Bleeding Edge

While the US health care costs consistently soar — the American people feel that they do not get their money’s worth from any of the candidates claiming to have some sort of solutions.

But even in the likes of Bernie Sanders and Elizabeth Warren were to get elected — we are in for a new hosing with all the ghost billing and all the surprises lurking in our hospital bills, regardless of who sits behind the desk at 1600 Pennsylvania Avenue.

Why?

Because in this Election year the members of Congress have squandered yet another chance to tackle the obvious injustices of the Health Care System by focusing instead on a the Civil War illusions of impeachment and mayhem with crazy cat-calls for blood on the streets by some of the lunatics hiding amongst our representatives, like Crazy Maxine, alki-Pelosi, and her pencil neck fag-boy.

And thus they have wasted a precious three years in acrimony, instead of focusing on what American want which is a clear and predictable Health Care System.

Indeed a simple system where there are no things like what is called “GHOST BILLS” and “SURPRISE BILLING” from hospitals and clinicians, where in a typical scenario, a patient having a heart attack is taken by ambulance to the nearest emergency room of the hospital and after he hopefully rest saved or even if he dies — he gets “hit” with a bill of over $100,000 to be paid immediately, because that particular hospital happened to not be within his insurance network.

Or take another scenario, where the patient who carefully selects an in-network provider, for a minor procedure, like a colonoscopy, he gets the procedure done as planned, and then he gets billed tens of thousands of dollars, for the “out-of-network” surgeon, the “out-of-network” anesthesiologist or the “out-of-network” pathologist, who participated in this minor surgical procedure that took all of an hour in a day surgery in-and-out facility.

So we now have to ask our Lawmakers this:

Who is it that they are serving with their “refried beans” of infighting amongst the party dogs of the two main political parties those of the Republicans and of the Democrats?

And to whom will they listen?

Will they listen to the pleas of the Citizens and the patients?

Or will they listen to the hospital operators who support their campaigns?

Will they listen to the Doctors?

Or will they listen to the insurers?

Or, maybe finally in this election year, they will heed their voters calls, for patients’ rights, and heaqlth care reform and finally make an effort to curb “ghost bills” to make health care cheaper, and remove “surprise billing” for all Americans?

But we already know the answers to those questions…

Yet maybe we want to ask ourselves a few poignant questions because we finally need to know who are the major organizations that are illegally profiteering from this mess?

And who are the people that are gaining an economic advantage from our outrageous “ghost bills” and “surprise medical billing” because it appears that these illegal profiteers are the same people who are supposedly advocating on our behalf, and who claim to be representing us.

So that begs the question — who are the real people supporting us, in our quest to fix the health care system in order to serve all of us?

The surprise answer is no one.

There is none, except yourself.

Like the proverbial “babe in the woods,” so are the American consumers, patients and citizens — when they are facing the massive “Medical Industrial Complex” whose only God is the Mammon of the greenback.

A “Babe in the Woods” indeed…

And if you are smart and ask the right questions — you shall find out that the Medical Industrial Complex is just another “machine” that abides only to three simple rules where billing is concerned:

1) There are no standards for billing.
2) There’s money to be made in billing for anything and everything.
3) Prices will rise to whatever the market will bear.

The first rule is a reaffirmation of the known deficiencies of our episode based, fee-for-service system. Payment for individual services drives the delivery of a greater number of individual services.

The second rule is absolutely true.

And the third rule is horrifyingly true as well, and indeed it has a devastating impact on individuals, families, businesses and our economy.

And because the issue of health care costs has been and remains a central part of the national health care debate. For most of the past 20 years, the country has focused most of our attention on the cost of health care coverage (insurance) for individuals, families, businesses and government programs. What we haven’t done is focus on the cost of individual health care services. This may be changing. There appears to be an appetite and growing interest in addressing the cost of health care services as we head into the 2018 congressional elections and the 2020 presidential election.

The recently published 2016 Health Care Cost and Utilization Report(www.healthcostinstitute.org) from HCCI points to reasons for growing concern. Here are four key takeaways:

Total spending per person is growing faster than in prior years.
a. Per capita spending grew 4.6 percent in 2016 and 4.1 percent in 2015. This represents significant increases from 2012-2014 when spending growth was less than 3 percent annually.
b. In 2016, per person spending for a commercially insured individual reached $5,407. This broke down as follows: $1,049 on inpatient services, $1,821 on professional services, $1,507 on outpatient services and $1,030 on prescription drugs.

Spending growth in each year from 2012 to 2016 was almost entirely due to price increases.
a. The report points to large increases in prices for administered drugs, emergency room visits and surgical hospital admissions.
b. Prescription drug prices increased 24.9 percent.

3. Utilization of most health care services remained unchanged or declined.
a. Utilization of most services declined except for prescription drugs. Utilization of inpatient services had the largest decline, with admission rates decreasing 12.9 percent.

4. Consumer out-of-pocket (OOP) spending per person increased, but it grew slower than total spending.
a. OOP spending, per person in 2016, was $848.
b. OOP spending grew 12 percent from 2012 to 2016. The trend is pointing to increasing OOP spending.
The HCCI report points to one truly alarming trend. Utilization of primary care is decreasing, and utilization of specialists is increasing at alarming rates. According to the report, from 2012 to 2016 “there was a 6 percent decrease in the spending on office visits to primary care physicians. The decline in spending on PCP office visits over the study period was driven by the 18 percent decline in the use of these visits. In contrast, the increased utilization of specialist visits contributed to a 31 percent spending increase for those visits.”

The report raises several reasons for why this may be occurring — shift of PCP from fee-for-service to alternative payment models such as ACOs, etc. A second possibility is hospitals and health systems are driving greater utilization to their higher-cost specialist and emergency rooms.

The decline in primary care visits, coupled by the dramatic increase in utilization of specialists and emergency departments represents an opportunity, but, as mentioned is alarming. A recent blog post in Health Affairs (www.healthaffairs.org) did a great job of capturing why this trend, if it were to continue, is so harmful for patients and the health care system. The blog notes, “The cost-effectiveness of primary care is well documented, going back to Barbara Starfield, who demonstrated that health care systems which have more comprehensive primary care improve population health at lower costs and with greater equity.” The authors go on to state, “yet the HCCI analysis seems to document a striking collective resistance to attend to this evidence.”

And since every politician on the stump condemns the phenomenon of “surprise medical billing” and “ghost billing” as we are seeing all over the place this week, where all the Democratic candidates on the primaries are talking about fixing this broken system, and as we speak, at least two committees in the Houses of Congress, are marking up new “surprise billing” legislation.

One of the few policy proposals President Trump has brought up in this year’s State of the Union address was his 2019 executive order targeting them. In the Democratic debates, candidates have railed against such medical bills, and during commercial breaks, back-to-back ads from groups representing doctors and insurers proclaimed how much the health care sector also abhors this uniquely American form of patient extortion.

Patients, of course, hate surprise bills most of all. And yet, no one with authority in Washington has done much of anything about it.

Here’s why: Major sectors of the health industry have helped to invent this toxic phenomenon, and none of them want to solve it if it means their particular income stream takes a hit. And they have allies in the capital.

That explains why President Trump’s executive order, issued last year, hasn’t resulted in real change. Why bipartisan congressional legislation supported by both the House Energy and Commerce Committee and the Senate Health Committee to shield Americans from surprise medical bills has gone nowhere. And why surprise billing provisions were left out of the end-of-year spending bill in December, which did include major tax relief for many parts of the health care industry.

Surprise bills are just the latest weapons in a decades-long war between the players in the health care industry over who gets to keep the fortunes generated each year from patient illness — $3.6 trillion in 2018.

Here’s how they came to be:

Forty years ago, when many insurers were nonprofit entities and being a doctor wasn’t seen as a particularly good entree into the 1 percent, billed rates were far lower than they are today, and insurers mostly just paid them. Premiums were low or paid by an employer. Patients paid little or nothing in co-payments or deductibles.

That’s when a more entrepreneurial streak kicked in. Think about the opportunities: If someone is paying you whatever you ask, why not ask for more?

Commercial insurers as well as Blue Cross Blue Shield Plans, some of which had converted to for-profit status by 2000, began to push back on escalating fees from providers, demanding discounts.

Hospitals and doctors argued about who got to keep different streams of revenue they were paid. Doctors began to form their own companies and built their own outpatient surgery centers to capture payments for themselves.

So today your hospital, your doctor and your insurer — all claiming to coordinate care for your health, are often in a three-way competition for your money.

As the battle for revenue has heated up, each side has added new weapons to capture more: Hospitals added facility fees and infusion charges. Insurers levied ever-rising co-payments and deductibles. Most important they limited the networks of providers to those that would accept the rates they were willing to pay.

Surprise bills are the latest tactic: When providers decided that an insurer’s contracted payment offerings were too meager, they stopped participating in the insurer’s network; either they walked away or the insurer left them out. In some cases, physicians decided not to participate in any networks at all. That way, they could charge whatever they wanted when they got involved in patient care and bill the patient directly. For their part, insurers didn’t really care if those practitioners demanding more money left.

And, for a time, all sides were basically fine with this arrangement.

But as the scope and the scale of surprise bills has grown in the past five years, more people have experienced these costly, unpleasant surprises. With accumulating bad publicity, they have became impossible to ignore. It was hard to defend a patient stuck with over $500,000 in surprise bills for 14 weeks of dialysis. Or the $10,000 bill from the out-of-network pediatrician who tends to newborns in intensive care. How about the counties where no ambulance companies participate in insurance, so every ambulance ride costs hundreds or even thousands of dollars?

These practices are an obvious outrage. But no one in the health care sector wants to unilaterally make the type of big concessions that would change them. Insurers want to pay a fixed rate. Doctors and hospitals prefer what they call “baseball- style arbitration,” where a reasonable charge is determined by mediation. Both camps have lined up sympathetic politicians for their point of view, and that guarantees gridlock to go on forever…

Yours,

Dr Churchill

PS:

Here is a quick overview of spending in the U.S. health care system. So how does the United States compare to other countries? Are we getting value for the investment we are making in health care? A recent article in JAMA entitled Health Care Spending in the United States and Other High-Income Countries(jamanetwork.com) points out some known, yet startling, statistics. The authors looked at health care spending in the United States and 10 other high-income countries (Germany, Japan, Australia, etc.).

It is important to note that all of the countries, except the United States have “an automatic or compulsory enrollment process. Private insurance as the primary form of insurance is highest in the United States at 55.3 percent, followed by Germany at 10.8 percent. The majority of the countries do not have private insurance as the primary form of insurance.”

Here are some key data points that are probably familiar. The United States spends $9,403 per capita on health care. The mean of the 11 countries in the study was $5,419. The U.S. spends 17.8 percent of its GDP on health care. The mean for the 11 countries was 11.5 percent. The United States had the lowest percentage of the population older than 65 years at 14.5 percent of population compared to a mean of 18.2 percent. The U.S. had the highest rate of poverty with 24 percent of the population below the poverty line, followed by Japan at 22 percent and Canada at 21 percent. Spending does not equate to better outcomes. The U.S. falls below the mean in every category evaluated in the study.

We must remember thought that all “medical & health delivery systems” had relatively similar levels of public spending as a percentage of GDP (defined as spending from government and/or social or compulsory insurance funds), with the United States spending at about the mean level (8.3 percent) of all the countries, although, unlike the other countries, this spending covered only about 37 percent of the population.

So, nothing has changed at the federal level, even though the Affordable Care Act muddied the waters and yet it’s hard to imagine another issue for which there is such widespread consensus to “solve” it and the demand for solving it goes across both political parties.

Today, two-thirds of Americans say they are worried about being able to afford an unexpected medical bill — more than any other household expense. Nearly eight in 10 Americans say they want federal legislation to protect patients against surprise billing, ghost bills and runaway medical expenses.

After all it is well known that the greatest cause of bankruptcies is the catastrophic Health Care episodes in the families of Americans…

Today, some states are passing their own “surprise billing” laws, though they lack power since much of insurance is regulated at a national level.

Yet, as of now the chances of any of the proposed bills making it out of Committee are slim to none, and as for any other being voted up by the Senate — FORGET ABOUT IT.