging for cancer care

If they can, patients and their families should negotiate their medical bills aggressively. That’s because there can be significant variations in what hospitals charge, for example, with cancer treatment. The institutions don’t discuss these but they should be forced to disclose them, experts at the Johns Hopkins University School of Medicine have found in a study recently published in a medical journal.

They examined billing records for more than 3,400 hospitals across the country, discovering that “charges for outpatient oncology services such as chemo infusion or radiation treatment vary widely and exceed what Medicare will pay by two-fold to six-fold.” They said that “high markups” in cancer care can put patients at some hospitals at risk of getting overcharged for medical services that already may be crushing in cost.

“Unwarranted price markups contribute to the skyrocketing cost of health insurance and out-of-pocket costs to patients,” Dr. Martin Makary, a cancer surgeon, health policy expert, and senior author of the study has said in a statement. “We found some cancer centers bill fairly while others engage in outright price gouging of insurers, patients and their employers. Hospital differences in quality or charity care do not account for these dramatic price differences. … Cancer patients shouldn’t be put into household bankruptcy just because a hospital inflates a bill well above what an insurance company would pay for the exact same service.”

The researchers noted that insurers don’t help cancer patients with practices that, instead, make treatment prices higher and murkier, rather than more affordable and transparent. Patients struggle with high-deductible policies that may make premiums more affordable but make them dig deeper into their own pockets for care. They get hit with higher charges, for example, because insurers force them into narrow provider networks and zing them if they get out of network treatments — care over which patients really have little choice or control (especially from specialists like oncologists, radiologists, and anesthesiologists.)

The researchers call on lawmakers to step in with better protections for patients. They would, of course, be battling politically formidable forces in doctors and hospitals. And, of course, hospitals, yet another study finds — confirming common sense — boost their profits not by making themselves more efficient and reducing costs but by jacking up their prices as much as markets will bear before trying alternatives.

Hospitals could, however, tackle a burgeoning and onerous cause of rising health care costs by whacking at the explosive, kudzu-like growth of their medical billing operations. Aw, c’mon, it took financial whizzes from Duke and Harvard to delve deep into the “life of a medical bill” to discover that hospitals’ billings are costly, resource intensive, and wasteful — perhaps the tune of $500 billion annually? The researchers found that billing takes precious doctor time away from what caregivers would prefer to do — treating patients. Instead, all the hubbub with patients, insurers, hospitals, and MDs getting caught up in a hurricane of billings means that it can cost $99,000 annually just to collect what’s owed for the services of a single, primary care doc.

Skimpy health plans

Americans aren’t silly about their well-being, and they’re clearly taking all the steps they can to protect themselves — like enrolling for health coverage under the Affordable Care Act, aka Obamacare, no matter the obstacle. But the Trump Administration, aiming to do what the Republican-controlled Congress failed to do, keeps trying to unravel the ACA. This is occurring administratively and at the state level, where it may be harder for patient-consumers to fight back.

Administration officials and partisans, for example, now are promoting “short term” health insurance and association plans. They’re touted as less expensive options. But anyone considering them should read and understand carefully what they’re getting: In a nutshell, not much. The premiums may be lower. But the coverages are skimpy or negligible, so that customers will find that, if they need medical services, their insurance probably won’t pay for it.

These products, including the counter factual claim that they will be more beneficial if sold across state lines, haven’t proved out before — quite to the contrary.

Here’s also what they do, along with state experiments, notably the extreme Idaho ACA proposal: They slash at Obamacare protections and resurrect aspects of health coverage that Americans had come to loathe. They let insurers off the hook on minimum medical benefits they will cover, including preventive care and women’s health. They vaporize lifetime and annual payment limits, so insurers can boot patients off coverage when they deem.

They erode or eliminate measures to prevent insurers from denying coverage due to patients’ preexisting conditions, whether for reasons clearly major (cancer or heart disease) or dubious (allergies, ankle sprains, and jock itch — yes, these all are reasons that folks once got for coverage denials). This also means that those seeking coverage, outside of work, again will be forced to fill out insurers’ long, intrusive questionnaires or to undergo the firm’s phone cross-examinations by nurses.

Partisans hope that large numbers of younger, healthier Americans will be gulled into taking skimpy coverage, turning the ACA marketplaces just into high-risk pools — exchanges that will be forced to charge older, sicker people unaffordable rates, leading to Obamacare’s potential collapse.

In my practice, I see the giant harms that patients suffer while seeking medical services, and their constant, huge struggles to access and afford quality care. Sadly, too many Americans, years after the Great Recession seems to have subsided, still exist on the financial edge with spare resources. Medical debt and its related bankruptcies are all too common part of the American health system still. It’s just unacceptable to exploit poorer patients with bedside loans or by gouging even those who can afford them for complex and already costly treatments for conditions like cancer. Health coverage can’t be a privilege, it needs to be a right — a shared responsibility for our collective well-being so all of us, living one step away from accident or catastrophic injury or illness need not quake in fear of tomorrow and what it might bring.

*Data visualization credits: The Price Changes figure courtesy of the economist Mark J. Perry of AEI. The Excel chart comes from the Twitter account of Dr. Eric Topol, director, Scripps Translational Science Institute.
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