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  Price gouging is a pejorative term referring to when a seller spikes the prices of goods, services or commodities to a level much higher than is considered reasonable or fair, and is considered exploitative, potentially to an unethical extent. Usually this event occurs after a demand or supply shock: common examples include price increases of basic necessities after hurricanes or other natural disasters. In precise, legal usage, it is the name of a crime that applies in some jurisdictions of the United States during civil emergencies. In less precise usage, it can refer either to prices obtained by practices inconsistent with a competitive free market, or to windfall profits. In the former Soviet Union, it was simply included under the single definition of speculation.

The term is similar to profiteering but can be distinguished by being short-term and localized, and by a restriction to essentials such as food, clothing, shelter, medicine and equipment needed to preserve life, limb and property. In jurisdictions where there is no such crime, the term may still be used to pressure firms to refrain from such behavior.

 

Balance Billing is a scam that it is still legal in many states. And medical providers use and abuse it, especially for ambulance and IR services.

Even if the bill is correct, you should still set up a time to speak with someone in the billing office — someone with the authority to negotiate on your balance. Go into the conversation equipped with the knowledge that Medicare and insurance companies rarely pay the hefty price tags that consumers see.

Standard practice for insurers is to negotiate with providers to pay merely a fraction of the cost. In the case of inpatient hospital bills, for example, a NerdWallet study found Medicare negotiates, on average, a 73% discount. While the ambulance service may not agree to such a large discount for you, coming to any negotiation equipped with such knowledge will put the company on notice that you aren’t going to lay down and take its bullying or an inflated bill.

Consider how much you are able to pay. If the ambulance service isn’t willing to deduct a good portion of the original bill, think about how much is fair and reasonable for the service your husband received and your budget. Negotiating a lower balance, even if you can’t pay it off in a lump sum, will remove a considerable burden from your shoulders. It may even benefit the ambulance company, which might fear receiving no payment from you at all, since the majority of bills in collections are never paid off. If you do set up a formal payment agreement, make sure to get it in writing.

Negotiating with an ambulance service or any medical provider is not easy, but it is possible. Be persistent. If your efforts prove fruitless, you can always consider hiring a professional. A medical billing advocate is able to represent clients’ interests much in the way an attorney would advocate for you in a courtroom. Their experience and expertise in the field can sometimes prove more effective (and less stressful) than taking on a stubborn provider alone.

How much do patient and medical billing advocates cost?

Patient advocates are often members of your family, nonprofit organizations or clergy, and may not charge you for their services. In most cases, however, there will be a fee associated with patient advocates, and it usually depends on the amount of time they spend with you and your doctor. Advocates on the hospital staff may have their charges built into your bill. For this reason, costs may vary from as little as $75 for a single doctor’s visit to a few thousand dollars for an extended hospital stay.

Medical billing advocates usually have more concrete charges. Some charge hourly, at a rate of $100-$200. Others charge as a percentage of savings—usually 25%-35% of the price they got your total charges reduced by, but some charge as little as 15% of savings.

Where can I find a patient or medical billing advocate?

You can find patient and medical billing advocates through the National Association of Healthcare Advocacy Consultants or the Alliance of Claims Assistance Professionals.

 


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Old News ;-)

[Apr 06, 2017] The country will spend over $440 billion this year for drugs that would likely sell for less than $80 billion in a free market.

Apr 06, 2017 | economistsview.typepad.com
anne , April 06, 2017 at 05:31 AM
http://cepr.net/blogs/beat-the-press/robert-atkinson-pushes-pro-rich-protectionist-agenda-in-the-washington-post

April 6, 2017

Robert Atkinson Pushes Pro-Rich Protectionist Agenda in the Washington Post

The Washington Post is always open to plans for taking money from ordinary workers and giving it to the rich. For this reason it was not surprising to see a piece * by Robert Atkinson, the head of the industry funded Information Technology and Innovation Foundation, advocating for more protectionism in the form of stronger and longer patent and copyright monopolies.

These monopolies, legacies from the medieval guild system, can raise the price of the protected items by one or two orders of magnitudes making them equivalent to tariffs of several hundred or several thousand percent. They are especially important in the case of prescription drugs.

Life-saving drugs that would sell for $200 or $300 in a free market can sell for tens or even hundreds of thousands of dollars due to patent protection. The country will spend over $440 billion this year for drugs that would likely sell for less than $80 billion in a free market. The strengthening of these protections is an important cause of the upward redistribution of the last four decades. The difference comes to more than $2,700 a year for an average family. (This is discussed in "Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer," ** where I also lay out alternative mechanisms for financing innovation and creative work.)

Atkinson makes this argument in the context of the U.S. relationship with China. He also is explicitly prepared to have ordinary workers pay the price for this protectionism. He warns that not following his recommendation for a new approach to dealing with China, including forcing them to impose more protection for U.S. patents and copyrights, would lead to a lower valued dollar.

Of course a lower valued dollar will make U.S. goods and services more competitive internationally. That would mean a smaller trade deficit as we sell more manufactured goods elsewhere in the world and buy fewer imported goods in the United States. This could increase manufacturing employment by 1-2 million, putting upward pressure on the wages of non-college educated workers.

In short, not following Atkinson's path is likely to mean more money for less-educated workers, less money for the rich, and more overall growth, as the economy benefits from the lessening of protectionist barriers.

* https://www.washingtonpost.com/opinions/global-opinions/how-trump-can-stop-china-from-eating-our-lunch/2017/04/05/b83e4460-1953-11e7-bcc2-7d1a0973e7b2_story.html

** http://deanbaker.net/images/stories/documents/Rigged.pdf

-- Dean Baker

[Apr 06, 2017] Health Care Renewal Not Going to Take it Anymore - Doctors in the Pacific Northwest Unionize, Begin Collective Bargaining with Hospital Systems

Apr 06, 2017 | hcrenewal.blogspot.com
Managerialist Tactics: Outsourcing

The NYT article opened with

in the spring of 2014, when the administration announced it would seek bids to outsource its 36 hospitalists , the hospital doctors who supervise patients' care, to a management company that would become their employer.

The outsourcing of hospitalists became relatively common in the last decade, driven by a combination of factors. There is the obvious hunger for efficiency gains. But there is also growing pressure on hospitals to measure quality and keep people healthy after they are discharged. This can be a complicated data collection and management challenge that many hospitals, especially smaller ones, are not set up for and that some outsourcing companies excel in.

Outsourcing is a now familiar entry in the managerialists' playbook. It is seen more in manufacturing than in health care. Although touted as improving economic "efficiency," it also may reduce the accountability of the managers of the organization that does the outsourcing.

Pursuit of Economic Efficiency

In this case,

Outsourced hospitalists tend to make as much or more money than those that hospitals employ directly, typically in excess of $200,000 a year. But the catch is that their compensation is often tied more directly to the number of patients they see in a day - which the hospitalists at Sacred Heart worried could be as many as 18 or 20, versus the 15 that they and many other hospitalists contend should be the maximum.

It was the idea that they could end up seeing more patients that prompted outrage among the hospitalists at Sacred Heart, which has two facilities in the area, with a total of nearly 450 beds. 'We're doctors, we're professionals,' Dr. [Rajeev] Alexander said. 'Giving me a bonus for seeing two more patients - I'm not sure I should be doing that. It's not safe .' (A hospital representative said patient safety was 'inviolate.')


A constant theme of managerialism, and the neoliberalism that underlies it, is economic efficiency. The usual narrative is that efficiency means providing better goods and services at lower costs. Instead, managerialism and neliberalism may mean decontenting goods and services so as to lower costs to the organizations providing them, but not necessarily providing more value to consumers. In health care terms, managerialism and neliberalism may lead to less accessible, more mediocre health care that increase revenue to the organizations providing it, as implied by the physicians' comments above. Making the US the most commercialized, managerialist run, and arguably neoliberal health care system among the developed countries has not led to lower costs, better access, or better health care quality.


The backstory for the outsourcing emphasizes that managerialism, and the resulting economic efficiency was indeed the goal of PeaceHealth...

In 2012, Sacred Heart's parent, PeaceHealth, a nonprofit health care system, installed an executive named John Hill to adapt its Oregon hospitals to the latest trends in health care . Mr. Hill, in an effort to rein in the budget and improve the efficiency of a hospital that administrators said was lagging in key respects, including how long the typical patient stayed, eventually concluded that the hospitalists at Sacred Heart should be outsourced.

Centralization of Control

Furthermore,

The hospitalists also chafe at the way the administration has tried to centralize decisions they used to make for themselves. This might include hiring fellow doctors or the order in which they see patients on any day. They also complain of being loaded down with administrative tasks.

'We're trained to be leaders, but they treat us like assembly line workers ,' said Dr. Brittany Ellison, a hospitalist in the group. 'You need that time with the patient,...'


A major feature of managerialism is the concentration of power within (generic) management. To quote Komesaroff(1),

In the workplace, the authority of management is intensified, and behaviour that previously might have been regarded as bullying becomes accepted good practice. The autonomous discretion of the professional is undermined, and cuts in staff and increases in caseload occur without democratic consultation of staff. Loyal long-term staff are dismissed and often humiliated, and rigorous monitoring of the performance of the remaining employees focuses on narrowly defined criteria relating to attainment of financial targets, efficiency and effectiveness.

We're Only In It for the Money

Also, the negotiations that started once the PeaceHealth physicians formed their union demonstrated a central tenet of managerialism

Even starker than the divide over these questions are the differences in worldview represented on opposite sides of the table. During a bargaining session last fall, the administration proposed increasing the number of shifts a year. Hospitalists now earn about $223,000 a year for 173 shifts and are paid extra for working more. The hospital offered $260,000 for a mandatory 182 shifts, and up to $20,000 in bonus pay for hitting certain medical performance targets. The hospitalists work seven days on and seven days off, so this would have effectively eliminated any time off for sick days or vacation.

When the doctors pointed this out, the administration responded that if they missed a few days, it would make sure they got extra days to hit the required number of shifts for full pay.

The hospitalists assured the administration negotiators that their concern had nothing to do with money - that none of this had ever been about money. They preferred to work less and make less to avoid burnout, which was bad for them and worse for patients. At which point the administration responded that money was always the issue , according to several people in the room. (The hospital declined to comment.)

Suddenly it dawned on the doctors why they had failed to break through, Dr. Alexander said. 'Imagine Mr. Burns,' the cartoonishly evil capitalist from 'The Simpsons,' 'sitting across the table,' he said. 'There's no way we can say, 'This isn't what we're talking about. We're not trying to get the bonus.''


Again, managerialism is based on neoliberalism, and neoliberal view is that the market rules. The market is the arbiter of success, and money is the only outcome that matters. As Komesaroff put it(1),

The particular system of beliefs and practices defining the roles and powers of managers in our present context is what is referred to as managerialism. This is defined by two basic tenets: (i) that all social organisations must conform to a single structure; and (ii) that the sole regulatory principle is the market .

Mission-Hostile Management

Never mind that the centrality of money seems entirely inconsistent with the stated mission of PeaceHealth ,

We carry on the healing mission of Jesus Christ by promoting personal and community health, relieving pain and suffering, and treating each person in a loving and caring way.

Ostensibly, this is accompanied by core values, such as,

Stewardship We choose to serve the community and hold ourselves accountable to exercise ethical and responsible stewardship in the allocation and utilization of human, financial, and environmental resources. and,

Social Justice
We build and evaluate the structures of our organization and those of society to promote the just distribution of health care resources.


We have frequently discussed how leadership of contemporary health care organizations often seem to act contrary to the organizations' stated mission, that is, mission-hostile management .

Value Extraction

Finally, while managerialism is ostensibly concerned with economic efficiency, whose efficiency matters. When managers address physicians' efficiency, they seem to look at amount of work done divided by the cost to the hospital of paying physicians. However, they never seem to look at their own costs, the costs of management, as being a negative.

The PeaceHealth 2014 form 990 , the latest available, states that the then CEO, Mr Alan Yordy (whose highest academic degree was an MBA, according to his LinkedIn page ) had total compensation in 2013 of $1,366,742, and 11 other managers had total compensation greater than $250,000, with 9 having total compensation greater than $500,000. Those figures should be compared to the highest compensation offered the hospitalists, a maximum of $280,000 for 182 shifts a year, eliminating all vacation and sick leave. So if it is all about the money, the managers are making the most of it.

We have discussed ad nauseum the ridiculous compensation of the leaders of health care organization, even non-profit organizations. Value extraction by top management has become a central feature of the US and global economy (look here ).

The NYT article did not discuss whether the upset hospitalists knew about their bosses' compensation. I suspect they did.

Forming a Functioning Union at the University of Washington

The media coverage of the UW housestaff unionization was less detailed. It does appear, though, that a stimulus was the pursuit of economic efficiency by UW management through squeezing the pay of housestaff, as described in the December article in the Seattle Times . In it the house staff said,

they account for about one-fifth of King County's doctors and they want higher pay, new child-care benefits and free parking. Some UW residents and fellows earn so little that they qualify for welfare programs like Temporary Assistance for Needy Families and the Seattle City Light Utility Discount Program, according to the UWHA [University of Washington Housestaff Association.]

Another article in early January, 2016 in the Seattle Times added,

The association has proposed that residents and fellows earn at least the same salary as the UW's lowest-paid physician assistants . Because the doctors in training work very long hours, they sometimes earn less than Seattle's minimum hourly wage , the UWHA has said.

The council members, in their letter to Cauce, called the situation shocking. And based on information from the UWHA, they wrote that some residents and fellows qualify for welfare programs like Temporary Assistance for Needy Families (TANF).


The Seattle articles noted that the UW housestaff may earn from just over $53,000 to just under $70,000 a year. Keep in mind, however, that under current rules, house staff may work up to 80 hours a week. So $53,000 for someone working those hours translates into $13.25/ hour, under what many people now claim is the living wage. That could be considered exploitation of workers with doctoral degrees working in often highly stressful situations where lives may be on the line. Whether there were issues other than money (and the respect it implies) involved at UW was not apparent based on the minimal press coverage.

[Apr 05, 2017] Health Care Renewal managerialism

Apr 05, 2017 | hcrenewal.blogspot.com
John Stossel Discovers Health Care Dysfunction, Blames it on "Socialists" - Like Maurice Greenberg (AIG), John Thain (Merrill Lynch), Sanford Weill (Citigroup), and David H Koch? We have been ranting for a while about the dysfunctionality of the US health care system. Unfortunately, many people only realize how bad things are when they become patients, when they have bigger things to worry about than complaining. Furthermore, even if they complain, many patients may not feel they understand enough about what has gone wrong to suggest solutions.

Bad Customer Service at New York Presbyterian

This may not apply when media pundits, especially those with strong ideological views, become patients. So this week Fox News commentator and well known libertarian John Stossel disclosed his new illness, and vented his opinions about his hospital stay . Mr Stossel unfortunately developed lung cancer, although he was optimistic about his prognosis: "My doctors tell me my growth was caught early and I'll be fine. Soon I will barely notice that a fifth of my lung is gone."

However, he was not happy about his hospital's customer service:

But as a consumer reporter, I have to say, the hospital's customer service stinks . Doctors keep me waiting for hours, and no one bothers to call or email to say, 'I'm running late.' Few doctors give out their email address. Patients can't communicate using modern technology.

I get X-rays, EKG tests, echocardiograms, blood tests. Are all needed? I doubt it. But no one discusses that with me or mentions the cost .

Also,
I fill out long medical history forms by hand and, in the next office, do it again . Same wording: name, address, insurance, etc.
And,
In the intensive care unit, night after night, machines beep, but often no one responds . Nurses say things like 'old machines,' 'bad batteries,' 'we know it's not an emergency.'
Finally,
Some of my nurses were great -- concerned about my comfort and stress -- but other hospital workers were indifferent .
Unfortunately, long wait times, poor communications, excess paperwork, and misapplied technology are all too familiar problems to those in the health care system.

Moreover, this all was happening at one of the most highly rated US hospitals,

After all, I'm at New York-Presbyterian Hospital. U.S. News & World Report ranked it No. 1 in New York .
Were "Socialist Bureaucracies" Responsible?

Mr Stossel had his own ideas about the causes of these problems.

Customer service is sclerotic because hospitals are largely socialist bureaucracies. Instead of answering to consumers, which forces businesses to be nimble, hospitals report to government, lawyers and insurance companies.

Whenever there's a mistake, politicians impose new rules: the Health Insurance Portability and Accountability Act paperwork, patient rights regulations, new layers of bureaucracy...

Also,

Leftists say the solution to such problems is government health care. But did they not notice what happened at Veterans Affairs? Bureaucrats let veterans die, waiting for care. When the scandal was exposed, they didn't stop. USA Today reports that the abuse continues. Sometimes the VA's suicide hotline goes to voicemail.

Patients will have a better experience only when more of us spend our own money for care. That's what makes markets work.

A "Socialist Bureaucracy" with a VIP Penthouse?

I am sorry to hear Mr Stossel has lung cancer, and hope that his prognosis is indeed good. I am a bit surprised that a media celebrity who became a patient found big issues with "customer service" at such a prestigious hospital. After all, many big hospitals have programs to give special treatment to VIPs (for example, see these posts from 2007 and 2011 ).

In particular, back in 2012 we posted about the contrast between the VIP services specifically at New York - Presbyterian Hospital and how poor patients are treated there. Then we quoted from a 21 January, 2012 article from the New York Times focused on the ritzy comforts now provided for wealthy (but perhaps not very sick) patients at the renowned New York Presbyterian/ Weill Cornell Hospital. It opened,

The feverish patient had spent hours in a crowded emergency room. When she opened her eyes in her Manhattan hospital room last winter, she recalled later, she wondered if she could be hallucinating: 'This is like the Four Seasons - where am I?'

The bed linens were by Frette, Italian purveyors of high-thread-count sheets to popes and princes. The bathroom gleamed with polished marble . Huge windows displayed panoramic East River views. And in the hush of her $2,400 suite, a man in a black vest and tie proffered an elaborate menu and told her, 'I'll be your butler.'

It was Greenberg 14 South, the elite wing on the new penthouse floor of NewYork-Presbyterian/Weill Cornell hospital . Pampering and décor to rival a grand hotel, if not a Downton Abbey, have long been the hallmark of such 'amenities units,' often hidden behind closed doors at New York's premier hospitals. But the phenomenon is escalating here and around the country, health care design specialists say, part of an international competition for wealthy patients willing to pay extra, even as the federal government cuts back hospital reimbursement in pursuit of a more universal and affordable American medical system.

Additional amenities include:

A waterfall, a grand piano and the image of a giant orchid grace the soaring ninth floor atrium....
Also,
the visitors' lounge seems to hang over the East River in a glass prow and Ciao Bella gelato is available on demand....
An architect who specializes in designing such luxury facilities for hospitals noted:
'These kinds of patients, they're paying cash - they're the best kind of patient to have,' she added. 'Theoretically, it trickles down.'
It appears that someone failed to book Mr Stossel into the penthouse. Instead, he found out what service was like for the masses.

Perhaps this was why Mr Stossel railed at the "socialist bureaucracies" he perceived as running New York - Presbyterian Hospital. However, calling the hospital management "socialist" seems - not to put too fine a point on it - wrong.

A "Socialist Bureaucracy" Paying Millions to its CEOs?

First of all, New York Presbyterian is hardly a government agency. It is a private, non-profit corporation. Every year as such it files a form 990 with the dread US Internal Revenue Service. (The latest publicly available version is from 2013, here.) Obviously, US government agencies do not file with the IRS.

In fact, the New York Presbyterian system seems about as far from a federal government agency as one can imagine.

First, its top managers are paid like for-profit corporate executives. In 2014, we posted about the humongous compensation given to its previous, long-serving CEO, Dr Herbert Pardes, who received multi-million dollar compensation every year through his 2011 retirement, and then continued to receive several million a year from the system in his retirement. His successor, current CEO Dr Steven Corwin, received $3.6 million in 2012. (More recent compensation figures are not yet available.)

A "Socialist Bureaucracy" Dominated by Managers, with Stewardship by Top Financial Executives, and one of the Koch Brothers?

The current leadership of New York Presbyterian is dominated by businesspeople, not physicians, nurses, or other health care professionals. Only 10 of 33 listed senior leaders are health care professionals. The rest have administrative/ management or legal backgrounds and training. Many appear to be generic managers , that is, people with background and experience primarily in administration or management, but not in medicine, health care, public health, etc.

The hospital system's board of trustees was and is filled with some of the top business executives in the US, including some finance executives who have been cited as responsible for the global financial collapse/ great recession.

For example, we wrote about Mr Dick Fuld, a trustee until recently. Mr Fuld was the CEO who presided over the bankruptcy of Lehman Brothers, which heralded the beginning of the great financial crisis/ great recession of 2008 onward. Mr Fuld seemed to lack the sort of compassionate approach one might expect from someone charged with the stewardship of a big hospital system. He had once publicly said about those who sold Lehman Brother stock short: "what I really want to do is I want to reach in, rip out their heart, and eat it before they die ."

[Mar 23, 2017] A "good start" at the expence of sick people for Collectly a new medical debt collection startuo -- they now collect twise larger share of debt then before. The founder is a former CEO of a debt collection agency and collected over $100 million before

Notable quotes:
"... our intelligent algorithm using state of the art innovative techniques of automation innovation disruption innovation disruption automatically sends orders to police and judges to prepare and serve pay or stay warrants, making sure your debtor goes to jail for their crime! ..."
Mar 23, 2017 | www.nakedcapitalism.com

"All 51 startups that debuted at Y Combinator W17 Demo Day 2" [ TechCrunch ] ( day one ). This is a good one:

Collectly helps doctors collect 2x's more debt than they have before. It's a business with $280 billion sent to debt but the debt collectors only collect on average up to 20%. The founder is a former CEO of a debt collection agency and collected over $100 million before

The acerbic Pinboard comments:
D Pinboard * Follow

@Pinboard

YC so far: surreptitious recording of phone calls, bus tickets for
the starving, debt collection, go live in a box, cow collars,
chatbots

11:41 PM-21 Mar 2017

He's not wrong. (And any time you encounter an online company with a cute name that's also an adverb, like collectly , run a mile, because it's a startup that wants to harm you. Kidding! I think .)

cocomaan , March 22, 2017 at 4:03 pm

Collectly is some really depressing stuff. Wow. More from their website.

3. Transparent collection
Our intelligent software automatically reaches out to customers that didn't pay in time, so you will never need to manually chase them again. And you can see every action on every case.

Totaly fair.

Totaly fair? I had to read it twice. Is that a typo? Or does it mean something?

Next up: our intelligent algorithm using state of the art innovative techniques of automation innovation disruption innovation disruption automatically sends orders to police and judges to prepare and serve pay or stay warrants, making sure your debtor goes to jail for their crime!

Edit: Weird, this went in the wrong place. Oh well.

[Mar 17, 2017] The Affordable Care Act came nowhere close to universal healthcare insurance coverage:

Mar 17, 2017 | economistsview.typepad.com
anne -> Fred C. Dobbs... March 16, 2017 at 06:41 AM , 2017 at 06:41 AM
The Affordable Care Act came nowhere close to universal healthcare insurance coverage:

https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf

September 13, 2016

People Without Health Insurance Coverage, 2007-2015

(Thousands without insurance for entire year)

2007 ( 44,088)
2008 ( 44,780)
2009 ( 48,985) Obama

2010 ( 49,951) (Affordable Care Act)
2011 ( 48,613)
2012 ( 47,951)
2013 ( 41,795)
2014 ( 32,968)

2015 ( 28,966)

anne -> Fred C. Dobbs... , March 16, 2017 at 07:26 AM
https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf

September 13, 2016

People Without Health Insurance Coverage, 2007-2015

(Percent without insurance for entire year)

2007 ( 14.7)
2008 ( 14.9)
2009 ( 16.1) Obama

2010 ( 16.3) (Affordable Care Act)
2011 ( 15.7)
2012 ( 15.4)
2013 ( 13.3)
2014 ( 10.4)

2015 ( 9.1)

[Mar 17, 2017] The difficulties that many families have paying for cancer treatments. The piece points out that even middle income families with good insurance may still face co-payments of tens of thousands of dollars a year

Mar 17, 2017 | economistsview.typepad.com
anne : March 16, 2017 at 06:19 AM

, 2017 at 06:19 AM
http://cepr.net/blogs/beat-the-press/government-granted-patent-monopolies-cause-people-to-skip-cancer-treatments

March 16, 2017

Government Granted Patent Monopolies Cause People to Skip Cancer Treatments

National Public Radio had an interesting segment * on the difficulties that many families have paying for cancer treatments. The piece points out that even middle income families with good insurance may still face co-payments of tens of thousands of dollars a year.

One item not mentioned in this piece is that the reason the prices of new cancer drugs is high is that the government grants companies patent monopolies. This is done as a way to finance research. In almost all cases these drugs would be available for less than a thousand dollars ** for a year's treatment if the drugs were sold in a free market.

While it is necessary to pay for research, there are more modern and efficient mechanisms than patent monopolies (see "Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer" *** ).

* http://www.npr.org/sections/health-shots/2017/03/15/520110742/as-drug-costs-soar-people-delay-or-skip-cancer-treatments

** http://www.thebodypro.com/content/78658/1000-fold-mark-up-for-drug-prices-in-high-income-c.html

*** http://deanbaker.net/images/stories/documents/Rigged.pdf

-- Dean Baker

anne -> anne... , March 16, 2017 at 06:20 AM
http://deanbaker.net/images/stories/documents/Rigged.pdf

October, 2016

Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer
By Dean Baker

The Old Technology and Inequality Scam: The Story of Patents and Copyrights

One of the amazing lines often repeated by people in policy debates is that, as a result of technology, we are seeing income redistributed from people who work for a living to the people who own the technology. While the redistribution part of the story may be mostly true, the problem is that the technology does not determine who "owns" the technology. The people who write the laws determine who owns the technology.

Specifically, patents and copyrights give their holders monopolies on technology or creative work for their duration. If we are concerned that money is going from ordinary workers to people who hold patents and copyrights, then one policy we may want to consider is shortening and weakening these monopolies. But policy has gone sharply in the opposite direction over the last four decades, as a wide variety of measures have been put into law that make these protections longer and stronger. Thus, the redistribution from people who work to people who own the technology should not be surprising - that was the purpose of the policy.

If stronger rules on patents and copyrights produced economic dividends in the form of more innovation and more creative output, then this upward redistribution might be justified. But the evidence doesn't indicate there has been any noticeable growth dividend associated with this upward redistribution. In fact, stronger patent protection seems to be associated with slower growth.

Before directly considering the case, it is worth thinking for a minute about what the world might look like if we had alternative mechanisms to patents and copyrights, so that the items now subject to these monopolies could be sold in a free market just like paper cups and shovels.

The biggest impact would be in prescription drugs. The breakthrough drugs for cancer, hepatitis C, and other diseases, which now sell for tens or hundreds of thousands of dollars annually, would instead sell for a few hundred dollars. No one would have to struggle to get their insurer to pay for drugs or scrape together the money from friends and family. Almost every drug would be well within an affordable price range for a middle-class family, and covering the cost for poorer families could be easily managed by governments and aid agencies.

The same would be the case with various medical tests and treatments. Doctors would not have to struggle with a decision about whether to prescribe an expensive scan, which might be the best way to detect a cancerous growth or other health issue, or to rely on cheaper but less reliable technology. In the absence of patent protection even the most cutting edge scans would be reasonably priced.

Health care is not the only area that would be transformed by a free market in technology and creative work. Imagine that all the textbooks needed by college students could be downloaded at no cost over the web and printed out for the price of the paper. Suppose that a vast amount of new books, recorded music, and movies was freely available on the web.

People or companies who create and innovate deserve to be compensated, but there is little reason to believe that the current system of patent and copyright monopolies is the best way to support their work. It's not surprising that the people who benefit from the current system are reluctant to have the efficiency of patents and copyrights become a topic for public debate, but those who are serious about inequality have no choice. These forms of property claims have been important drivers of inequality in the last four decades.

The explicit assumption behind the steps over the last four decades to increase the strength and duration of patent and copyright protection is that the higher prices resulting from increased protection will be more than offset by an increased incentive for innovation and creative work. Patent and copyright protection should be understood as being like very large tariffs. These protections can often the raise the price of protected items by several multiples of the free market price, making them comparable to tariffs of several hundred or even several thousand percent. The resulting economic distortions are comparable to what they would be if we imposed tariffs of this magnitude.

The justification for granting these monopoly protections is that the increased innovation and creative work that is produced as a result of these incentives exceeds the economic costs from patent and copyright monopolies. However, there is remarkably little evidence to support this assumption. While the cost of patent and copyright protection in higher prices is apparent, even if not well-measured, there is little evidence of a substantial payoff in the form of a more rapid pace of innovation or more and better creative work....

Tom aka Rusty said in reply to anne... , -1
I'm trying to imagine why anyone would write a 900 page textbook, plus add-ons (test bank, solutions manual) and then give it away.

I have refused to co-author several times because the work is agonizing, the revisions never ending, and only a few texts make anyone rich.

[Mar 07, 2017] Americans' Challenges with Health Care Costs

Notable quotes:
"... Three in ten (29 percent) Americans report problems paying medical bills, and these problems come with real consequences for some. For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items. ..."
"... Challenges affording care also result in some Americans saying they have delayed or skipped care due to costs in the past year, including 27 percent who say they have put off or postponed getting health care they needed, 23 percent who say they have skipped a recommended medical test or treatment, and 21 percent who say they have not filled a prescription for a medicine. ..."
Mar 07, 2017 | economistsview.typepad.com
anne : March 06, 2017 at 11:40 AM , 2017 at 11:40 AM
http://kff.org/health-costs/poll-finding/data-note-americans-challenges-with-health-care-costs/

March 2, 2017

Americans' Challenges with Health Care Costs
By Bianca DiJulio, Ashley Kirzinger, Bryan Wu, and Mollyann Brodie

As lawmakers debate the future of the country's health care system and outline plans to repeal and replace the Affordable Care Act, much of the current debate surrounds how to change or eliminate the health insurance marketplaces developed under the ACA where individuals eligible for financial assistance could compare plans and purchase insurance. While this is an important source of coverage for some, the vast majority of Americans with insurance have coverage from other sources, such as an employer, Medicaid or Medicare, and the public's top priority for lawmakers is reducing what Americans pay for health care. Two recent Kaiser Health Tracking Polls take stock of the public's current experience with and worries about health care costs, including their ability to afford premiums and deductibles. For the most part, the majority of the public does not have difficulty paying for care, but significant minorities do, and even more worry about their ability to afford care in the future. Some of the key findings include:

Four in ten (43 percent) adults with health insurance say they have difficulty affording their deductible, and roughly a third say they have trouble affording their premiums and other cost sharing; all shares have increased since 2015.

Three in ten (29 percent) Americans report problems paying medical bills, and these problems come with real consequences for some. For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items.

Challenges affording care also result in some Americans saying they have delayed or skipped care due to costs in the past year, including 27 percent who say they have put off or postponed getting health care they needed, 23 percent who say they have skipped a recommended medical test or treatment, and 21 percent who say they have not filled a prescription for a medicine.

Even for those who may not have had difficulty affording care or paying medical bills, there is still a widespread worry about being able to afford needed health care services, with half of the public expressing worry about this.

Health care-related worries and problems paying for care are particularly prevalent among the uninsured, individuals with lower incomes, and those in poorer health; but women and members of racial minority groups are also more likely than their peers to report these issues....

Peter K. -> anne... , March 06, 2017 at 11:48 AM
"For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items."

That's what the neoliberals like our dear trolls kthomas and PGL want.

They're in the pocket of the lobbyists.

[Mar 07, 2017] Uncertainty and the Welfare Economics of Medical Care

Mar 07, 2017 | economistsview.typepad.com
anne -> anne... March 06, 2017 at 05:11 PM , 2017 at 05:11 PM
https://web.stanford.edu/~jay/health_class/Readings/Lecture01/arrow.pdf

December, 1963

Uncertainty and the Welfare Economics of Medical Care
By KENNETH J. ARROW

I. Introduction: Scope and Method

This paper is an exploratory and tentative study of the specific differentia of medical care as the object of normative economics. It is contended here, on the basis of comparison of obvious characteristics of the medical-care industry with the norms of welfare economics, that the special economic problems of medical care can be explained as adaptations to the existence of uncertainty in the incidence of disease and in the efficacy of treatment.

It should be noted that the subject is the medical-care industry, not health. The causal factors in health are many, and the provision of medical care is only one. Particularly at low levels of income, other commodities such as nutrition, shelter, clothing, and sanitation may be much more significant. It is the complex of services that center about the physician, private and group practice, hospitals, and public health, which I propose to discuss.

The focus of discussion will be on the way the operation of the medical-care industry and the efficacy with which it satisfies the needs of society differ from a norm, if at all. The "norm" that the economist usually uses for the purposes of such comparisons is the operation of a competitive model, that is, the flows of services that would be offered and purchased and the prices that would be paid for them if each individual in the market offered or purchased services at the going prices as if his decisions had no influence over them, and the going prices were such that the amounts of services which were available equalled the total amounts which other individuals were willing to purchase, with no imposed restrictions on supply or demand.

The interest in the competitive model stems partly from its presumed descriptive power and partly from its implications for economic efficiency. In particular, we can state the following well-known proposition (First Optimality Theorem)....

a

[Mar 07, 2017] Notes on US healthdoesntcare

Mar 07, 2017 | economistsview.typepad.com
libezkova : March 06, 2017 at 08:41 PM

The problems with US Healthdoesn'tcare started around 1980.

What we observe now (completely broken and corrupt to the core system) is the result of long term term slow deterioration.

Now the US Healthdoesn'tcare in many cases represent the completely opposite practice to healthcare -- health racket.

And they even created their specialized firms that help to extract maximum dollars for private providers.

An interesting example of how pervert the USA healthcare system became in the USA under neoliberalism is proliferation of private ambulance services which are technically are always "out of network" and after providing services (often non-essential and equal to the ride to ER, but mostly unavoidable as soon as 911 service or traffic police is involved, especially for those who are in this situation for the first time ) they bill an outrageous amount to lemmings who do not know how to fight the system.

Average private ambulance bill is probably around $5K in the USA. And that if this was just a ride to ER.

If you have insurance it will pay around the same as Medicare and your bill will be around ~$3.5K

This so called differential billing in now outlawed in a couple of states (CA, partially NY), but still is legal in most other states.

This industry also creates specialized collector agencies that deal almost exclusively with collecting ambulance bills like Revenue Guard - Ambulance Billing & Financial Management ( https://www.revenue-guard.com/). And look who is at the helm of this wonder of neoliberal health industry (pretty profitable -- currently bills over 120 million in revenue annually taking in probably lion share of that) -- James J. Loures, President & CEO

James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region.

Is not neoliberalism wonderful social system ?

So when somebody is taking about destruction of the US health care system by Trump one needs to understand that there is not much left to destruct. Most of the heavy lifting was done by previous administrations.

Including Obama with his coward method of betrayal of his voters and serving medical industrial complex.

Trump is bad, but to claim that because of that Obama was good is silly. He was just a perfect example of neoliberal "bait and switch" politician.

B.T. :
, March 06, 2017 at 07:51 PM
So it's like the ACA?

Or it's terrible?

Make up your minds neoliberals. Since you didn't want single payer.

libezkova -> B.T.... , March 06, 2017 at 09:12 PM
It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. ( http://khn.org/morning-breakout/health-care-billing-errors/ )

"thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones."

Private medical industry and insurance are symbiotic in their desire to milk patients out of their money in the most efficient way possible.

And while those "death panel" decisions are very difficult indeed, fraud is rampant and they are very successful in over-billing patients.

This symbiosis is very similar in nature to what we observe with body shops and car insurance.

[Mar 06, 2017] Something about the meaning of life under neoliberalism

Notable quotes:
"... Probably the most telling example on neoliberal transformation is transformation of healthcare. ..."
"... Mulligan's research shows how "market values come to displace competing notions of what is "good" or "right" in health care" (Mulligan 2010:308–309). She argues that quality in health care is not only a technical matter for evaluating the performance of systems, but, more importantly, it is a particular epistemology, a specific way of knowing. ..."
"... Managing for-profit health care systems successfully requires innovative mechanisms of population control (Abadía-Barrero et al. 2011), including people's acceptance of market principles. ..."
"... In this historical context, what is crucial is the understanding of the relationship between techniques of governance and the production of social inequality (i.e., an ideological domination reflected in people's support for political practices that are antithetical to their interests). ..."
"... James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region. ..."
Mar 03, 2017 | economistsview.typepad.com
libezkova : March 03, 2017 at 03:51 PM
Something about the "meaning of life" under neoliberalism

Probably the most telling example on neoliberal transformation is transformation of healthcare.

http://onlinelibrary.wiley.com/doi/10.1111/maq.12161/full

== quote ==

Several anthropologists have written about how "market ideology and corporate structures are shaping medicine and health care delivery" (Horton et al. 2014; Lamphere 2005; Rylko-Bauer and Farmer 2002:476).

Mulligan's research shows how "market values come to displace competing notions of what is "good" or "right" in health care" (Mulligan 2010:308–309). She argues that quality in health care is not only a technical matter for evaluating the performance of systems, but, more importantly, it is a particular epistemology, a specific way of knowing.

The information that is produced in technical public health policy terms, and, I would add, in technical legal terms, is "a knowledge-making practice that creates information about the health care system and for managing the system in new ways" (Mulligan 2010:309).

Managing for-profit health care systems successfully requires innovative mechanisms of population control (Abadía-Barrero et al. 2011), including people's acceptance of market principles.

In this historical context, what is crucial is the understanding of the relationship between techniques of governance and the production of social inequality (i.e., an ideological domination reflected in people's support for political practices that are antithetical to their interests).

According to Fassin (2009), Foucault's undeveloped concept of a Politics of Life can illuminate how in regulating populations and normalizing societies, moral ideas about the meaning of life and about how life is valued are enforced.

An understanding of moral definitions of human life must take into account how history becomes embodied, which then illuminates the political tensions that support differential values by which life is organized, represented, and responded to, for example through public policy (Fassin 2007).

== end of quote ==

See also

https://www.youtube.com/watch?v=TsoZeg6CDRY

An interesting example of how pervert the healthcare system became in the USA under neoliberalism is proliferation of private ambulance services which are technically always "out of network" and after providing services (often non-essential) bill outrageous amount to lemmings who do not know how to fight the system. Average private ambulance bill is probably around $5K in the USA. If you have insurance your bill will be around ~$3.5K

This so called differential billing in now outlawed in a couple of states, but still is legal in most states.

This industry also creates specialized collector agencies that deal almost exclusively with collecting ambulance bills like Revenue Guard - Ambulance Billing & Financial Management ( https://www.revenue-guard.com/)

== quote ==

Revenue Guard Executive Team

James J. Loures, President & CEO
James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region. After merging MultiCare with the publicly traded Rural-Metro in 2001, James then founded Revenue-Guard in 2004. The company has grown to be a premier provider of EMS revenue cycle and management services in the hospital marketplace, and currently bills over 120 million in revenue annually for their clients. James studied economics at Rutgers University .

Steven J. Loures, Co-Founder and Chief Operations Officer
Steven Loures has 30 years of experience in the Emergency Medical Services / Mobile Health Services field and is considered an expert in revenue cycle, compliance and improving ambulance service operating margins. His real-world revenue cycle knowledge combined with 20 years of managing ambulance operations uniquely differentiates himself with a comprehensive industry perspective. His leadership has provided client confidence to initiate targeted change knowing his proven track record. He is the point of contact for all new and existing clients.

Prior to his current role Steven was the New Jersey Division General Manager of Rural Metro Ambulance. Rural Metro is a large nationwide provider of Emergency Medical Services. He was responsible for oversight of 350 employees, 6 operating locations in three states including New Jersey, Pennsylvania and New York City. Additionally, Steven's responsibilities included all budgets, revenue cycle management, billing compliance, and Sarbanes Oxley financial controls.

Prior to Rural Metro Steven was a Commercial Lear Jet Pilot. The operation provided nationwide long distance critical care air ambulance services. Steven graduated from Embry-Riddle Aeronautical University, Daytona Beach Florida with his Federal Aviation Administration Commercial, Multi-Engine, and Instrument ratings. Early in his career path Steven was a certified NJ paramedic at age 21 and one of the youngest certified paramedics in New Jersey.

Stephanie Dall, Vice President of Finance
Stephanie joined Revenue-Guard in 2005 and is responsible for Finance, Administration, Compliance and client reporting. She has 20 years experience in finance and administration with Rural-Metro Inc. the leading EMS provider in the nation. Stephanie develops budgets and establish performance metrics for Revenue-Guard. Stephanie has a bachelors degree in accounting from Rutgers University.

Jennifer Aldana, Vice President of Revenue Cycle
Jennifer joined Revenue-Guard in 2007 to manage and run the billing services division. She manages a staff of 60 billing specialist processing over $120M in ambulance claims annually. Jennifer is a former revenue cycle manager at Rural-Metro The country's largest EMS service based in Scottsdale, Arizona. She handles all system customizations, ePCR integration and client support services. Jen studied at Pace University in New York City.

[Mar 03, 2017] U.S. Medical Coding System

Notable quotes:
"... Successful medical coders learn and follow coding guidelines and use them to their benefit. Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a way to appeal the denial and get the claim paid. ..."
"... Each diagnosis code has to be coded to the highest level of specificity , so the insurance company knows exactly what the patient's diagnosis was. ..."
"... I've helpfully underlined places where an "unusual opportunity for profit" might be spotted and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for management. ..."
"... A pair of transposed digits in a medical identification number was the difference between insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic hired for help caught the innocuous mistake - the sole reason his insurance company had refused to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep. ..."
"... Had it remained unnoticed - as often happens to patients faced with daunting medical debt - Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little choice but to live in bankruptcy. ..."
"... thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising. ..."
"... More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that. ..."
"... The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software. ..."
"... eight of 10 bills its members have audited from hospitals and health care providers contain errors. ..."
"... It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. ..."
"... Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent. ..."
"... Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used for facility services (such as the room charge in image). ..."
"... ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure codes are sometimes used for payments but usually only on inpatient claims. ..."
Mar 03, 2017 | www.nakedcapitalism.com
From my review of Akerlof and Shiller's Phishing for Phools , November 25, 2015 :

As businesspeople choose what line of business to undertake - as well as where they expand, or contract, their existing business - they (like customers approaching checkout) pick off the best opportunities. This too creates an equilibrium. Any opportunities for unusual profits are quickly taken off the table, leading to a situation where such opportunities are hard to find. This principle, with the concept of equilibrium it entails, lies at the heart of economics.

The principle also applies to phishing for phools. That means that if we have some weakness or other - some way in which we can be phished for fools for more than the usual profit - in the phishing equilibrium someone will take advantage of it . Among all those business persons figuratively arriving at the checkout counter, looking around, and deciding where to spend their investment dollars, some will look to see if there are unusual profits from phishing us for phools. And if they see such an opportunity for profit, that will (again figuratively) be the "checkout lane" they choose.

And economies will have a "phishing equilibrium," in which every chance for profit more than the ordinary will be taken up.

We might summarize Akerlof and Shiller as "If a system enables fraud, fraud will happen," or, in stronger form, "If a system enables fraud, fraud will already have happened."[1] And as we shall see, plenty of "opportunities for unusual profits" exist in medical coding.

... ... ...

Here is the medical coding process, from the coders perspective, as described by MB-Guide, a site for aspiring medical coders :

Successful medical coders learn and follow coding guidelines and use them to their benefit. Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a way to appeal the denial and get the claim paid.

Hmm. "Their" benefit. Here are the guidelines:

I've helpfully underlined places where an "unusual opportunity for profit" might be spotted and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for management. The Denver Post gives a horrific example:

Miscoding Fictions, frauds found to abound in medical bills

A pair of transposed digits in a medical identification number was the difference between insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic hired for help caught the innocuous mistake - the sole reason his insurance company had refused to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep.

Had it remained unnoticed - as often happens to patients faced with daunting medical debt - Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little choice but to live in bankruptcy.

Finally, there's "upcoding," and if you are reminded of "upselling" you are exactly right. The Center for Public Integrity :

But the Center's analysis of Medicare claims from 2001 through 2010 shows that over time, thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising.

More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that.

The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software.

Now, I'll be the first to admit that I can't quantify the impedance mismatches, the miscoding, and the upcoding. Regardless, medical coding is the key dataflow in the healthcare system :

"Roughly $250 billion is moving through those codes," [says Steve Parente, professor of finance at the Carlson School of Management at the University of Minnesota]. On top of that, about 80% of medical bills contain errors, according to Christie Hudson, vice president of Medical Billing Advocates of America, making already-expensive bills higher. Today's complex medical-billing system, guided by hundreds of pages of procedure codes, allows fraud, abuse and human error to go undetected, Hudson says. "Until the fraud is detected in these bills the cost of health care is just going to increase. It's not accidental. We've been fighting these overcharges they continue to happen and we continue to get them removed from bills." These errors, which are hard to detect because medical bills are written in a mysterious code, can result in overcharges that run from a few dollars to tens of thousands.

That "mysterious code" is (now) ICD-10, and it's the mystery plus the profit motive that creates the phishing equilibrium. Kaiser Health News quotes the Denver Post :

Experts say there are tens of thousands more like Dziedzic across the country with strangling medical debts.

Medical Billing Advocates of America, a trade group in Salem, Va., says that eight of 10 bills its members have audited from hospitals and health care providers contain errors.

It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. Some say new reform laws will only make things worse." Others say that errors occur largely because of "the complexity of deciphering bills and claims weighted down by complex codes."

Even if the "trade group" is talking it's book, it's still quite a book . NBC :

Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent.

Gee, I wonder if the errors are randomly distributed?

Neoliberal "Consumer"-Driven Solutions

My guts have started to gripe, so I won't go into detail about how you too, the citizen , can learn medical billing codes if you want to dispute your bill. See this cheery post from NerdWallet on "How to Read Your Medical Bill :

Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes and overcharges.

Your medical bill is going to be chock-full of codes and words you may not understand, so the first step is gathering resources that will translate them into plain English.

Ivy , March 2, 2017 at 2:29 pm

One useful adjunct to the coding discussion concerns other billing details such as meds. There is wide variability in prices charged, and when you see $160 for a single pill (e.g., Hexabrix) or $26 for a single Tylenol, then something is not right. Of course, that does not include any allocation for nurses, pharmacy or other potential costs, since those are rolled into other line items to decipher. When hospital billing reps are asked about the reasonability and basis of their charges, they spout the canned line about being in line with their local competitors.

Why not have some program with mutual insurance companies, removing in theory some of the profit that is driving the typical health care insurers?

TheBellTolling , March 2, 2017 at 2:31 pm

Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used for facility services (such as the room charge in image).

ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure codes are sometimes used for payments but usually only on inpatient claims.

_________________________________

Additionaly, coding also affects "risk adjustment" in Medicare Advantage and ACA payments and this form of payment does use ICD codes. They use the codes on the claims to determine how "sick"(has conditions that will cost more) each member is and give insurers more or less money based on the average risk scores of their members. Since it relies on coding this system is also subject to gaming.

In Medicare Advantage this is done relative to non-Medicare Advantage population, so if the MA plans are upcoding they get more money from Federal government. In 2010 CMS was given the ability to use some adjustment factors to MA payments to address the issue but I don't really know how effective it is.

In ACA this is done relative to all the other insurers in the individual/small group market(so all the money is changing hands between the insurers). More established plans generally do better since they have more data on members from before ACA to make sure they get coded in addition to resources they probably built from Medicare Advantage. This ends up disadvantaging smaller and newer plans like co-ops.
_____________

[Mar 03, 2017] How to Read Your Medical Bill

Notable quotes:
"... That is not the bill you want. To know what you're actually being charged for, you'll want to call the clinic or hospital and ask for the complete, itemized bill for all services you received, with codes. It is your right to know what you're being charged for, but you will probably have to call and request the detailed charges. The body of that bill should look more like this: ..."
NerdWallet
Clerical errors are more likely than you might think, says Gross, who has seen small mistakes in names and addresses result in huge billing complications. Before you move on, make sure your name, address, insurance information and dates of care are correct on the top of the bill.

header

When you receive inpatient or outpatient care, the first statement you'll receive is most likely a summary bill. Often, but not always, health care providers will send only a summary of charges with a final charge at the end. The body of the bill has a few generic categories and no codes, looking something like this:

summarybill

That is not the bill you want. To know what you're actually being charged for, you'll want to call the clinic or hospital and ask for the complete, itemized bill for all services you received, with codes. It is your right to know what you're being charged for, but you will probably have to call and request the detailed charges. The body of that bill should look more like this:

detailed

Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes and overcharges.

Next, know what the codes are for

Before we get into the nuts and bolts of reading your medical bill, it's worth noting that there's more than one type of code that may be listed on your bill.

svccode

HCPCS Level I, or CPT Codes, are universal, used by all providers in the U.S. and consist of five digits that identify procedures or tests. Often, they are listed as service codes.

svccode2

HCPCS Level II Codes identify supplies or products used during your visit. These codes often start with a letter, rather than a number, but are also referred to as service codes.

[Feb 27, 2017] Why Markets Can't Cure Healthcare

Feb 27, 2017 | economistsview.typepad.com
anne -> anne... February 26, 2017 at 02:07 PM , 2017 at 02:07 PM
http://krugman.blogs.nytimes.com/2009/07/25/why-markets-cant-cure-healthcare/

July 25, 2009

Why Markets Can't Cure Healthcare
By Paul Krugman

Judging both from comments on this blog and from some of my mail, a significant number of Americans believe that the answer to our health care problems - indeed, the only answer - is to rely on the free market. Quite a few seem to believe that this view reflects the lessons of economic theory.

Not so. One of the most influential economic papers of the postwar era was Kenneth Arrow's "Uncertainty and the Welfare Economics of Health Care," * which demonstrated - decisively, I and many others believe - that health care can't be marketed like bread or TVs. Let me offer my own version of Arrow's argument.

There are two strongly distinctive aspects of health care. One is that you don't know when or whether you'll need care - but if you do, the care can be extremely expensive. The big bucks are in triple coronary bypass surgery, not routine visits to the doctor's office; and very, very few people can afford to pay major medical costs out of pocket.

This tells you right away that health care can't be sold like bread. It must be largely paid for by some kind of insurance. And this in turn means that someone other than the patient ends up making decisions about what to buy. Consumer choice is nonsense when it comes to health care. And you can't just trust insurance companies either - they're not in business for their health, or yours.

This problem is made worse by the fact that actually paying for your health care is a loss from an insurers' point of view - they actually refer to it as "medical costs." This means both that insurers try to deny as many claims as possible, and that they try to avoid covering people who are actually likely to need care. Both of these strategies use a lot of resources, which is why private insurance has much higher administrative costs than single-payer systems. And since there's a widespread sense that our fellow citizens should get the care we need - not everyone agrees, but most do - this means that private insurance basically spends a lot of money on socially destructive activities.

The second thing about health care is that it's complicated, and you can't rely on experience or comparison shopping. ("I hear they've got a real deal on stents over at St. Mary's!") That's why doctors are supposed to follow an ethical code, why we expect more from them than from bakers or grocery store owners.

You could rely on a health maintenance organization to make the hard choices and do the cost management, and to some extent we do. But HMOs have been highly limited in their ability to achieve cost-effectiveness because people don't trust them - they're profit-making institutions, and your treatment is their cost.

Between those two factors, health care just doesn't work as a standard market story.

All of this doesn't necessarily mean that socialized medicine, or even single-payer, is the only way to go. There are a number of successful healthcare systems, at least as measured by pretty good care much cheaper than here, and they are quite different from each other. There are, however, no examples of successful health care based on the principles of the free market, for one simple reason: in health care, the free market just doesn't work. And people who say that the market is the answer are flying in the face of both theory and overwhelming evidence.

* https://web.stanford.edu/~jay/health_class/Readings/Lecture01/arrow.pdf

anne -> anne... , February 26, 2017 at 02:44 PM
Correcting again and continuing:

Though Krugman always praises the work of Arrow on healthcare markets, Krugman never seems much been influenced by the work.

Though praising Arrow on healthcare markets, Krugman seemingly has spent no time on or possibly has dismissed research affirming Arrow and has not supported the sorts of healthcare insurance systems that would follow from accepting the work of Arrow:

https://promarket.org/there-is-regulatory-capture-but-it-is-by-no-means-complete/
/
March 15, 2016

"There Is Regulatory Capture, But It Is By No Means Complete"
By Asher Schechter

Kenneth J. Arrow, one of the most influential economists of the 20th century, reflects on the benefits of a single payer health care system, the role of government and regulatory capture.

Mr. Bill : , February 26, 2017 at 03:32 PM
So Anne, what your saying is that "health care" is a monopolistic industry that makes more money by restricting care and charging more ? Allowing people that can't afford to live, too die?

Well. yes, I agree with your presumed hypothesis, and I admire your boldness for stepping out in front of this moving freight train, risking your beloved tenure.

To me ? Thanks for asking.

I think that the 3 % administrative costs of the existing single payer system are more pareto optimal than the 25 % that the monopolists' extract. What do I know. This is America. Dumb is not an option.

anne : , February 26, 2017 at 06:33 PM
Turning again to Kenneth Arrow and healthcare markets, assuming that Arrow was correct for all these years, and subsequent research repeatedly has confirmed Arrow, then a typical American market-based healthcare insurance system is going to prove unworkable. Why then has the work of Arrow which is at least superficially so broadly praised by economists not been more influential in forming policy?
libezkova -> anne... , February 26, 2017 at 07:12 PM
"It is difficult to get a man to understand something, when his salary depends on his not understanding it."

― Upton Sinclair, I, Candidate for Governor: And How I Got Licked

[Jan 23, 2017] Consumer Guide to Health Care - Coping with Medical Bills and Debt Wisconsin Department of Health Services

Notable quotes:
"... Record the names and phone numbers of the people you are dealing with. ..."
"... Document the date, time, and results of your phone calls. ..."
"... Pay something - even a small amount - on each bill each month as a gesture of good faith. ..."
"... Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. ..."
"... Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately. ..."
"... Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt ..."
Jan 23, 2017 | dhs.wisconsin.gov
Unless you have successfully challenged your bill, you are responsible for paying all of your medical bills. If you cannot pay, here are some things to consider.
  1. Try to negotiate a payment plan. Your hospital or provider may be willing to accept smaller monthly payments. Keep in mind that your payments generally need to be reasonable and you must keep up with your payments. In its advice to parents of chronically ill children (link is external) , the American Academy of Family Physicians recommends the following:
    • Notify the appropriate offices quickly.
    • Keep in touch with your creditors.
    • Record the names and phone numbers of the people you are dealing with.
    • Document the date, time, and results of your phone calls.
    • Pay something - even a small amount - on each bill each month as a gesture of good faith.
  2. Get information on charity care in Wisconsin hospitals.
  3. Apply for Wisconsin Medicaid or BadgerCare Plus . If you are eligible, Medicaid may pay for some of your existing medical bills. Wisconsin Medicaid coverage can begin as early as the first day of the month, three months before the month you apply, if you would have been eligible in those months, so apply as soon as possible.
  4. Go for credit counseling. Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. Make sure you are working with a credit counseling service (also known as an adjustment service agency) that is licensed by the Wisconsin Department of Financial Institutions.
  5. Be creative about finding help from outside sources. Charitable foundations, civic organizations and churches and community groups might be able to help. The Patient Pal (link is external) (PDF, 197 KB) from the Patient Advocate Foundation (link is external) includes some fundraising ideas for those with high medical bills.
  6. Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately.
  7. Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt for two reasons:
    • The interest rates on your credit card will add significantly to your total payment.
    • Transferring medical debt to a credit card may affect your eligibility for Medicaid. Some medical costs can be deducted from gross income to determine your Medicaid eligibility. Medical debt on a credit card may no longer qualify as medical debt.
Dealing with collection agencies

If your hospital or other health care provider has turned your bill over to a collection agency, you are protected against harassment by the Fair Debt Collection Practices Act (FDCPA).

If you have questions about your rights or the conduct of a collection agency, contact the Department of Financial Institutions at (608) 264-7969, or 1-800-452-3328 (in Wisconsin only).

Bankruptcy The decision to file for bankruptcy should be last resort. More (PDF, 129 KB) information on how bankruptcy works and the different types (link is external) is available from the Wisconsin Department of Agriculture, Trade and Consumer Protection.

Legal help

If you find that you need legal help to deal with your medical debt, the Wisconsin State Bar Association's website provides general information on finding a lawyer (link is external) and information on finding a lawyer if you have a low income (link is external) .

The Legal Services Corporation (link is external) , a private, non-profit corporation established by Congress, provides a list of Wisconsin local legal aid programs (link is external) from its website.

[Jan 23, 2017] Medical Debt Collections –Unexpected Health Problems Costs

Jan 23, 2017 | www.debt.org

Medical debt collectors must abide by specific regulations, as set forth by the Fair Debt Collection Practices Act . Collectors cannot harass or lie to debtors, or perform any other practices deemed unfair.

[Jan 23, 2017] Medical Debt Collection

You can get a free Kindle version of "Debt Collection Answers" ebook on Amazon here .
Notable quotes:
"... We have heard from consumers who first hear about a medical bill from a collection agency. There is no federal law that protects you from this type of situation. ..."
Jan 23, 2017 | www.debtcollectionanswers.com
Having even a small medical debt reported as past due or in collections can seriously damage your credit history, you may be tempted to pay just to protect your credit.

Some medical providers may even try to pressure you into paying your debt owe by refusing to provide you (or one of your family members) with additional medical care until you do. Some of them may even refuse you future care while you are paying off your debt through an installment plan! Others may have a policy that as long as you owe them money, you must pay up-front for all future medical services they provide to you.

Warning: Aggressive medical providers can be a special problem for seniors living on fixed incomes when their spouses have been hospitalized or have accumulated a large outstanding bill with one or more of their doctors.


When Can I Be Sent to Collections On a Medical Bill?

If at all possible, you want to keep a medical bill out of collections. Once it is turned over to a collection agency, it will likely appear on your credit reports as a collection account and damage your credit rating.

Your medical debt may be turned over to collections:

How can you protect yourself from medical debt collection? Don't ignore medical bills. Talk to the medical provider. Get everything in writing, or follow up in writing yourself

... ... ...

If You Have Insurance and Your Insurer Refuses to Pay All or a Portion of Your Medical Bills

It's not unusual for health insurers to deny coverage for medical care. If that happens to you and you believe that the care should be covered, or if your insurer pays some but not all of your medical bill and you believe it should cover the entire bill, here's what we recommend:

[Jan 23, 2017] In debt and afraid: dealing with debt collectors

Notable quotes:
"... The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service. ..."
"... Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you. ..."
"... Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney. ..."
"... Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die! ..."
"... Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. ..."
"... Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death ..."
Jan 23, 2017 | finance.yahoo.com
Sarah Skidmore Sell, AP Personal Finance Writer

It's a scary place to be - in debt and afraid.

A new Consumer Financial Protection Bureau report found that more than one in four consumers felt threatened when contacted by debt collectors. The first-ever national survey of consumer experiences with debt collectors found consumers often faced calls that came too often, at odd hours and contained warnings of jail time and other threats. Some were contacted for debts they didn't owe. And many said when they asked the collector to stop contacting them, the request was ignored.

CFPB Director Rich Cordray said the report casts a "troubling light" on the industry, and that the bureau is working to stop abuses. But what are your rights when facing off with a debt collector?

A few things to know:

YOU ARE NOT ALONE

The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service.

The Federal Trade Commission, which enforces the Fair Debt Collection Practices Act, also said debt collectors generate more complaints to its offices than any other industry. While many debt collectors are careful to comply with consumer protection laws, some engage in illegal practices.

YOU ARE PROTECTED

The Fair Debt Collection Practices Act provides protection for those being pursued for personal debts, such as money owed on a credit card account, an auto loan or a mortgage. It doesn't cover debts incurred to run a business.

YOU HAVE RIGHTS

Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you.

They may not contact you at inconvenient times or places, such as early in the morning or late at night. And they may not contact you at work if they're told not to.

Debt collectors may not harass, oppress, or abuse you, according to the FTC. That includes threats of violence or using obscene language. Federal law also limits the number of calls a debt collector can place.

Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney.

YOU CAN TAKE ACTION

Report any problems you have with a debt collector to your state Attorney General's office, the Federal Trade Commission and the Consumer Financial Protection Bureau. Many states have their own debt collection laws that vary from federal law, so contact your attorney general's office for help.

Gary G

They are debt collectors the lowest form of bottom feeding #$%$ on the planet.step one, NEVER tell them any personal information whatsoever.step two, get a phone number and case number so you can call them back.step three call them from a phone that can record the conversation (theres an app for that)step three, call them when you are really ready to talk to them Inform them the call is being recorded. let them know clearly what forms of contact are and are not acceptable.step four, get the pertinent information about the debt including the debtor any account numbers and any settlement offers they have. Still NEVER give away any personal information. once you have all the information you need end the call, if at any time during the call you feel you are being harassed or intimidated inform them it is not acceptable (remember you are recording the conversation) and terminate the call. call back later.Now you are in control and can make informed decisions.If at some point you want/need to work out a settlement NEVER finalize anything on the phone, GET IT IN WRITING. NEVER, agree to give them your credit card or banking information under any circumstances!!!once you make an arrangement keep the printed document with the arrangement on file for the rest of your life.

Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die!

steven

Based on personal experience, the worst debt collectors are of the medical variety. Two years of a fatal ovarian cancer case overwhelmed not only my finances, but jeopardized my mental health as well. The only thing that kept me going was the necessity of showing up for work, and the support of coworkers and (may I say this?) my managers as well.

Mark

Consumer Financial Protection Bureau will be gutted under the GOP agenda. So the next time some cable company, Wall Street bank, or some other huge corporation screws you over, you'll have no recourse and you'll be on your own.

pfk

I find tgheses stories and the ads on TV (If you owe $1000 to IRS..., If you have more than $5,00 credit card debt, Reduce $50,00 debt to $5000..., etc) to e morally contemptible. If you cannot afford something do not buy it; if you have a job, pay your IRS taxes, etc. I'm tired paying extra for everything I buy or do for these people who spend and expect someone else (me) to pay.

a

hogwash! To scare off a junk debt buyer attorney all you need to do is make one call to your attorney. Many of you collectors "start fake lawsuits" to coerce debtors to pay. With no filing numbers, court stamps, etc... Once the debtor's attorney files a 'notice of appearance' and asks for a real lawsuit/trial, what happens? The creditor never files the lawsuit. Why? Because the junk debt buyer has to PROVE IT. The JDB creditor has no original contract signed to prove the debt exists, no chain of assignment/invoice to show they have standing to sue (own the debt) nor the account statements to verify what is owed. They are hoping at best for default judgements.

Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. You see Junk Debt Buyers buy debt with no contract signed by debtors, have no invoice they even own this particular debt in detail and no account statements to verify correct amount owed.

So debtors, beware, pay the few hundred dollars to your attorney to ask for a lawsuit and notice of appearance and see how fast that debt collector disappears. 99% of junk debt buyers/creditors buy unwarranted debt and CAN NOT PROVE IT IN COURT. There is a disclaimer on the debt stating there is no contract, invoice that it is sold nor account statements offered.

Just sue these junk debt buyers and they go away. If they sell the debt to another JDB again sue again and they drop the debt again. Resold debt has even less chance of winning in court because even less proof is available every time it is sold.

But DO NOT AVOID the fake lawsuit. If you do the creditor gets the default judgement and will garnish wages, lien your house, and will win. Now if the original creditor files the lawsuit you will most likely lose and owe (they have all the proof in their records). So in this case make a settlement offer of lump sum repay or payments you can afford.

Call me scum or whatever but I have used this strategy and it works. After a few decades of paying usurious interest rates I have some cash finally coming back; and no need to file bankruptcy. After 7 years it drops off your credit report and credit score goes way up. Make it anywhere to 4-7 years (depending on your state law timeframe) and the statute of limitations kicks in and money not legally owed any longer. Just do not make any payments on it to renew statute of limitations. No problems! Hell I gambled the money away anyway, how was I suppose to get it back -Ha, Ha. Joke was on the JDB in my case!

Gregory

Very poor article. Take it from some one who was being threatened for some one else's debt. A certified letter to the debt collector explaining you do not owe the debt means that once they receive the letter they can no longer contact you.

Violation of that law carries a 10,000 dollar fine. If the amount is in dispute the same tactic works, except they can contact you with the proof of what you owe. A lot times this involves too much work and they do not pursue it. So if they do not pursue it once the Statute of Limitations is over the debt can no longer be collected.

The limit varies by State Law and amount. Finally be aware that uncollected debts are often sold and the new "owner" of the debt may try to collect on it. Again a certified letter stops them as you have proof of notification that the debt is not owed. I hope this helps the victims out there.

Chub

Buying debt has become a large industry that attracts a lot of crooks. Companies buy debt for as little as a dime on the dollar! The original lender benefits because they are getting a little something out of a debt that they have no hope of collecting. The buyer of the debt benefits because the potential profit is very

Many of the people buying debt aren't your traditional debt collection agency. They are many times just an individual with a cell phone who could bend the rules because they can change their name and location as easy as you can report their activity. Many times you are just dealing with thugs with cellphones. If you owe them, don't be afraid to offer a lesser amount because they had bought the debt so cheap that they may still make a pretty good profit.

Chief_blamestormer

Realize that some debtors never borrowed a dime. It could be the result of a civil judgement. If you think all civil judgements are fair, then have a look at the cases in your local courthouse, or serve a couple rounds of jury duty.

W, 19 hours ago

Industry? There's nothing industrious about. Bill collectors are mostly thugs who can't get real jobs so they have to leverage their values off other people's misery. Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death , which is similar to a developing country, not a developed superpower.

[Jan 15, 2017] Doctors in the United States get paid on average more than $250,000 a year

Jan 15, 2017 | economistsview.typepad.com
libezkova -> anne... , January 14, 2017 at 10:45 PM
"Doctors in the United States get paid on average more than $250,000 a year,"

I am sure that this is a right estimate. Certain specialties probably yes (dentists, cardiologist, gastroenterologists, neurosurgeons, etc), but family doctors, probably no.

[Jan 15, 2017] The Congressional defeat, insured by Democrats, of the proposal by Bernie Sanders to allow the import of drugs from Canada to lower drug prices in the United States

Jan 15, 2017 | economistsview.typepad.com
JohnH -> anne... , January 14, 2017 at 08:00 AM
The Congressional defeat, insured by Democrats, of the proposal by Bernie Sanders to allow the import of drugs from Canada to lower drug prices in the United States.
'
This is only the beginning of Democrats' appeasement of Trump and Republicans...it will be stunning to watch how much damage Republicans can do during Trump's first 90 days with only a slim majority in the Senate. During the first 90 days under Obama, who had a true electoral mandate and big majorities in both houses, Democrats basically sat on their hands, blaming Republicans for their unwillingness to do much for the American people.
Observer -> anne... , January 14, 2017 at 08:50 AM
So if we matched Canada, we'd see a 30% decrease, of a segment which comprises 10% of health care spending, or 3% overall decrease.

"PwC's Health Research Institute projects the 2017 medical cost trend to be the same as the current year – a 6.5% growth rate."

So reaching Canadian spending levels would counter ~ 6 months of health care cost increases. Reaching OECD levels buys you another couple of months.

Put another way, reaching OECD levels for drug spending closes 10% of the US-OECD spending gap.

Not nothing, but "fixing" drug prices seems more like an emotional (i.e. political) talking point than a real silver bullet for health care costs.

http://www.pwc.com/us/en/health-industries/health-research-institute/behind-the-numbers.html

pgl -> Observer... , January 14, 2017 at 11:17 AM
Ever noticed that marketing costs are 30% of revenue? This is a by product of the monopoly power in this sector. Dean Baker has often noted we could have the government do the R&D and then have real competition in manufacturing.
libezkova -> Observer... , January 14, 2017 at 10:40 PM
Don't be a lobbyist for Big Farma.

You forgot that those researchers often produce useless or even dangerous drags, which are inferior to existing. Looks as scams practiced with hypertension drugs.

This rat race for blockbuster drugs is the same as corruption in financial industry.

http://www.alternet.org/story/148907/15_dangerous_drugs_big_pharma_shoves_down_our_throats

pgl -> anne... , January 14, 2017 at 11:16 AM
Actually the industry profile is very relevant but goes in a different direction - if US firms were compelled to charge market (not monopoly) prices, we would better compete with foreign firms.
pgl -> Observer... , January 14, 2017 at 11:14 AM
Any excuse to charge sky high prices for drugs that don't cost that much to manufacture? If these monopoly profits were not so high, we would buy more drugs and employ more people.
Observer -> pgl... , January 14, 2017 at 12:57 PM
Do you think we would really buy materially more drugs if prices were lower? Particularly enough more, at those (30-50%?) lower prices, to generate the funds to employ more people?

(If that actually generated at much or more funds, it would seem like the pharma companies, seeking to make as much money as possible, would have already set prices at that lower per unit level.)

In any case, that seems like a LOT more drugs.

Perhaps Anne has data on the number of scripts per person in the US vs OECD.

pgl -> Observer... , January 14, 2017 at 01:06 PM
There are lots of poor people who don't take drugs because they can't afford them. This will become especially true if the Republican repeal Obamacare.
anne -> Observer... , January 14, 2017 at 09:05 AM
The point of course is wildly exploiting ordinary people in need of healthcare in every possible way, or a reflection of what we have come to. Returning now to the market...

[Jan 14, 2017] Insurance overhead runs are probably the best argument for single payer

Jan 14, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , -1
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

[Jan 13, 2017] Reducing the cost of healthcare

Jan 13, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , January 13, 2017 at 07:12 AM
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

anne -> Observer... , January 13, 2017 at 07:37 AM
https://www.nytimes.com/2017/01/12/us/politics/health-care-congress-vote-a-rama.html

January 12, 2017

Senate Takes Major Step Toward Repealing Health Care Law
By THOMAS KAPLAN and ROBERT PEAR

In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes....

[Jan 13, 2017] What was at stake why Cory Booker joined Senate Republicans to kill a measure to import cheaper medicine

Jan 13, 2017 | economistsview.typepad.com
anne -> Observer... , January 13, 2017 at 07:39 AM
https://twitter.com/lhfang/status/819677587408568320

Lee Fang ‏@lhfang

What was at stake & why Cory Booker joined Senate Republicans to kill a measure to import cheaper medicine:

https://theintercept.com/2017/01/12/cory-booker-joins-senate-republicans-to-kill-measure-to-import-cheaper-medicine-from-canada/

BERNIE SANDERS INTRODUCED a very simple symbolic amendment Wednesday night, urging the federal government to allow Americans to purchase pharmaceutical drugs from Canada, where they are considerably cheaper.

2:49 PM - 12 Jan 2017

Peter K. -> anne... , January 13, 2017 at 09:33 AM
Cory Booker, another progressive neoliberal....
pgl -> Observer... , January 13, 2017 at 09:37 AM
Very good. On health insurance, they get 20% gross margins. I have argued many times we can cut this to 10%.

[Jan 12, 2017] Almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill

Jan 12, 2017 | www.nakedcapitalism.com
Class Warfare

"In a report from Bankrate.com, the firm found that almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill" [ 247 Wall Street ]. "While Millennials may be looked down on by older demographics, they are the most equipped generation to pay for an unexpected expense using their savings. It was found that 47% of those within the ages of 18 to 29 responded that they would use their savings to cover such a burden, up from 33% in 2014." I'd argue that's not virtue, but a rational response to the neoliberal destruction of universal benefits and government services generally.

Knifecatcher , January 12, 2017 at 2:12 pm

Re: Bankrate story – is there such thing as a $1k ER bill anymore? We paid nearly $3k for our unexpected trip, which involved 15 minutes with the doc, no tests or scans, and only a single dose of Childrens' Tylenol for consumables. (5 year old tried to poke his eye out with a stick and failed – but only just).

And of course our crapified insurance hadn't hit the deductible so we had to pay the whole bill out of pocket.

Vatch , January 12, 2017 at 2:31 pm

I'm lucky - I only have a $150 deductible, which is what I paid when I needed five stitches in my hand last year. The total bill was "only" about $1250, probably because I never saw an actual doctor. A nurse practitioner sewed me up. The explanation of benefits from the insurance company later showed that they only paid the hospital about one third of the billed price. I'm sorry that you had to pay the whole thing; I guess the insurance companies only enforce their standard payable fees when it's their money on the line.

optimader , January 12, 2017 at 2:58 pm

The kids I grew up with, that would have been crazy-glue/packaging-tape unless a finger articulation was compromised

http://morethanjustsurviving.com/stitches-bandages-or-super-glue/

btw..Animal bites should be left open and bandaged and treated w/ antibiotic so they heal from the inside out..

I remember in my misspent college youth an idiot scuba diver in Honduras (feeding a moray eel cheese wiz out of a can, guess what happened when she ran out?) who came to my friend's dad (a surgeon) insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some kick-ass antibiotics. She was sure she was being undeserved (w/ gratis treatment) because he refused to sew her up, potentially trapping an infection.

ian , January 12, 2017 at 2:43 pm

I had a similar experience: 3 stitches on my sons finger. Treated by nurse (no doc), sutures and lidocaine was $1800. It got me wondering about how anyone could hope to reform health care when the accounting is so completely out of whack with reality.

[Jan 12, 2017] Cory Booker understands that a candidate cannot expect the Democratic nomination if he/she goes against the interests of BigPharma.

Jan 12, 2017 | www.nakedcapitalism.com
Benedict@Large , January 12, 2017 at 2:53 pm

Cory Booker understands that a candidate cannot expect the Democratic nomination if he/she goes against the interests of BigPharma.

RUKidding , January 12, 2017 at 3:26 pm

After spending day time hours publically going after Jeff Sessions (good), Booker uses the cover of darkness to reveal who he really works for.

Here's a clue: it isn't any of the 99%, whether in NJ or elsewhere.

Talk's cheap, but money walks – eh, Booker?

EndOfTheWorld , January 12, 2017 at 3:40 pm

Somewhere I saw that Bernie praised Trump taking on Big Pharma.

curlydan , January 12, 2017 at 3:33 pm

'specially if you're from Jersey. Kind of like Biden, Delaware, and credit cards. The strings on the puppets are awfully tight.

[Jan 12, 2017] 200PM Water Cooler 1-12-2017 naked capitalism

Jan 12, 2017 | www.nakedcapitalism.com
Class Warfare

"Hierarchies aren't natural phenomena within the human race. Outside of parenting, human beings aren't born with the inclination to be ruled, controlled, 'managed,' and 'supervised' by other human beings" [ The Hampton Institute ]. Hierarchies are artificial constructs designed to serve a purpose. They are a necessity within any society that boasts high degrees of wealth and power inequities. They are a necessity for maintaining these inequities and ensuring they are not challenged from below."

"In a report from Bankrate.com, the firm found that almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill" [ 247 Wall Street ]. "While Millennials may be looked down on by older demographics, they are the most equipped generation to pay for an unexpected expense using their savings. It was found that 47% of those within the ages of 18 to 29 responded that they would use their savings to cover such a burden, up from 33% in 2014." I'd argue that's not virtue, but a rational response to the neoliberal destruction of universal benefits and government services generally.

"[A] good deal of [Wallace] Stevens's poetic output conveyed a feeling of sehnsucht ("inconsolable longing"). For example, in 'Sad Strains of a Gay Waltz,' Stevens writes of American southerners (although the words just as easily apply to their author) as 'voices crying without knowing for what, / Except to be happy, without knowing how.' The object of Stevens's inconsolable longing changed over time. In his early professional days, when he first moved to New York City, it was his hometown of Reading, Pa. Writing to his future wife, Elsie, Stevens lamented that he 'lost a world' when he left there" [ The American Conservative ].

Knifecatcher , January 12, 2017 at 2:12 pm

Re: Bankrate story – is there such thing as a $1k ER bill anymore? We paid nearly $3k for our unexpected trip, which involved 15 minutes with the doc, no tests or scans, and only a single dose of Childrens' Tylenol for consumables. (5 year old tried to poke his eye out with a stick and failed – but only just).

And of course our crapified insurance hadn't hit the deductible so we had to pay the whole bill out of pocket.

Vatch , January 12, 2017 at 2:31 pm

I'm lucky - I only have a $150 deductible, which is what I paid when I needed five stitches in my hand last year. The total bill was "only" about $1250, probably because I never saw an actual doctor. A nurse practitioner sewed me up. The explanation of benefits from the insurance company later showed that they only paid the hospital about one third of the billed price. I'm sorry that you had to pay the whole thing; I guess the insurance companies only enforce their standard payable fees when it's their money on the line.

optimader , January 12, 2017 at 2:58 pm

The kids I grew up with, that would have been crazy-glue/packaging-tape unless a finger articulation was compromised

http://morethanjustsurviving.com/stitches-bandages-or-super-glue/

btw..Animal bites should be left open and bandaged and treated w/ antibiotic so they heal from the inside out..

I remember in my misspent college youth an idiot scuba diver in Honduras (feeding a moray eel cheese wiz out of a can, guess what happened when she ran out?) who came to my friend's dad (a surgeon) insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some kick-ass antibiotics. She was sure she was being undeserved (w/ gratis treatment) because he refused to sew her up, potentially trapping an infection.

ian , January 12, 2017 at 2:43 pm

I had a similar experience: 3 stitches on my sons finger. Treated by nurse (no doc), sutures and lidocaine was $1800. It got me wondering about how anyone could hope to reform health care when the accounting is so completely out of whack with reality.

[Jan 11, 2017] the DEPRAVED nature of the American "Health Kare" system

Jan 11, 2017 | www.nakedcapitalism.com
clarky90 , January 10, 2017 at 6:12 pm

For me, often it is the "small crimes" that exemplify the DEPRAVED nature of the American "Health Kare" system. (See the right hand panel of The Last Judgment Bosch triptych) https://en.wikipedia.org/wiki/The_Last_Judgment_(Bosch_triptych)

US drugmaker charges 200 times UK price for common worm pill

A US drugmaker has put a price tag of more than $800 on a pinworm treatment - 200 times more expensive than the equivalent medicine on British pharmacy shelves, in the latest example of "price gouging" in the world's largest healthcare market.
Impax Laboratories (Bastards!) started selling mebendazole this year at an average wholesale price of $442 per pill, according to figures seen by the Financial Times, which were checked with several US pharmacy chains including Walgreens and CVS.

Most cases of pinworm, a parasitic infection also known as threadworm, require two pills, meaning a course of treatment costs about $884. The drug is available prescription-only in the US but can be bought over the counter in the UK, where Boots, a British chemist chain, charges £6.99 for a pack of four pills, or £1.75 each.

The pinworm parasite, which is common in children, affects 200m people a year worldwide and up to 40m in the US. It is recommended that family members are treated for the highly contagious infection at the same time, meaning a household of five's treatment costs more than $4,400.

https://www.ft.com/content/f0080fe4-c3ad-11e6-9bca-2b93a6856354

"Mebendazole came into use in 1971, after it was developed in Belgium.[4] It is included in the WHO Model List of Essential Medicines, the most important medications needed in a basic health system .[5] Mebendazole is available as a generic medication.[6] The wholesale cost in the developing world is between 0.004 and 0.04 USD per dose .[7] In the United States a single dose is about 884.00 USD as of 2016.[8]

https://en.wikipedia.org/wiki/Mebendazole

[Jan 02, 2017] U.S. Healthcare Is A Global Outlier (And Not In A Good Way)

Jan 02, 2017 | www.zerohedge.com

Historically, the United States has spent more money than any other country on healthcare.

In the late 1990s, for example, the U.S. spent roughly 13% of GDP on healthcare, compared to about a 9.5% average for all high income countries.

However, as Visual Capitalist's Jeff Desjardins notes, in recent years, the difference has become more stark . Last year, as Obamacare continued to roll out, costs in the U.S. reached an all-time high of 17.5% of GDP . That's over $3 trillion spent on healthcare annually, and the rate of spending is expected accelerate over the next decade .

HIGH COSTS, HIGH BENEFIT?

With all that money being poured into healthcare, surely the U.S. must be getting better care in contrast to other high income countries.

At least, that's what one would think.

Today's chart comes to us from economist Max Roser (h/t @NinjaEconomics ) and it shows the extreme divergence of the U.S. healthcare system using two simple stats: life expectancy vs. health expenditures per capita.

Courtesy of: Visual Capitalist

THE DIVERGENCE OF U.S. HEALTHCARE

As you can see, Americans are spending more money – but they are not receiving results using the most basic metric of life expectancy. The divergence starts just before 1980, and it widens all the way to 2014.

It's worth noting that the 2015 statistics are not plotted on this chart. However, given that healthcare spend was 17.5% of GDP in 2015, the divergence is likely to continue to widen. U.S. spending is now closing in on $10,000 per person.

Perhaps the most concerning revelation from this data?

Not only is U.S. healthcare spending wildly inefficient, but it's also relatively ineffective. It would be one thing to spend more money and get the same results, but according to the above data that is not true. In fact, Americans on average will have shorter lives people in other high income countries.

Life expectancy in the U.S. has nearly flatlined, and it hasn't yet crossed the 80 year threshold. Meanwhile, Chileans, Greeks, and Israelis are all outliving their American counterparts for a fraction of the associated costs. buckstopshere , Jan 1, 2017 10:02 PM

A shorter life expectancy makes Social Security look more solvent.

Cooking the books.

junction buckstopshere , Jan 1, 2017 10:08 PM
The chart shows that Monsanto and the New World Order are succeeding, that more glyphosate herbicide in the food, more toxic chemtrails and more unneccessary operations are having the desired effect, to cull the American population. Helped immeasurably by the cocaine and heroin flown into the USA by the Bush Crime Cartel on Air Force cargo planes.
cheka junction , Jan 1, 2017 10:10 PM
nyc runs US health care. that tells one all he needs to know.
Pinch Dog Will Hunt , Jan 2, 2017 12:58 AM
Republitards and Freedumb-lovers need to watch Michael Moore's movie about this called "Sicko"

https://www.youtube.com/watch?v=thkBLpRwdSM

You need MORE socialism, not less.

Tards.

Chief Wonder Bread balolalo , Jan 1, 2017 10:42 PM
Australia, Norway, Switzerland, Germany, South Korea, Japan, Italy, U.S.

Which of these countries is not like any of the others? Haha. Multiculturalism is such a fantastic deal. Some "cultures" just don't make good lifestyle decisions such as thinking that grape drank and swisher sweets are healthful choices.

philipat cheka , Jan 1, 2017 10:35 PM
It is, of course, in part a "Lifestyle" issue but the US system is grossly inefficient because there are adverse incentives built in (Adverse selection etc.). The US still uses a "Fee for service" model which has never been able to control costs anywhere in the world. On top of that, high pharmaceutical prices in the US account for up to 90% of total Big Pharma profits ane Medical Malpractise insurance not only directly adds large costs but indirectly forces the use of an unnecessary number of tests and the use of the newest drugs etc. Without any sensible controls at any point in the system it will only continue to get further out of control, as ACA has illustrated.
Ballin D philipat , Jan 1, 2017 10:41 PM
What's the alternative to "fee for service?" Seems pretty standard to charge for services rendered.
philipat Ballin D , Jan 1, 2017 11:47 PM
Except that more services = more fees = higher costs. Hence multiple tests, multiple procedures and multiple drugs = higher costs and higher fees = inefficiency bias and higher still costs. Physicians are human and the Healthcare providers have become experts at maximising costs to breaking point. There are many alternative models within which to control costs through negotiated standard procedures and fixed costs for each procedure and drug formularies (including the use of generic drugs) etc. Single payer is used by much of the developed world where the supplier agrees to supply at a negotiated price or doesn't get to participate, which focuses their attention nicely. The benefits of scale, in whatever system is used, should result in lower prices but don't in the US where USG is already the largest single provider of healthcare (Medicare/Medicaid etc).
Canoe Driver philipat , Jan 2, 2017 12:36 AM
A lot of people, certainly not just doctors, are making a lot of money from this dysfunctional medical system. That is the difference no one is talking about. The money is not disappearing down a rabbit hole. It is being pocketed by thousands of multi-millionaires. It is a profit-based system. Medicine is the one field where Capitalism has no hope of efficiency. Why? Because the demand is infinite and inelastic. A recipe for the financial rape of millions.
dogsandhoney2 junction , Jan 2, 2017 12:43 AM
yeah,
and it also shows the effect of a
30% increase in psychological stress since 1980.
stress = ^stress hormones = stressed immune system =
anxiety/depression/cardiovascular disease/hyper inflammatory response/etc..

all to be treated by those in the stressed-out health care system,
usually with hyper-cost pharmaceuticals.

it's well past due date for the u.s. to become civilized by starting
single payer medical plans.

health insurance corporations = the terror.

sinbad2 heresy101 , Jan 1, 2017 10:48 PM
I wouldn't count on it.

Private healthcare and insurance is very profitable 2 of the 3 trillion the US spends on healthcare would go to shareholders and management of healthcare companies.

Mr Trump is a businessman and a realist. The media would be calling him a commie if he tried to fix it.

sinbad2 , Jan 1, 2017 10:38 PM
Americans would not have it any other way.

The countries that have the most cost effective healthcare, are countries that provide government run health insurance.

Americans would never tolerate claiming helthcare costs back from a Government run health providor, like in Australia, or waisting taxpayers money building hospitals.

Americans have to pay for their belief that private for profit health insurance is cheaper and better than government provided insurance.

Xena fobe sinbad2 , Jan 1, 2017 11:41 PM
Americans would accept single payer. But insurance companies would not.
TheEndIsNear I Write Code , Jan 2, 2017 12:05 AM
250,000 deaths in 2015 were due to medical error, the third leading cause of death in the U.S.
http://www.hopkinsmedicine.org/news/media/releases/study_suggests_medica...

38,300 people were killed on U.S. roads in 2015.
http://www.newsweek.com/2015-brought-biggest-us-traffic-death-increase-5...

33,636 deaths due to "Injury by firearms" of which only 11,208 were homicides, 21,175 were self inflicted suicides, and the remainder were due to accidental/negligent discharge of a firearm or "undetermined intent".
https://en.wikipedia.org/wiki/Gun_violence_in_the_United_States

brooklinite8 , Jan 1, 2017 11:07 PM
When I was visiting India I saw few women administer a baby birth basically in few minutes with bare hands, water, oil and some sarees. Here in the US I believe the bill comes around 5-10k at the least. Did we ever ask the question as to why do we need insurance to afford health care? Did we ever ask how has it become so out of control? Why has healthcare become such a big business? Where are the morals of humanity?

In USA the welfare of the state takes precedence to the welfare of the people. Human beings are valued at no different rate in USA than India. Welcome to the Land of the Free, Home of the Brave. Good Old USA. We are outliers and Everything we do should be an outlier. If not we will revisit and make sure it becomes an outlier. Lol

Canoe Driver brooklinite8 , Jan 2, 2017 12:57 AM
The total cost per childbirth in the US is said to be $50-65k. This figure is so outrageous that it is impossible to correlate it with the cost of providing the services. It is simply a bunch of profiteers taking their cut. And the profit can be several hundred percent of the underlying cost, precisely because the "customer" has no choice at all. Capitalism, which works well in many contexts, fails miserably in medicine. Demand is infinite and inelastic in the medical field.
hairball48 , Jan 1, 2017 11:15 PM
A shitty diet of sugar laden, high carbohydrate fast food products is what contributes to most Americans' shorter life spans, not "poor health care".

Health care is expensive because it's run by a de facto "health care mafia". I worked in the technical field of health care for 28 years. Excessive regulation is but just one reason health care is so expensive in the USA. Barriers to entry are another. Try to establish a medical school. See how long it takes. Fewer docs, the higher the price of docs. ECO 101. Don't look for a change anytime soon.

hairball

Miffed Microbio... hairball48 , Jan 2, 2017 12:14 AM
When I was an intern for clinical microbiology they gave us $300/month as a stipend. Today an internship costs $24k. This is on top of the 4 years degree. Plus the mechanization of the lab is continuing every year to the point there will be fewer jobs in the future. Hate to say it but my field is fucked. Much of my time is spent meeting regulatory compliance and it gets worse every year.

Miffed

tyberious , Jan 1, 2017 11:52 PM
Me, 20 years in Healthcare BS, MSPH, , started in reference labs, then trauma center, biotech and now in healthcare insurance quality improvement (Medicare). 1st of all the money is in the government, we all know that!

But my main response to the article is that the America sheep are being sheared! The assault starts at birth with 21 vaccines by adulthood( infant mortality), hormones in the food (preteen secondary sex characteristics)(breast cancer)(prostate cancer) , HFC (diabetes, heart diseases, and other complications) GMO's, glycophosphates, glutens, and the multitude of useless pharmaceuticals.

My point is Americans are being poisoned, not so much intentionally, but through fascist business models.

So recap: Chronic preventable illnesses, extensive bureaucracy, poor food choices (# 1 in my book), and a government that cares zero fucks about you!

chosen , Jan 2, 2017 12:18 AM
Doctors are way overpaid. Hospitals charge ridiculous prices that have no relation to reality. Insurance companies screw us even more.

The US medical system is worse than the university system. Both are scams whose main goal is to make the providers more and more money, and the users poorer and poorer. It is sick.

Canoe Driver chosen , Jan 2, 2017 1:12 AM
Basically, you are right. The idea is that the price is all the funds the "customer" has in the world, every time there is significant illness. This is because the demand for healthcare is essentially infinite and inelastic. If you want to live, pay us everything you have, then declare bankruptcy. That is what happens naturally in a for-profit medical system.

[Dec 30, 2016] Payment for Emergency Ambulance Services.

Dec 30, 2016 | dfs.ny.gov
The Office of General Counsel issued the following opinion on June 7, 2006, representing the position of the New York State Insurance Department.

Payment for Emergency Ambulance Services.

Re: Payment for Emergency Ambulance Services.

Questions Presented:

1. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or health maintenance organization ("HMO") has made partial payment of a bill?

2. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or health maintenance organization has denied payment entirely?

Conclusions:

1. Pursuant to N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006), the ambulance company may not bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or HMO has made partial payment of a bill under an insurance contract that provides major medical or similar comprehensive-type coverage. However, if such a contract is not involved, these provisions do not apply and there is no prohibition in the Insurance Law against the ambulance company billing the patient directly for the balance of the bill.

2. Yes. The ambulance company may bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or HMO has denied payment entirely, subject to the remedies available to the patient.

Facts:

This inquiry is general in nature.

Analysis:

N. Y. Ins. Law § 4303 (McKinney Supp. 2006) applies to non-profit health plans and HMO's. Although HMO's are primarily regulated by the New York Health Department, their subscriber contracts are regulated by the Insurance Department as if they were subscriber contracts of non-profit health insurers. See N.Y. Public Health Law § 4406(1) (McKinney 2002).

N.Y. Ins. Law § 4303(aa) (McKinney Supp. 2006) provides, in relevant part, as follows:

(aa)(1) Every contract issued by a hospital service company or health service corporation which provides major medical or similar comprehensive-type coverage shall include coverage for prehospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service issued a certificate to operate pursuant to section three thousand five of the public health law.

(2) Payment by an insurer pursuant to this section shall be payment in full for the services provided. An ambulance service reimbursed pursuant to this section shall not charge or seek any reimbursement from, or have any recourse against an insured for the services provided pursuant to this subsection, except for the collection of copayments, coinsurance or deductibles for which the insured is responsible for under the terms of the policy.

(3) An insurer shall provide reimbursement for those services prescribed by this section at rates negotiated between the insurer and the provider of such services. In the absence of agreed upon rates, an insurer shall pay for such services at the usual and customary charge, which shall not be excessive or unreasonable.

(4) The provisions of this subsection shall have no application to transfers of patients between hospitals or health care facilities by an ambulance service as described in paragraph one of this subsection. . . .

N.Y. Ins. Law § 3221(l)(15) (McKinney Supp. 2006), which applies to group or blanket accident and health insurance policies issued by commercial insurers and N.Y. Ins. Law § 3216(h)(24) (McKinney Supp. 2006), which applies to individual accident and health insurance policies issued by commercial insurers contain identical provisions.

In accordance with the above, if the insurance contract provides major medical or similar comprehensive-type coverage, it must include coverage for prehospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service issued a certificate to operate pursuant to section three thousand five of the public health law. The insurer must provide coverage for emergency ambulance services based upon the rates negotiated between the insurer and the provider of such services. If no participating provider contract exists, the insurer must pay for the services at the usual and customary charge, which shall not be excessive or unreasonable.

Once the insurer makes payment at the usual and customary charge, the provider must accept such payment as payment in full. The provider may not bill the patient directly for emergency ambulance services for the balance of a bill, except for the collection of copayments, coinsurance or deductibles that the insured is responsible for under the terms of the insurance contract.

Please note that N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006) are applicable only to insurance contracts that provide major medical or similar comprehensive-type coverage. Thus, if such a contract is not involved, these provisions do not apply and there is no prohibition in the Insurance Law against the ambulance company billing the insured directly. In addition, these provisions do not address a situation in which a New York authorized insurer or HMO has denied payment entirely for emergency ambulance services (i.e. where the insurer or HMO states that coverage was not in effect or that treatment was not medically necessary). In such cases, the ambulance company may bill the patient directly, subject to the remedies available to the patient.

If the ambulance company or patient disputes a payment made by the insurer or HMO as not constituting the usual and customary charge or disputes the fact that no payment was made, the ambulance company or patient may raise the issue with the insurer or HMO and/or file a complaint with the Department's Consumer Services Bureau.

Lastly, the New York Attorney General's Office has conducted an investigation on balance billing by ambulance companies. For further information, the inquirer was directed to contact the Attorney General's Office at (518)474-7330 or access their web site which is located at http://www.oag.state.ny.us.

This opinion does not provide an analysis of the No-Fault Insurance Law, which would result in a different analysis and conclusion, since the inquirer already had OGC Opinions on this subject. 1 Please note also that this opinion is limited to an interpretation of the New York Insurance Law. No opinion is rendered on any other laws.

For further information you may contact Associate Attorney Pascale Jean-Baptiste at the New York City Office.


1 See OGC Opinion No. 03-02-18, dated Feb. 18, 2003 and OGC Opinion No. 03-04-36, dated April 30, 2003; see also OGC Opinion No. 05-05-29, dated May 28, 2005.

[Dec 30, 2016] 20 things to know about balance billing

Notable quotes:
"... Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . ..."
"... Balance billing complaints are up 1,000 percent in Texas . ..."
"... The rise in balance billing is partially attributable to a lack of network transparency with patients. ..."
"... The New York Times ..."
"... Kaiser Health News ..."
"... In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635. ..."
"... Montana Public Radio ..."
"... Sunshine State News ..."
"... The New York Times ..."
"... The New York Times ..."
Dec 30, 2016 | www.beckershospitalreview.com

Patients, caught in the financial crosshairs, often feel powerless to negotiate costs. Consumer advocacy groups and federal and state legislators are turning their attention to balance billing practices this year with renewed vigor, forcing payers and providers to find other ways to settle financial disagreements.

Here are 20 things to know about balance billing.

1. Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . In 2015, a nationwide study from Consumers Union found nearly one third of privately insured Americans received an unanticipated bill when their health plan paid less than expected for medical services within the past two years.

2. Balance billing complaints are up 1,000 percent in Texas . According to the Texas Department of Insurance , balance billing complaints rose from 112 in 2012 to 1,334 in 2015, an increase of 1,000 percent.

3. Lack of provider, network transparency. The rise in balance billing is partially attributable to a lack of network transparency with patients. In many cases patients are unaware they have received out-of-network care until they receive a balance bill in the mail. Nearly 70 percent of individuals with unaffordable out-of-network medical bills did not know the healthcare provider was not in their plan's network at the time of care, according to a survey conducted by Kaiser Family Foundation and The New York Times .

4. Emergency room services to blame, in part. A Health Services Research survey found in 2011, 68 percent of inpatient involuntary contact with out-of-network physicians was related to emergency care. These kinds of unanticipated medical bills may arise when a hospital participates in an insurer's network but its employed emergency physicians do not. For example, more than half of the hospitals in some Texas insurers' networks did not have a single physician on staff covered by the insurer, according to a 2015 study from the Centers for Public Policy Priorities in Austin.

5. Balance billing and contracted physicians. Many hospitals use physician outsourcing firms for anesthesiologists, emergency physicians, pathologists and radiologists, or will bring in an outside assistant surgeon to help with procedures. In many cases, these physicians do not participate in the same network as the hospital, unbeknownst to the patient. When physician groups and insurers are unable to resolve reimbursement disputes, patients can be served with much higher out-of-network charges. In Texas, for example, the specialty services most likely to submit balance bills are anesthesiologists, lab services, surgery and radiology, reports the Texas Department of Insurance .

6. Payers will fight out-of-network physicians with lower reimbursement rates. Last year, health insurance giant UnitedHealthcare said it would scale back how much it pays out-of-network physicians who practice at in-network hospitals, accusing physicians of demanding excessively high reimbursement levels, according to Kaiser Health News . During a billing dispute with out-of-network Bayonne (N.J.) Medical Center, the insurer accused the hospital of charging out-of-network rates 10 to 12 times higher for a medical service than area hospitals participating in United'snetwork. If a payer refuses to match physician reimbursement rates, the financial burden is passed on to the patient. In the aforementioned dispute between Bayonne and UnitedHealthcare, the patient was balance billed $1,170 for a total of five stitches.

7. Insurers are narrowing networks in an effort to reduce costs. As insurance companies have narrowed provider networks to keep premiums down, the number of patients who inadvertently received out-of-network care has jumped at hospitals, particularly with regard to contracted physicians.

8. Payers have sued providers for 'excessive' out-of-network fees. Aetna has sued a half dozen out-of-network physicians in recent years, alleging gross over charging for medical services. In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635.

9. Balance billing can occur even when a payer adjusts out-of-network emergency bills to in-network rates for patients. A patient recently accused Duke University Medical Center in Durham, N.C., of balance billing his account for an out-of-network rate after the patient submitted in-network payment rates to Blue Cross Blue Shield. Owing to the medical emergency of his situation, Matthew Aitken said he received an in-network rate from Blue Cross Blue Shield of North Carolina. However, Mr. Aitken alleged Duke proceeded to charge him for the remainder of the bill at the higher out-of-network rate, resulting in a bill nearly double that of Mr. Aitken's out-of-pocket limit.

10. Air ambulance billing disputes, complaints on the rise. In rural areas of the U.S. the high price for life-saving air ambulance flights has grabbed media attention as rural residents, faced with excessive balance billing, have turned to state and federal auditors for intervention. Those in rural areas often must rely on air ambulance flights in life-or-death situations in lieu of feasible ground transportation. Reimbursement rate disputes between payers and medical air transport companies have strapped patients with devastating medical bills. When Amy Thomson's newborn daughter was in heart failure, Ms. Thomson had to use an air ambulance service in rural Montana for transport to a more capable facility. At the time her insurance company, PacificSource, did not have an in-network air ambulance company near her family, reports Montana Public Radio . Ms. Thomson received a $43,000 balance bill from Airlift Northwest after PacificSource contributed a policy cap of $13,000.

11. Provider-based billing practices. Consumers have been increasingly vocal about surprise medical bills derived from provider-based billing practices. Provider-based billing allows a healthcare organization to bill patients for physician care in addition to a service charge for the patient's use of hospital facilities and equipment. In some cases, a patient may be responsible for the service bill if their insurance declines to pay or if the patient has a high deductible health plan. Large hospitals like Cleveland Clinic have faced increased scrutiny for provider-based billing practices. After paying a $30 copayment for in-network care with a Cleveland Clinic chiropractor, Julie Beinhardt reported receiving a balance bill of $3,000 for provider-based service fees her insurance plan refused to cover.

12. President Barack Obama signed legislation against provider-based billing. Last year, President Obama signed legislation outlawing provider-based billing at off-campus outpatient facilities. The legislation does not apply to existing outpatient centers that already engage in the practice, however.

13. The president's 2017 budget proposal includes a provision to eliminate surprise medical bills. Although details are minimal, the president's 2017 budget proposal includes a provision to eliminate balance billing privately insured patients. The administration would address the issue by requiring physicians who regularly provide services in hospitals to accept in-network rates for service reimbursement, even if they aren't in the insurer's network.

14. About a quarter of U.S. states have laws that protect consumers from out-of-network medical bills incurred by emergency care. According to a study from Kaiser Family Foundation , 24 states have implemented laws that restrict providers from balance billing in emergency care situations, including California, Delaware, New Jersey, New York and Pennsylvania, among others.

15. More states are proposing independent dispute resolution between payers and providers in balance billing cases. Independent dispute resolution establishes a legal space in which providers and health insurers can settle disagreements regarding balance billing without involving the patient. The states of Illinois and New Yorkhave arbitration methods in place, and Florida , Washington and Pennsylvania are currently considering a similar resolution methods.

16. New York has some of the strongest consumer protection laws. Under New York law , consumers are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services. Patients can complete an assignment of benefits form that absolves them of financial responsibility and allows the provider to pursue payment from the health plan in balance billing disputes.

17. Florida state legislature is currently embroiled in a fight to pass balance billing laws. Legislation to outlaw balance billing in Florida has continued to creep through the state legislature since last fall. Introduced in both the house and senate, the bills have sparked conflicting and outspoken opinions from patients, payers, hospitals and physicians. Hospitals have largely denounced the bill, blaming balance billing disputes on payers that demand allegedly unsustainable reimbursement rates, reports Sunshine State News .

18. The "End Surprise Billing Act". Federal lawmakers are making moves to outlaw balance billing nationally. Co-sponsored by 25 lawmakers, the End Surprise Billing Act would protect patients from balance billing who went to in-network facilities for emergency services, reports Consumerist . In non-emergency cases, it would require providers to notify patients within 24 hours if an out-of-network specialist will be involved in an episode of care.

19. Consumers don't know how to navigate the legal waters. According to a Consumer Union report, 57 percent of patients who encountered balance billing from contracted physicians within the last two years paid in full because they didn't know their rights to fight the bills. An overwhelming majority (87 percent) did not know which agency or department in their state government is tasked with handling complaints about health insurance. "So many times, people just give up [in surprise billing disputes]," Elisabeth Benjamin, vice president of health initiatives with Community Service Society of New York, told NPR .

20. The New York Times dedicated a series to consumer encounters with surprise healthcare bills. Elisabeth Rosenthal's series in The New York Times entitled Paying Til it Hurts examined the personal and financial implications of excessive, unexpected medical costs on Americans, their families and their healthcare consumption. Ms. Rosenthal's installments often feature individuals with unaffordable balance bills like Peter Drier , who was served a $117,000 balance bill for an out-of-network physician's assistant he never knew was present during surgery.

[Dec 26, 2016] Are Psychiatric Medications Hurting More Patients Than They Help?

Notable quotes:
"... Scientific American ..."
Dec 26, 2016 | science.slashdot.org
(scientificamerican.com) 431

Posted by EditorDavid on Sunday December 18, 2016 @01:34PM from the depressing-anti-depressant-news dept.

An anonymous reader quotes Scientific American 's Cross-Check blog :

Two new posts on this website have me contemplating, once again, the terrible possibility that psychiatry is hurting more people than it helps. Reporter Sarah G. Miller notes in "1 in 6 Americans Takes a Psychiatric Drug" that prescriptions for mental illness keep surging. As of 2013, almost 17 percent of Americans were taking at least one psychiatric drug , up from 10 percent in 2011, according to a new study. "Antidepressants were the most common type of psychiatric drug in the survey, with 12 percent of adults reporting that they filled prescriptions for these drugs..."

This increase in medications must be boosting our mental health, right? Wrong. In "Is Mental Health Declining in the U.S.?," Edmund S. Higgins, professor of psychiatry at the Medical University of South Carolina, acknowledges the "inconvenient truth" that Americans' mental health has, according to some measures, deteriorated ...

It's all more evidence of something their blogger wrote in 2012. "American psychiatry, in collusion with the pharmaceutical industry, may be perpetrating the biggest case of iatrogenesis -- harmful medical treatment -- in history ."

[Dec 26, 2016] 5 Ways to Lower Your Medical Bills Personal Finance

Notable quotes:
"... "One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills." ..."
Nov 29, 2007 | US News

Insurance companies aren't the only ones who can negotiate a lower price -- you can, too. Here's how.

By U.S. News & World Report

Sanjiv Luthra of Los Altos, Calif., suffered from the pain and fatigue of rapid-onset arthritis so severe that he couldn't walk 10 feet until he underwent double knee-replacement surgery in 2006. Now, two years later, he can walk and run, but he still suffers the fallout from another ailment: medical bills.

Six hours in an operating room, two knee replacements, medications and a five-day hospital stay added up to a bill of $80,000, Luthra estimates. That's not counting bills for an anesthesiologist, physical therapy, additional medicines and special exercise equipment to help him recover.

"One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills."

Luthra's insurance company was able to negotiate with the hospital so that it paid about $20,000, and he parted with about $5,000, including expenses outside the hospital.

But individual patients can haggle for lower medical bills, too. Here are tips on how to go about it.

Work up the courage to ask. It's not just insurance companies that can negotiate.

"The typical insurer gets about a 60% discount," says Gerard Anderson, the director of the Johns Hopkins Center for Hospital Finance and Management. "If you go into the hospital and ask the chief financial officer , you may get a 30% discount, but you have to ask for it. It's totally up to the discretion of the CFO how much they or the person in the billing office are willing to give you."

Although it's common to negotiate with a real-estate agent or car salesperson you probably never will see again, it's much more difficult to negotiate with a doctor you trust to make you well and to provide continuing care for your family. Only 31% of Americans have tried to negotiate the price of medical bills, a survey by Consumer Reports National Research Center indicated. But of those who tried, 93% have been successful at least once, and more than a third saved more than $100.

Explore low-cost treatments. Many doctors incurred large loans to finance medical school and probably understand the need to get a fair price as well as you do.

But even though almost 80% of physicians will prescribe a generic medication over a brand-name drug to save patients money, far fewer consider patient costs when recommending diagnostic tests (51%) or choosing between hospitalization and outpatient treatment (40%), according to a survey of physicians by the Center for Health System Change and the University of Chicago

If money is an issue, you need to ask your doctor if cheaper, medically sound options are available. The trick is to keep it friendly and ask nicely. For minor health ailments such as ear infections and pinkeye, drugstore clinics list reasonable prices upfront, with no negotiating required.

Find the correct person. Although they are heavily involved in treatment decisions, doctors may not be directly involved in other billing issues, so you need to find a person with the ability to adjust your bill.

"I would suggest the consumer go to the office manager," says Timothy Cahill, a health-care consultant in Louisville, Ky., who has negotiated hospital bills on behalf of patients. The office manager should be able to direct you to the person in charge of billing.

Offer cash payments. This could be a mutually beneficial solution for you and the medical establishment.

"Paying cash is worth a lot to a doctor in terms of time and trouble, and it is a lot less complex for the hospital to deal with," says Shankar Srinivasan. He is a co-founder and the chief technology officer of Vimo.com, a company that uses public records to figure out what prices insurers negotiate with hospitals. Cash, he says, saves hospitals the trouble of negotiating financing terms, paying credit card transaction fees and sending collection agencies after patients who fail to pay.

Scrutinize the bill and your insurance. If you don't have the cash to pay a large medical bill, you need to educate yourself about what your insurance should cover and try to negotiate a discount off the sticker price.

"As a consumer, just like a detective, you have to really understand the specifics of your insurance benefit plan, take the initiative of setting up conference calls (including yourself, the hospital and your insurance company) proactively, and you have to document everything," says Luthra, who is chief operating officer of the health-care-consulting company Benu. "You don't just pay the bill as is."

This article was reported and written by Emily Brandon for U.S. News & World Report.

[Dec 26, 2016] How to avoid and handle surprise medical bills

Notable quotes:
"... The average balance billed to patients was $622.55 , though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills. ..."
"... Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill. ..."
"... If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available. ..."
"... Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. ..."
"... At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. ..."
"... If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate. ..."
"... If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org , to estimate what the procedure typically costs in your locality. ..."
"... If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely. ..."
thehill.com
Surprise bills are never a welcome surprise. Typically, they arrive after you arranged care from a doctor and a hospital that were both in your health plan's network, but then you were unexpectedly treated by one or more other providers who, unbeknownst to you, were outside that network.

When these out-of-network providers send you a bill for their services, you may have to pay the full amount out of pocket or, if your health plan covers out-of-network care, to pay the balance of the bill that your insurance fails to cover. And the balance bill generally requires you to pay more than the out-of-pocket amount you would have owed if you had been treated by an in-network provider.

Emergency rooms are one of the most common locations where healthcare results in surprise bills.

As detailed recently in an article by two Yale scholars in the New England Journal of Medicine, in more than one in five cases nationwide, ER visits to an in-network facility involved out-of-network physicians. The average balance billed to patients was $622.55, though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills.

Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill.

Several states have already enacted laws to protect consumers against surprise bills, although some of the statutes protect patients only in the case of balance bills for out-of-network ER services for a serious medical emergency. Currently, the issue is being discussed in a number of statehouses. In the meantime, here are steps you can take to protect yourself from such surprises.

Prevent surprise bills

The best defense against a surprise bill is prevention. If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available.

However, for a planned surgery or other procedure, you probably have time to speak up. Make sure that your doctor and hospital are in your plan's network. Check with them and with your plan. Ask your physician and your hospital in advance if they can arrange to have only in-network providers treat you.

Some hospitals may have no in-network specialist for care you might require. Find out if another hospital in your area can provide all your necessary services on an in-network basis. In some areas, there may be no in-network specialists available of the type you need. In that case, inform your plan that its network lacks necessary services and find out if the terms of the plan or state law provide you protection from large balance bills in such circumstances.

Always refer to your plan by its exact official name. Often insurers have multiple plans with similar names but different networks. If you use the wrong plan name when inquiring about a plan's network, you may get a wrong and costly answer. Make your inquiries and requests in writing so you have documentation. Ask for the names of the providers who will be involved in your care, and check with your insurer and with the providers themselves to see if they are all in your plan's network.

Check if your state protects consumers

If you do get a surprise bill, take action. Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. Many states have laws that require HMOs to protect consumers from surprise bills, especially with respect to necessary ER services. Fewer states have similar protections for other types of health plans, such as PPOs and EPOs.

At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. Generally, these laws provide that the consumer is required to pay only the amount he or she would owe for the services if provided in-network. States have different mechanisms for settling the balance, but they generally involve the insurer and the provider, not the patient.

If your state does not provide protection

If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate.

If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org, to estimate what the procedure typically costs in your locality. If your plan's reimbursement is based on an amount that is less than the typical charge, you can use this information to ask the plan to pay the provider on the basis of at least the typical rate. If the out-of-network provider's charge is higher than the typical rate, you might be able to negotiate with the provider to reduce your costs. You can try to persuade the provider to reduce the charge, or to discount an excessive balance bill, by showing the provider that his or her charge is above the typical market rate.

If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely.

Robin Gelburd, JD, is the president of FAIR Health, a national, independent nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement. FAIR Health oversees the nation's largest repository of private healthcare claims data, comprising over 21 billion billed medical and dental charges that reflect the claims experience of over 150 million privately insured Americans. Follow on twitter @FAIRHealth

[Dec 25, 2016] How to Fight Back Against Outrageous E.R. Bills

Two excellent resources-Healthcare Blue Book and FAIR Health-can give you estimates of how much health care services should cost in your area. Plus, your insurer's website may also provide a tool that will allow you to compare costs.
Notable quotes:
"... But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says. ..."
"... "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says. ..."
"... "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money." ..."
"... This piece is by Drew Anne Scarantino ..."
www.thefiscaltimes.com

It's no secret that hospital bills in the U.S.-especially ones from the E.R.-can often hit astronomical proportions.

According to a recent cost study conducted by researchers at Stanford University, the University of Minnesota, the University of California, San Francisco and the Ecologic Institute, the median charge for an emergency room trip in the U.S. comes in at $1,233. But where it really gets interesting is when you look at the specific reasons for those E.R. visits: The researchers found that the treatment price for a headache could range from $15 to a whopping $17,797. As for a sprained ankle, it could set someone back a paltry $4 or up to $24,110!

So what gives with these wildly fluctuating price points?

For starters, most emergency room prices are inflated based on the rates at which insurance companies will reimburse the hospital on a patient's behalf. That's why a single aspirin can cost $30 per pill in the E.R., which is more than six times the price for a bottle of them at the drug store.

On the flip side, patients will often contact the hospital or surgeon's billing office to ask for a cost reduction, further adding to the inconsistency in pricing. It's a practice that often works in a patient's favor, says billing advocacy specialist Sharon Salters of Medical Cost Advocatea professional medical bill negotiation service.

And then there's also the fact that most hospitals offer discounts to self-paying individuals-especially if there's a risk that they might not pay at all.

So to help shed some light on the complexities of hospital medical billing for the average consumer, we asked three people to share their craziest emergency room stories, the even crazier bills that followed-and the steps they took to remedy them.

... ... ...

The Emergency: Head Injury
The Bill: $9,000

A few months ago, Amanda Harris, 27, of Morristown, N.J., fainted at work, hitting her head in the process. Due to liability concerns, her production company required Harris to take an ambulance to the emergency room, despite her refusal. "I didn't even have a cut on my head, just a slight bump. No headache, no nausea, no confusion, nothing," she says.

Harris waited for over an hour in the E.R. before her husband told the nurse that they were leaving. Minutes later, a doctor spoke to Harris for under a minute, confirming that she was fine to go. "He didn't do any tests-no light in my eyes, no blood pressure," says Harris. "I left thinking I wouldn't even get a bill."

But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says.

RELATED: Hospital Costs Explode: Between $127 and $151 Billion

What This Patient Did: Harris called her insurer and fought the bill. Luckily, her insurance covered all but a $3,000 deductible-but she was too exhausted to push for more. "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says.

What the Expert Says: Even though Harris didn't want to take an ambulance, Salters says that her company's suggestion was well-advised. "However, she should consider working with her employer to file the claim with her company's worker's compensation carrier," says Salters. "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money."

How You Can Avoid Outrageous E.R. Bills (Really!)

When it comes to a trip to the E.R., the reality is that there's usually no time to shop around and compare prices in advance. But if you do some research before an emergency happens, you could potentially keep costs significantly down.

The negotiation can seem like a lot of extra work, but the payoff can be tens of thousands of dollars in savings shaved off a potentially outrageous E.R. bill.

This piece is by Drew Anne Scarantino.

http://www.insure.com/articles/healthinsurance/haggling.html

[Nov 23, 2016] 7 Tips For Fighting And Paying A Big Hospital Bill

Notable quotes:
"... Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation. ..."
"... don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections. ..."
Sep 17, 2013 | www.forbes.com

Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at once.

You may also be able to successfully bargain down the particular dollar amounts you've been charged.

Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital, you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less than the initial rate quoted - the figure charged to uninsured patients.

Go online to check the rates other local hospitals charge for the procedure you had. Then, if you find your bill was way out of line, use this data as ammunition to try to get your fees lowered. You can get this type of information at such sites as Clear Health Costs, Healthcare Blue Book and FAIR Health.

Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation.

2. Vigilantly review the bills. "It's very common for hospital bills to contain errors and overcharges, so make sure you've actually received the services they said you did," Detweiler says.

Candice Butcher, vice president of Medical Billing Advocates of America, says if you're discharged in the morning (as most patients are), protest if you're socked with a full daily-room rate for the date you left the hospital.

And if you brought your medications with you, make sure you weren't charged for them by the hospital. "This frequently happens," Butcher says.

Also, dispute any additional fees on the bill for routine supplies, like gowns, gloves or sheets. These items should be factored into the hospital daily-room charge, because, Butcher says, they are "considered the cost of doing business."

3. Challenge your health insurer's decisions, when warranted. Keep track of any hospital bills the company rejects on grounds that the procedure or drug isn't covered by your policy. If you believe the insurer should be paying more, don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections.

4. Negotiate bills once you know how much you'll have to pay out of pocket. If you just want extra time to send the money, Dale says, "it is relatively easy to speak with hospital or clinic business office staff to arrange a payment plan."

Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at once.

You may also be able to successfully bargain down the particular dollar amounts you've been charged.

Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital, you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less than the initial rate quoted - the figure charged to uninsured patients.

Go online to check the rates other local hospitals charge for the procedure you had. Then, if you find your bill was way out of line, use this data as ammunition to try to get your fees lowered. You can get this type of information at such sites as Clear Health Costs, Healthcare Blue Book and FAIR Health.

Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation.

5. Consider hiring a pro. Since hospital bills are hairy, messy beasts, it may be worth your while to bring in a patient- or medical-billing advocate (Detweiler recommends the advocacy firm Copatient.com, which charges 30% of what it saves you) or an attorney. "It's like hiring a CPA to do your taxes," Dale says.

Be sure you won't be required to pay this expert any fees upfront. Patient advocates typically charge 20 to 30% of your savings; some put a cap on their fees. Karis' firm, for example, charges no more than $3,000. Attorneys often charge 30% of the savings they achieve.

... ... ...

Caroline Mayer is a consumer reporter who spent 25 years working for The Washington Post. Follow her on Twitter TWTR -0.69% @consumermayer.

[Nov 22, 2016] Negotiating can cut hundreds off your medical bills

Notable quotes:
"... There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. ..."
13 WTHR Indianapolis
But you can fight back against skyrocketing medical costs.

"I've heard discounts up in the area of 30 percent sometimes, which can be pretty significant," said Cathryn Perron, director of program development with Consumer Credit Counseling.

She says it's possible to negotiate down your medical bills - everything from ambulance rides to surgery. She says you can also bargain with your dentist, the lab that does your blood tests, the eye doctor - even the company that makes you prescription medication.

"Each company has a specific number you can call to fill out an application and many times, you'll get a discount, or you'll get the product free through the drug companies, if you qualify financially," Perron said.

All you have to do, with or without insurance, is make a call. Each case is handled differently. In most cases, everyone wants to pay the bill, but they're afraid to contact their doctor or hospital. They'll work with you to make sure the cost is paid.

So how do you pay less?

There are a number of options:

  • Offer to pay in cash - You may get an up-front discount of 10 percent or more.
  • Ask about a payment plan - They're usually interest-free and determined by your budget.
  • If you don't have insurance - Some hospitals will give you a discount that is equal to what it may have given the insurance company.

Charity care - Bills are forgiven, based on your income and expenses, but you'll have to fill out hardship paperwork.

"You'll most likely have to provide proof of income, they'll ask about your monthly living expenses and your other bills that you have to pay every month," said Perron.

Sholar called Indianapolis EMS.

"He says, 'Sir, you got to pay for the ambulance, all the stuff in the ambulance, the two people who drive the ambulance. That's just the way it is'," he said.

But he didn't give up.

"This bill says $1,300. She said, 'Yeah, that sounds about right.' I said, 'Let me talk to a supervisor'," Sholar said. "The supervisor's name is John. John wasn't too happy."

Mike put on the pressure and the bill was reduced by $532. The wounds to his buttocks are healed, but the other injury he got that night, on his thumb, is a constant reminder of the cost of healthcare.

"I don't need no X-rays, I don't need no other stuff. Just give me the stitches and I still haven't received a bill for that," he said.

But he's ready to negotiate and he says, in the future, he'll also weigh the costs before calling 911.

"I would have put a rag over it and got a ride here," he said.

Tips to Negotiate Your Medical Costs

Consumer Credit Counseling and Apprisen offer tips to get your medical bills reduced:

First and foremost be informed. Understand what type of medical insurance coverage you have and what your co-pays or financial responsibilities are. Some insurance companies have contracts with certain medical providers to offer a discount if you receive treatment from a "preferred provider." We encourage individuals to meet with their Human Resource department or contact their insurance company to speak with a representative about their coverage and benefits prior to receiving medical treatment. This could reduce your financial responsibility significantly.

Apprisen recommends for you to review your itemized statement from your medical provider. If you feel there are discrepancies or charges in question, contact your medical provider to meet with their Patient Account Specialist to discuss your questions or discrepancies. Communication is a vital part of resolving your issues. Simply ignoring communication from your medical provider will not resolve the issue and could potentially lead to a negative impact on your credit rating if resolution is not reached.

Whether you have insurance or not, you are encouraged to contact your medical provider prior to treatment (if possible) to discuss costs associated with your treatment and to work out the possibility of negotiating those costs down. Many medical providers will consider giving discounts to individuals who are willing to pay the balance in full upon services rendered or within a short period of time after receiving treatment. If you find yourself in a position where you are not able to pay the balance in full, consider negotiating with your medical provider for a monthly repayment plan interest free. You are encourage to analyze your personal budget to insure you are able to make the financial commitment to your medical provider. Negotiating your medical bill then failing to follow through with the financial payment arrangement could negate your hard effort to reduce your medical bill.

If you are uninsured, you are encouraged to meet with a Patient Account Specialist or a "decision maker" to see if you qualify for any financial hardship programs. Most hardship programs require you to provide evidence of your financial situation and the award is based on financial need. Be prepared to give a full budget disclosure in order to be considered for the hardship program.

Apprisen's mission is "To help people improve their financial well-being through counseling, community outreach and financial education."

You can call Apprisen at 1-800-355-2227 or visit apprisen.com.

There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. You can find out more about those companies at objectivedx.com.

[Nov 22, 2016] Hiring a Guide to the Medical Bill Maze

Notable quotes:
"... As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate . It negotiated with the physician's health-care group to reduce her bill to $7,000. ..."
Apr 29, 2013 | Bloomberg

When Annrose Isaac's twins were born prematurely, she thought her insurer would cover their stay in the neonatal intensive care unit. "The hospital was in our network, but it turned out the physician in the NICU who saw our daughters didn't participate with our insurer," says the Westwood (New Jersey)-based financial planner. "All of a sudden we were getting bills for over $30,000."

As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate. It negotiated with the physician's health-care group to reduce her bill to $7,000.

More than 60 percent of all U.S. personal bankruptcies are linked to illness and unpaid medical bills, according to a 2009 Harvard University study, even though 78 percent of those filing for bankruptcy because of illness have some form of health insurance. So hiring a medical billing advocate can be an essential part of the cure to financial ills.

Yet finding the right advocate can be tough, and those in the direst situations can ill afford the typical $75- to $130-an-hour rate. "This business is painfully slow-growing," says Becky Stephenson, co-president of the Alliance of Claims Assistance Professionals (ACAP), an advocate trade group. "There are a lot of people with problems but not a lot of people willing to pay you to help them." Despite long experience, Stephenson herself has trouble making a good living purely from advocacy, so she supplements her income by serving as an expert witness in medical lawsuits.

Employees working at sizable companies may already have access to a health advocate. Just over half of U.S. companies with more than 500 employees offer it as a benefit, according to Steven Noeldner, a senior consultant for Mercer's Total Health Management practice. Many employees don't know the benefit exists, he says, and the services generally aren't as customized as those of an independent billing advocate.

Credential Check

Unlike with more established professions such as accounting or law, there is no standard credential to look for when seeking a qualified advocate. At the most basic level you should ask if an advocate has certifications in medical bill coding from either the American Academy of Professional Coders or the American Health Information Management Association.

Many people with those designations aren't advocates, however, working instead for hospitals or insurers. And understanding the codes is only half the battle. Because of the complexity of our health-care system, you'll need someone who specializes in your specific kind of billing problem.

A good place to start is Claims.org, ACAP's website. It lets you search for experienced advocates by state. In a case like Isaac's, you'd need someone who specializes in hospital bills. Other advocates specialize in Medicare appeals, long-term care insurance, workers' compensation and insurance for special needs children.

Privacy Issues

The best way to find the right specialist is to ask the advocate for a resume and references. This can be tricky, because laws about disclosing private medical information are so strict that some advocates have difficulty providing references. In order to do so, their clients must agree to discuss their medical history.

Stephenson specializes in hospital bill audits. She studies itemized bills line by line, identifies padding and mistakes and negotiates lower rates. Prior to starting her Austin (Texas)-based advocacy firm VersaClaim in 2002, she ran an organization that helped doctors affiliated with hospitals set up their practices. That included all aspects of hospital billing.

A registered nurse for 12 years, Stephenson has an intimate knowledge of medical terminology and hospital procedures. "I ask questions like, Are there dosages of medications that are not compatible with my medical experience in real life?" she says. "Do the charges look realistic, or is there an $85 Tylenol?"

Location Matters

Another important factor to consider is an advocate's location. State laws vary in how they regulate insurers and hospitals. For Katalin Goencz, an advocate in Stamford, Connecticut, location is often irrelevant because she specializes in Medicare appeals: "The rules for Medicare are federal and pretty much universal, so the client's location doesn't really matter."

For a patient negotiating a lower bill directly with a local hospital or private insurer, having an advocate who knows the specific state regulations helps. State rules for advocates can also vary dramatically. Florida has some of the strictest. "Due to the large senior population in our state, we have a strong urge to make sure our people adjusting medical claims are licensed, competent and held to a high standard," says Matthew Guy, a spokesman for Florida's Division of Agent and Agency Services, which licenses and regulates advocates.

The state's Public Adjuster license for advocates requires licensees to be fingerprinted, have a criminal background check and hold a $50,000 surety bond. "If there's any wrongdoing by the adjuster, we can take the bond amount and use that towards restitution for the consumer," Guy says. Adjusters must pass an exam and take 24 hours of continuing education classes every two years.

Contingency Basis

A handful of advocates will work on contingency if they think you have a negotiable claim. Most will impose strict conditions to ensure they get paid if they win. "When I started my practice, I did everything on contingency but learned very quickly that a lot of consumers who want you to take their case on contingency in the end don't want to pay you," says Sheri Samotin, a billing advocate at Life Bridge Solutions in Naples, Florida.

Now Samotin requires a credit-card authorization up front for an amount sufficient to cover what her estimated contingency fee will be if her work succeeds. If the client doesn't pay within 10 days of a settlement being reached, she charges the card. Her fee is 35 percent of the client's medical bill savings.

Samotin is unusual in the advocacy world as she is more of a generalist, taking on all kinds of medical billing problems, including those of the uninsured. She has 25 years of experience in the health-care industry, so she has the knowledge to handle different kinds of problems, Samotin says. For a monthly $285 fee she will manage her clients' entire billing life -- a common need for seniors who have lost their capacity or desire to manage daily finances.

Instead of being a member of ACAP, Samotin is a member of the American Association of Daily Money Managers, a trade group for generalists. Only a handful of the AADMM's 700-plus members have the skills to also handle medical billing advocacy, Samotin says. Nor does she expect rapid growth in the field.

"Because this is a disorganized profession, people entering the field have to be entrepreneurs," she says. "They have to hang out their shingle and go out and get clients. In my experience, the majority of people who are good medical analysts and advocates are not necessarily good business getters."

So until the profession matures, finding a good advocate will remain difficult, no matter how vital the service is.

(Lewis Braham is a freelance writer based in Pittsburgh.)

To contact the editor responsible for this story: Suzanne Woolley at swoolley2@bloomberg.net

[Apr 05, 2013] How to handle medical bill problems

Notable quotes:
"... Most states have laws saying that patients are entitled to an itemized medical bill that details what services and supplies are included in their charges. ..."
"... In 2006, California passed a law to prevent hospitals from collecting more money from uninsured patients than what Medicare or other public programs would pay for the same service. ..."
"... "Once a patient contacts the hospital and shows evidence of their financial situation, state law requires us to offer a discount based on Medicare rates," says Jan Emerson-Shea, vice president of external affairs for the California Hospital Assn. ..."
"... All communications with a provider should be in writing, experts say. Insist that your account be placed on hold until the dispute is resolved to avoid having the bill sent to collections. ..."
"... If you meet with resistance, don't waste time by calling back the customer service line or billing department. Go straight to the top. ..."
"... filing a complaint with your state's department of insurance. ..."
Apr 05, 2013 | http://articles.latimes.com/2013/apr/05

For those with confusing or huge hospital bills, experts advise knowing rights, getting written explanations, turning to the right places for help and filing complaints if necessary.

When Keith Yaskin and his wife, Loren, rushed their 2-year-old son to the hospital with a dangerous infection in his neck, they weren't thinking about how much his care would cost. After his three-day inpatient stay with nonstop intravenous antibiotics, they were hit with $8,900 in charges.

But the toughest lesson for the Scottsdale, Ariz., couple came a month or so later when they began to sort out the hospital bills. Their insurance policy had a $10,000 deductible. So they scrutinized every item, made some calls and had a few surprises.

When, for instance, they asked a medical group they had never heard of why it was charging them $839.25, they said they got no clear answers, just threats if they failed to pay.

After 21/2 months of calls and a complaint to their state attorney general, the Yaskins finally learned that a pediatrician affiliated with the group had treated their son in the hospital. The medical group eventually cut the bill in half.

None of this surprises Pat Palmer, the founder of Medical Billing Advocates of America. "We get feedback from consumers saying that providers are telling them 'We can't give you an itemized statement' or 'You should have asked for it before you left the hospital.'"

The idea is to discourage patients from asking for the details behind the charges, she said.

Experts offer a range of suggestions for dealing with medical billing problems.

Know your rights. Most states have laws saying that patients are entitled to an itemized medical bill that details what services and supplies are included in their charges.

"You can't be billed if they can't tell you what they are charging for," Palmer says.

Contact the billing department at either the hospital or medical group where you received services, she said. Let them know that you want an itemized bill, and tell them you are aware of your legal right to have it.

Also, a few states have laws limiting how much hospitals can charge patients who pay for care on their own. In 2006, California passed a law to prevent hospitals from collecting more money from uninsured patients than what Medicare or other public programs would pay for the same service.

"Once a patient contacts the hospital and shows evidence of their financial situation, state law requires us to offer a discount based on Medicare rates," says Jan Emerson-Shea, vice president of external affairs for the California Hospital Assn.

Get explanations in writing and take protests to the top. All communications with a provider should be in writing, experts say. Insist that your account be placed on hold until the dispute is resolved to avoid having the bill sent to collections.

If you meet with resistance, don't waste time by calling back the customer service line or billing department. Go straight to the top.

Address a certified letter to the chief executive or chief financial officer of the hospital or medical group explaining that you have tried to resolve billing issues but have hit a brick wall. "The CEO and CFO will take it very seriously," Palmer says.

Get help from your insurer. In the Yaskins' case, both the hospital and the medical group were in their insurer's network and had contracts to provide services at a negotiated discount.

"If you are in network - and this is one of the good reasons to stay in network - you can go to your insurer for help. It has a responsibility to some degree to what happens between you and a contracted physician," says Susan Pisano, spokeswoman for the trade group America's Health Insurance Plans.

Also, ask to make sure you're getting the rate your insurer has negotiated with in-network providers, says Lynn Quincy, senior health policy analyst for Consumers Union, the policy arm of Consumer Reports. Insurers often pass claims through without processing them at the reduced rate. Ask your insurer to re-process the claim if the discount wasn't applied.

Seek help and file complaints. If your bill is large or you're having a hard time making headway, patient advocates can help sort things out. For either a flat fee or a share of the money you save, organizations such as Medical Billing Advocates of America (www.billadvocates.com) and Health Proponent (www.healthproponent.com) can help you fight charges or lower your bill.

If you're being stonewalled by your healthcare provider, and your insurer hasn't helped, Quincy of Consumers Union suggests filing a complaint with your state's department of insurance. In California, patients with HMO coverage can file a complaint with the California Department of Managed Health Care by calling (888) 466-2219 or visiting healthhelp.ca.gov. Californians with PPO coverage should try the Department of Insurance at (800) 927-HELP (4357) or visit http://www.insurance.ca.gov. If your provider isn't contracted with your insurer, your state's attorney general's office is a place to turn for help.

The Yaskins ultimately enlisted the services of an advocate to help them sort through all their billing questions.

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