Opaque Transparency?

Lack of price transparency is one of the biggest problems plaguing American patients and well-intentioned state legislators are now taking a stab legislative fixes.

But is a government mandate the right approach? Dr. Keith Smith, for one, warns that it isn’t.  Here’s a recent example of just what can go wrong.

In one state, Ohio, the legislature passed a law now known as Ohio Revised Statute 5162.80, which has misdiagnosed the disease and has prescribed an ineffective and even potentially harmful cure, particularly for patients tied to an “insurance” plan.

On it’s face the bill seems straightforward: doctors and hospitals must give patients good faith estimates for charges and payments. Who could be opposed to that?

The devil is in the details, particularly in this section of the law:

A provider of medical services shall provide in writing before care is rendered: “The amount the health plan issuer intends to pay for the product, service, or procedure…”

Anyone who has ever tried to get an insurance company to divulge its contracted rates with providers prior to receiving care knows all too well what a herculean task it is.

To their credit, the bill’s authors included a provision to address this problem:

“Any health plan issuer contacted by a provider … shall provide such information to the provider within a reasonable time of the provider’s request.”

Again this looks like a reasonable provision at first glance, but it is really non-transparent transparency and worse could lead to delays in care.

Why should a patient have to contact a physician or facility to find out what his or her insurance plan will pay? This is in reality erecting a barrier between the patient and finding out what the actual costs for care will be at any given doctor or facility. It blocks meaningfully shopping for the best price.

We are not recommending government mandates, but  a more effective requirement might be to demand that the insurers release ALL of their reimbursement rates, both in network and out-of-network, in a transparent manner so that everyone, particularly patients enrolled in a plan, can easily see how much the insurer would pay paying before a patient even sets foot in a doctors office.

The bill as written only requires that the insurers divulge the info on a case by case basis to the “provider.” Why not also to the patient? After all the patient is at least purportedly the actual customer of the insurance company.

As Dr. Michel Accad explains, price opaqueness is a symptom of larger problem, pervasive third-party-payment, and not in itself the root cause.

In a free and competitive healthcare market, price transparency would rarely be an issue, as it is not an issue in the market for cell phones and bubble gum.  Doctors and hospitals could not survive without being upfront about fees.  But, in its great wisdom, and supported by the sound logic of healthcare analysts and healthcare economists, the government has ensured—through its tampering with and participation in health insurance—that charges would be as opaque as possible.

As demonstrated by free market facilities like the Surgery Center of Oklahoma — who post their actual prices not fictitious chargemaster rates — the ultimate solution to not only price transparency, but increasing access to high quality, low cost care, is to kick out the middlemen driving up and obscuring the prices.

Denied? Make Insurance Gatekeepers Responsible Too

“Snippets from the frontline” sent in from Gene Uzawa Dorio, M.D.

You’ve been told surgery required to repair a herniated disc has been denied; a mammogram to evaluate a new lump won’t be allowed; or you must be discharged from the hospital because an insurance company doctor you have never met will not approve further hospitalization.

As my patient’s advocate, I frequently must discuss their care with insurance doctors in peer-to-peer phone conversations. This is what I do starting this conversation: I get the doctor’s name; in what state they are licensed; their specialty; and tell them their name will be placed on the patient’s record as being a participant in medical decision-making.

With that, they must weigh their medical versus financial judgement, and know they might be subject to the same accountability I face. Does this make a difference? Sometimes.

Medical decision-making has been removed from your doctor and given to distant paper pushers of the insurance industry. Urge your physician in their peer-to-peer conversations to make insurance doctors responsible too.

Gene Uzawa Dorio, M.D.

Comments: http://scvphysicianreport.com/2017/07/29/doctors-diary-july-29-2017/

Tell CMS to Protect Patients and Physicians from Harmful Red Tape

CMS has released the proposed 2018 regulations for MACRA and is asking for comments.  The new changes don’t go far enough to protect independent physicians and their patients from harmful red tape.

CMS has a fact sheet about the proposed rule available here:

Comments are dues August 21 and can be submitted here:
https://www.regulations.gov/document?D=CMS-2017-0082-0002

Dr. Marcy Zwelling had put together sample comments to help everyone get the correct message to CMS.

Below are comments that you can cut and paste –

Medicare Administrators: 

We appreciate the sentiment of the new MIPS regulations, but it does not get the job done for many physicians struggling to go to work and NOT sit behind a computer all day. America’s physicians need to be able to just do our job and struggling with computers does not help us get it done.  It is not about micro-managing the regulations; it’s about our professionalism. 

We understand the statutory constraints, and we think we have the answer.  If the regulations could be edited to read 

Exemptions permitted:

Clinicians below the low-volume threshold – Medicare Part B allowed charges per physician less than or equal to $90,000 OR 200 or fewer Medicare Part B patients per physician up to a 6 person practice. 

Thank you for your serious consideration.  While this change does not save all small practices, we feel that this minor change will send the right message to American physicians and will encourage physicians to work with CMS and keep their offices open. 

 Further, we encourage CMS to follow thru with Dr. Price’s commitment to allow physicians to balance bill as a means of enhancing our patients’ options and keeping physicians’ doors open. 

The Ten Commandments of Healthcare

“Socialism is great until you run out of someone elses money.” ~Margaret Thatcher

Remember: Doctors for America was Doctors for Obama(partisan organization)

Read more: “Both Parties are Responsible for Healthcare Disaster” by Dr. Wax, published in Medical Economics, June 27, 2017 http://medicaleconomics.modernmedicine.com/medical-economics/news/both-political-parties-are-responsible-healthcare-disaster

Yet another failing report card for the “Affordable” Care Act

CMS released a county-level map of 2018 projected ACA Exchanges participation:

“This map shows that insurance options on the Exchanges continue to disappear.  Plan options are down from last year and, in some areas, Americans will have no coverage options on the Exchanges, based on the current data.”

“This is yet another failing report card for the Exchanges. The American people have fewer insurance choices and in some counties no choice at all. CMS is working with state departments of insurance and issuers to find ways to provide relief and help restore access to healthcare plans, but our actions are by no means a long-term solution to the problems we’re seeing with the Insurance Exchanges,” explains CMS Administrator Seema Verma.

58 Hours of CME George Orwell Style

Friend of IP4PI Jane Hughes, MD writes in:

Anyone who thought that things were on hold regarding continued implementation of ACA and the statist move by Medicare via MACRA and its payment scheme called MIPS to centralize and control patient and physician choices needs to read this upcoming offering for unprecedented free CME from one of our premier institutions, Johns Hopkins. Key to centralization is electronic medical records that are interoperable. Read that to mean 24/7 access by government/insurance for data gathering and eventual treatment rubrics. Note that all of these CME hours are not featuring medical or surgical issues, they deal with “educating” and indoctrinating physicians on the advisability of population based care.

This is a sinister turn for the worse. We should have gotten a health plan through in some form to start the dismantling of ACA and trumpet the message that this is the beginning of decentralizing healthcare. Critical to reform of Medicare and getting rid of MACRA is a stable, affordable, and accessible private option.

These sponsoring organizations are proceeding as if nothing has changed. Until Trump appointees get rid of entrenched bureaucrats subversive to the true reform of statist ACA this is no surprise. The collusion with insurance and govt also needs to be exposed. These two forces are insatiable looters of tax monies, people’s premium moneys, individual human dignity, and doctor and physician choices. Note they are offering 58 hours of CME credit/brainwashing. What an impotent feeling to read that even an institution as grand as John Hopkins has succumbed to the George Orwell form of medical care.

Real Patient Lives vs. Corporatized/Government Healthcare, Part IV

The insurance and government dominated system is failing our patients. A physician friend of IP4PI shares this shocking example about the system claiming another victim:

A 59 y/o man presented to my last employed practice, with an almost elephantiasis swelling bilateral legs.  He had pinpoint marks on the skin of his legs.  He held up a jar with what looked like a couple of tiny maggots.  He said, these come out of those holes every so often.  I said how long has this been going on??  He said 1.5 years.  “I’ve mentioned to several doctors, they just shrug and don’t do anything.”  I said we would do something, and called the hospitalist immediately to admit for workup and treatment.  I was directed to the nurse gatekeeper for approval for admission.  What’s wrong, she asked.  “4+ edema in both legs, which are also full of maggots.”  Hmmm, she said.  There is no medicare admissible diagnosis of ‘maggots in legs’.  What about his rising creatinine of 1.7?  Not bad enough to qualify under guidelines.  Call us back if it gets worse.  I did try to do some outpatient workup, but I think the man was disgusted.  He never followed up.  He was dead within the year.