Financial punishment is now a built-in aspect of U.S. health care system

debtmedicalkhnnpr-300x193The sky-high and relentlessly rising cost of U.S. health care is slamming patients, ensnaring them in pricey over-testing, over-diagnosing, and over-treatment. It is pounding them with pervasive, pernicious, and unacceptable medical debt.

The crushing burden of expensive health care is leaving consumers going without as they also struggle now with soaring prices for gas, food, and other household basics.

Punishing finances have become part and parcel of the American way of health care, with “more than 100 million people in America ― including 41% of adults ― beset by a health care system that is systematically pushing patients into debt on a mass scale,” according to an unfolding investigation by the independent, nonpartisan Kaiser Health News service and National Public Radio. As the media organizations reported:

“[Our] investigation reveals a problem that, despite new attention from the White House and Congress, is far more pervasive than previously reported. That is because much of the debt that patients accrue is hidden as credit card balances, loans from family, or payment plans to hospitals and other medical providers. To calculate the true extent and burden of this debt, the KHN-NPR investigation draws on a nationwide poll conducted by KFF (Kaiser Family Foundation) for this project. The poll was designed to capture not just bills patients couldn’t afford, but other borrowing used to pay for health care as well. New analyses of credit bureau, hospital billing, and credit card data by the Urban Institute and other research partners also inform the project. And KHN and NPR reporters conducted hundreds of interviews with patients, physicians, health industry leaders, consumer advocates, and researchers.”

The findings of this work are “bleak,” KHN and NPR reported:

“In the past five years, more than half of U.S. adults report they’ve gone into debt because of medical or dental bills, the KFF poll found. A quarter of adults with health care debt owe more than $5,000. And about 1 in 5 with any amount of debt said they don’t expect to ever pay it off … The burden is forcing families to cut spending on food and other essentials. Millions are being driven from their homes or into bankruptcy, the poll found. Medical debt is piling additional hardships on people with cancer and other chronic illnesses.

“Debt levels in U.S. counties with the highest rates of disease can be three or four times what they are in the healthiest counties, according to an Urban Institute analysis. The debt is also deepening racial disparities. And it is preventing Americans from saving for retirement, investing in their children’s educations, or laying the traditional building blocks for a secure future, such as borrowing for college or buying a home. Debt from health care is nearly twice as common for adults under 30 as for those 65 and older … Perhaps most perversely, medical debt is blocking patients from care. About 1 in 7 people with debt said they’ve been denied access to a hospital, doctor, or other provider because of unpaid bills, according to the poll. An even greater share ― about two-thirds ― have put off care they or a family member need because of cost.”

This initial segment of a promised multipart series by KHN and NPR also reports that a “highly lucrative,” and “shadowy” industry is growing by targeting and hounding those with medical debt, which patients, loved ones, and friends take on — and then can’t ever seem to shed, whether the sums are small or whopping.

The huge, stressful toll takes on debtors affects not only the poor and working poor but also those in the middle class and even those who would be considered by most to be relatively well to do, the news organizations have found. Because of big flaws in the way health coverage works in this country, notably with high deductible policies that force folks who can’t afford even seemingly slight out-of-pocket costs to pay up before they get care, medical debt is a menace both to the insured and uninsured, even with significant, beneficial changes brought about by the Affordable Care Act and Obamacare.

The slippery treatment slope

It’s no secret that over-testing, over-diagnosis, and over-treatment is a bankrupting menace in the U.S. health care system. And, separately, both NPR and KHN have reported on the nightmare of what policy experts politely refer to as a “cascade” of care involving low value, potentially harmful, invasive, sometimes painful medical services, notably diagnostic tests.

The news organizations describe, in anecdotal fashion, how doctors, hospitals, and clinics — all operating under a system that rewards them not for the overall quality of care but by paying them fees for each individual service — order up an array of “routine” tests.

But the more screens patients receive, the likelihood spikes, too, that the results will cause concerns for their doctors. They, in turn, order further tests and procedures — with costs mounting and patients also subjected to rising inconvenience, costs, and mental and physical discomforts.

NPR reported this, quoting Ishani Ganguli, a primary care physician who is an assistant professor of medicine at Harvard University:

“Over the past 30 years, doctors and researchers like Ganguli have flagged more than 600 procedures, treatments and services that are unlikely to help patients: Tests like MRIs done early for uncomplicated low back pain, prostate cancer screenings for men over 80, and routine vitamin D tests. Research suggests low-value care is costly, with one study estimating that the U.S. health care system spends $75 billion to $100 billion annually on these services. Ganguli published a paper in 2019 that found the federal government spent $35 million a year specifically on care after doctors performed EKG heart tests before cataract surgery — an example of low-value care. ‘Medicare was spending 10 times the amount on the cascades following those EKGs as they were for the EKGs themselves. That’s just one example of one service,’ said Ganguli.

“Cascades of care are common. Ninety-nine percent of doctors reported experiencing one after an incidental finding, according to a survey conducted by Ganguli. Nearly 9 in 10 physicians said they’d seen a cascade harm a patient, for example, physically or financially. And yet, in that same survey, Ganguli reported that 41% of doctors said they continued with a cascade even though they believed the next test was not important for medical reasons.”

KHN reported that patients, under Obamacare, may seek preventive medical services, knowing that many of these now may be covered and affordable. They can be shocked, though, to learn that follow-up procedures are not:

“Having to choose between paying rent and getting the testing they need can be a serious dilemma for some patients. Under the Affordable Care Act, many preventive services — such as breast and colorectal cancer screening — are covered at no cost. That means patients don’t have to pay the normal copayments, coinsurance, or deductible costs their plan requires. But if a screening returns an abnormal result and a health care provider orders more testing to figure out what’s wrong, patients may be on the hook for hundreds or even thousands of dollars for diagnostic services.

“Many patient advocates and medical experts say no-cost coverage should be extended beyond an initial preventive test to imaging, biopsies, or other services necessary for diagnosing a problem. ‘The billing distinction between screening and diagnostic testing is a technical one,’ said Dr. A. Mark Fendrick, director of the University of Michigan’s Center for Value-Based Insurance Design. ‘The federal government should clarify that commercial plans and Medicare should fully cover all the required steps to diagnose cancer or another problem, not just the first screening test.’”

Is anyone envisioning a politically riven Congress, especially with obdurate Republicans resistant to any federal involvement in health care, actually doing something to improve Americans’ health and helping them with staggering medical bills?

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to afford and access safe, efficient, and excellent health care. This has become an ordeal due to the skyrocketing cost, complexity, and uncertainty of therapies and prescription medications, too many of which prove to be dangerous and bankrupting drugs.

A summer of discontents

As the summer starts, the nation is seeing a U.S. House investigation expose irrefutable evidence of the corrupt, corrosive practices of a previous administration and its effort to launch a de facto coup to illegally and unconstitutionally hold power. We’re heading into brutal and further divisive midterm elections this fall. People are howling about out-of-control costs destroying their lives. And, in health care and medical terms, one party — the Republicans — have been unwilling to have Congress do anything. About health coverage expanded during the coronavirus pandemic and soon-to-expire. Prescription drug costs, especially run-away prices for lifesaving insulin. And battling the pandemic. By the way, did we mention unconscionable gun violence and soaring gas and food prices?

In the meantime, the Gallup polling organization has found this, the Axios news site reported:

“42% of adults over 50 but still too young for Medicare said they’re worried about being able to cover their medical expenses in the coming year, according to the survey Gallup and the nonprofit West Health conducted last fall as U.S. consumer prices began to spike. 26%, reflecting an estimated 16 million people, said they or a member of their household had a health problem in the past three months but didn’t seek treatment due to cost concerns. 18%, or an estimated 11 million, said they or a family member skipped a pill, prescribed dose, or other types of medication in the past year to save money. Adults over 50 reported they’ve cut back on clothing, over-the-counter drugs, food, and utilities, in that order, to pay for needed health care.”

We have much work to do to rein in bankrupting medical costs and debt and to ensure that health care is safe, accessible, affordable, efficient, excellent, and a right not a privilege for a wealthy few.

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