Medical Industrial Complex

News The Audacity of Greed Recommended Links Programmers and sysadmins health issues Neoliberal rationality Overuse of Cardiac Stents Linked to Patient Deaths Health insurance
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Living under Neoliberalism with its "greed is good" mentality and "homo homini lupus est" slogan is indeed dangerous  and requires knowledge of elementary "self-defense" strategies. this is especially important in order to avoid misdiagnosis and mistreatment by "medical-industrial complex". 

Neoliberalism completely corrupts medicine moving it from First, do no harm principle to "let's milk the suckers" principle. In other words, in no way medical industrial complex obeys "no harm" principle. It is strictly about profits.  The slogan is "Profits before people's health". Falsified drugs trials, over-prescription of drugs (with little concern about their possible interaction) the concept (and frantic search) of "blockbuster" drugs, useless surgeries such as  Overuse of Cardiac Stents  are just the tip of the iseberg.

Most destructive has been the commercialization of medicine as a big business — healing art transformed into profitable cash cow. Perverse financial incentives encourage disease mongering, false advertising, over testing, quick diagnosis, and unnecessarily aggressive treatment.

Medical marvels are oversold and overbought. Doctors need to be more humble and safety-conscious. We can’t overstep our knowlege base without putting our patients at risk.

Patients and doctors need to accept the uncertainty and limits of medicine. False certainty leads to terrible decisions.

Medical–industrial complex - Wikipedia, the free encyclopedia

The medical–industrial complex is the network of corporations which supply health care services and products for a profit. The term is analogous to "military–industrial complex" and builds from the social precedent of discussion on that concept.

The medical–industrial complex is often discussed in the context of conflict of interest in the health care industry.

The concept of a "medical–industrial complex" was first advanced by Barbara and John Ehrenreich in the November 1969 issue of the Bulletin of the Health Policy Advisory Center in an article entitled "The Medical Industrial Complex" and in a subsequent book (with Health-PAC), The American Health Empire: Power, Profits, and Politics (Random House, 1970). The concept was widely discussed throughout the 1970s, including reviews in the New England Journal of Medicine (Nov. 4, 1971, 285:1095). It was further popularized in 1980, Arnold S. Relman while he served as editor of the The New England Journal of Medicine.[1] in a paper titled "The New Medical-Industrial Complex." Relman commented, "The past decade has seen the rise of another kind of private "industrial complex" with an equally great potential for influence on public policy — this time in health care..." Oddly, Relman added, " In searching for information on this subject, I have found no standard literature and have had to draw on a variety of unconventional sources..."[1] Subsequently, this paper and the concept have been discussed continually.[2] An updated history and analysis can be found in John Ehrenreich, "Third Wave Capitalism: How Money, Power, and the Pursuit of Self-Interest have Imperiled the American Dream" (Cornell University Press, May 2016).

Manufacturers of medical devices fund medical education programs and physicians and hospitals directly to adopt the use of their devices.[3]

The management of health care organizations by business staff rather than local medical practice is one of the trends of the increasing influence of the medical-industrial complex.[4]

Another trend is that increased pressure to generate profit for providing services can decrease the influence of creativity or innovation in medical research.[5]

In the 1970s profit-seeking companies became significant stakeholders in the United States healthcare system.[6]

The influence of economic policy on the practice of medicine has a long history.[7]

Because the General Agreement on Trade in Services regulates international marketplaces, in countries where the industrial-medical complex is more strong there can be legal limitations to consumer options for accessing diverse healthcare services.[8]

Because the industrial-medical complex funds continuing medical education, this education has a bias to promote the interests of its funders.[9]

Market conditions for providing pain management services are influenced significantly by the medical-industrial complex.[10]


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[May 24, 2020] Private Equity Is Ruining Health Care, Covid Is Making It Worse: Investors have been buying up doctor s offices, cutting costs, and, critics say, putting pressure on physicians by Heather Perlberg

Highly recommended!
So not only ambulance service was destroyed by private equity, they now added other specialties. I wonder is those criminals who insert unnecessary stents in patients are connected to private equity.
Images removed
Notable quotes:
"... "You can't serve two masters. You can't serve patients and investors" ..."
"... Morganroth's defense of pandemic Botox might seem odd, but it made perfect sense within the logic of the U.S. health-care system, which has seen Wall Street investors invade its every corner, engineering medical practices and hospitals to maximize profits as if they were little different from grocery stores. At the center of this story are private equity firms, which saw the explosive growth of health-care spending and have been buying up physician staffing companies, surgery centers, and everything else in sight. ..."
"... But some doctors say that the private equity playbook, which involves buying companies, drastically cutting costs, and then selling for a profit -- the goal is generally to make an annualized return of 20% to 30% within three to five years -- creates problems that are unique to health care. "I know private equity does this in other industries, but in medicine you're dealing with people's health and their lives," says Michael Rains, a doctor who worked at U.S. Dermatology Partners , a big private equity-backed chain. "You can't serve two masters. You can't serve patients and investors." ..."
"... Yet over the past decade, lawyers devised a structure that allows investors to buy a medical practice without technically owning it: the MSO, or management service organization. Today, when an investment firm buys a doctor's office, what it's actually buying are the office's "nonclinical" assets. In theory, physicians control all medical decisions and agree to pay a management fee to a newly created company, which handles administrative tasks such as billing and marketing. ..."
"... Businessweek ..."
"... When individual doctors sell, they generally receive $2 million to $7 million each, with 30% to 40% of that paid in equity in the group. After the acquisition, doctors get a lower salary and are asked to help recruit other doctors to sell their practices or to join as employees. ..."
"... Patients, for the most part, are in the dark. Unlike when your mortgage changes hands, you usually aren't notified when a big investment firm buys your doctor. Sometimes the sign on the door bearing the physician's name stays put, and subtle changes in operations or unfamiliar fees may be the only clues that anything has happened. ..."
"... At Advanced Dermatology & Cosmetic Surgery , the largest private equity-backed group in the field, with more than 150 locations across the U.S., that sense of discomfort came shortly after Audax Group bought a controlling stake in what was then a much smaller chain in 2011. The new management team introduced a scorecard that rewarded offices with cash if they met daily and monthly financial goals, according to a lawsuit filed in 2013 against the company by one of its dermatologists. The doctor alleged that the bonus program encouraged staff to do as many procedures as possible, rather than strictly addressing patients' medical needs. ..."
"... Most dermatologists use outside labs and pathologists, but private equity-owned groups buy up existing labs and hire their own pathologists. Then doctors are encouraged to refer patients within the group and send biopsy slides to the company-owned labs, keeping the entire chain of revenue in-house. ..."
"... Now comes the cost-cutting. This is supposed to be the hallmark of private equity, and, done right, it can work to the benefit of doctors and patients. But there are pitfalls unique to medicine, where aggressive cuts can lead to problems, some of them merely inconvenient and some potentially dangerous. ..."
"... A doctor at Advanced Dermatology says that waiting for corporate approvals means his office is routinely left without enough gauze, antiseptic solution, and toilet paper. Even before the great toilet paper shortage of 2020, he would travel with a few rolls in the trunk of his car, to spare patients when an office inevitably ran out. The company declined to comment. ..."
"... One paradox of the Covid-19 pandemic has been that even as the virus has focused the entire country on health care, it's been a financial disaster for the industry. And so, while emergency room doctors and nurses care for the sick -- comforting those who would otherwise die alone, and in some cases dying themselves -- private equity-backed staffing companies and hospitals have been cutting pay for ER doctors. These hospitals, like the big medical practices, make a large portion of their money from elective procedures and have been forced into wrenching compromises. ..."
"... For investors with capital, on the other hand, the economic fallout from the virus is a huge opportunity. Stay-at-home orders have left small practices more financially strained than they've ever been. That will likely accelerate sales to private equity firms, according to Marc Cabrera, an investment banker focused on health-care deals at Oppenheimer & Co. Independent doctors or groups that previously rebuffed offers from deep-pocketed backers "will reconsider their options," he says. ..."
"... Many doctors may ultimately come to regret cashing out, but it's hard to get out once you're in. As part of an acquisition, the private equity groups typically require doctors to sign yearslong contracts, with noncompete clauses that prevent them from working in the surrounding area. ..."
May 20, 2020 | www.bloomberg.com

Not long after Gavin Newsom, the governor of California, ordered the state's 40 million residents to stay home to stop the spread of the new coronavirus, Dr. Greg Morganroth called his team of doctors and said their dermatology group was staying open.

Morganroth is chief executive officer of the California Skin Institute , which he founded in 2007 as a single office in Mountain View. He's since expanded to more than 40 locations using a financing strategy that's become exceedingly common in American health care: private equity. In this case, he took out a loan from Goldman Sachs Group Inc. that could eventually convert to an equity stake. CSI is now the largest dermatology chain in California.

But the Covid-19 pandemic put Morganroth in a precarious position. Most medical procedures were characterized as nonessential by government officials and practitioners. Doctors were closing offices, and patients were staying away to limit their potential exposure to the virus.

CSI took a different approach. Morganroth explained his thinking on April 2 in a Zoom call with more than 170 dermatologists from around the country organized by the Cosmetic Surgery Forum, an industry conference. Contrary to what they might have heard, Morganroth told them, they should consider staying open during the pandemic. "Many of us are over-interpreting guidelines," he said.

For a moment there was an awkward silence. Doctors had thought they were signing up for advice on how to apply for government money that would help them meet payroll while they were shut down; they hadn't expected to be told not to shut down at all. Morganroth continued: "We are going to be in a two-year war, and we need to make strategic plans for our businesses that enable us to survive and to rebound."

Back at CSI, the company's front-office staff was working the phones, calling patients in some of the worst-hit areas and reminding them to show up for their appointments, even for cosmetic procedures such as Botox injections to treat wrinkles. During the videoconference, Morganroth argued that offering Botox in a pandemic wasn't so different from a grocery store allowing customers to buy candy alongside staples.

"If I had a food supply company and had to stay open, and I had meat, bread, and milk, would I stop making lime and strawberry licorice?" Morganroth asked. "I would make everything and go forward."

From a public-health point of view, some of the doctors believed, this was questionable. Common reasons for visiting a dermatologist's office -- skin screenings, mole removals, acne consultations -- aren't particularly time sensitive. Serious matters, such as suspected cancers and dangerous rashes, can be handled, at least initially, with telemedicine consultations . Then doctors can weigh the risks for their patients and determine who needs to come in. In a statement, CSI says that it followed local and state laws for staying open, while providing "necessary care" for patients, and that it had not required doctors to come to work.

"You can't serve two masters. You can't serve patients and investors"

Morganroth's defense of pandemic Botox might seem odd, but it made perfect sense within the logic of the U.S. health-care system, which has seen Wall Street investors invade its every corner, engineering medical practices and hospitals to maximize profits as if they were little different from grocery stores. At the center of this story are private equity firms, which saw the explosive growth of health-care spending and have been buying up physician staffing companies, surgery centers, and everything else in sight.

Over the past five years, the firms have invested more than $10 billion in medical practices, with a special focus on dermatology, which is seen as a hot industry because of the aging population. Baby boomers suffer from high rates of two potentially lucrative conditions: skin cancer and vanity. Some estimates suggest that private equity already owns more than 10% of the U.S dermatology market. And firms have started to expand into other specialties, including women's health, urology, and gastroenterology.

There's nothing inherently wrong with any of this. But some doctors say that the private equity playbook, which involves buying companies, drastically cutting costs, and then selling for a profit -- the goal is generally to make an annualized return of 20% to 30% within three to five years -- creates problems that are unique to health care. "I know private equity does this in other industries, but in medicine you're dealing with people's health and their lives," says Michael Rains, a doctor who worked at U.S. Dermatology Partners , a big private equity-backed chain. "You can't serve two masters. You can't serve patients and investors."

Investment firms, and the practices they fund, say these concerns are overblown. They point out that they're giving doctors a financial shelter from the rapidly changing medical environment, a particularly attractive prospect now, and that money from private equity firms has expanded care to more patients. But they've also made it next to impossible to track the industry's impact or reach. Firms rarely announce their investments and routinely subject doctors to nondisclosure agreements that make it difficult for them to speak publicly. Bloomberg Businessweek spoke to dozens of doctors at 10 large private equity-backed dermatology groups. Those interviews, along with information obtained from other employees, investors, lawyers, court filings, and company records, reveal how the firms operate, and why they sometimes fail patients.

The process is never exactly the same, but there are familiar patterns, which tend to play out in five steps.

Step 1: Marriage

The strange thing about private equity money in medicine is that for-profit investors have long been prevented from buying doctor's offices. Corporate ownership goes against a doctrine set by the American Medical Association , the main trade group for doctors in the U.S., and is prohibited by law in many states, including Texas and New Jersey. For most of the past 100 years, if you wanted to make money on a medical practice, you needed to have a medical license.

Yet over the past decade, lawyers devised a structure that allows investors to buy a medical practice without technically owning it: the MSO, or management service organization. Today, when an investment firm buys a doctor's office, what it's actually buying are the office's "nonclinical" assets. In theory, physicians control all medical decisions and agree to pay a management fee to a newly created company, which handles administrative tasks such as billing and marketing.

In practice, though, investors expect some influence over medical decision-making, which, after all, is connected to profits. "When we partner with you, it's a marriage," said Matt Jameson, a managing director at BlueMountain Capital, a $17 billion firm that recently invested in a women's health company, while speaking at a conference in New York in September. "We have to believe it. You have to believe it. It's not going to be something where clinical is completely not touched." (When contacted by Businessweek , Jameson asked to clarify his comments. "Doctors and other qualified healthcare professionals at the providers we've invested in make medical decisions," he said in a statement.)

The typical buyout starts with the acquisition of a big, popular practice, often with multiple doctors and several locations, for as much as $100 million. (Investors typically pay between 9 and 12 times annual profit.) This practice functions as an anchor, like a name-brand department store at a shopping mall, attracting patients and doctors to the new group as it expands. Then comes the roll-up: The private equity firm purchases smaller offices and solo practices, giving the group a regional presence.

As part of the new structure, investors deal with paperwork and save money by buying medical supplies in bulk. Crucially they also negotiate higher insurance reimbursement rates. One dermatologist who sold her practice to the California Skin Institute says she was surprised to find out the bigger group's payouts from insurers were $25 to $125 more per visit.

When individual doctors sell, they generally receive $2 million to $7 million each, with 30% to 40% of that paid in equity in the group. After the acquisition, doctors get a lower salary and are asked to help recruit other doctors to sell their practices or to join as employees.

At first, doctors are generally thrilled by all of this. They have financial security and can focus on treating patients without the stress of running a business. Patients, for the most part, are in the dark. Unlike when your mortgage changes hands, you usually aren't notified when a big investment firm buys your doctor. Sometimes the sign on the door bearing the physician's name stays put, and subtle changes in operations or unfamiliar fees may be the only clues that anything has happened.

Step 2: Growth

The promise of more patients is a big draw for doctors. By sharing marketing costs and adding locations, the new companies can advertise more and attract customers. Private equity-owned practices have been diligent users of social media, announcing newly added doctors and posting coupons on Twitter and Instagram. But these practices can be aggressive in ways that make some doctors uncomfortable.

At Advanced Dermatology & Cosmetic Surgery , the largest private equity-backed group in the field, with more than 150 locations across the U.S., that sense of discomfort came shortly after Audax Group bought a controlling stake in what was then a much smaller chain in 2011. The new management team introduced a scorecard that rewarded offices with cash if they met daily and monthly financial goals, according to a lawsuit filed in 2013 against the company by one of its dermatologists. The doctor alleged that the bonus program encouraged staff to do as many procedures as possible, rather than strictly addressing patients' medical needs.

In some of the company's Florida offices, the doctor alleged, medical assistants responded to the bonus structure by ticking extra boxes on exam reports, stating that doctors checked many more areas of the body than they actually had. That led to higher patient bills, defrauding the government under its Medicare program, according to the lawsuit. The federal government declined to join the case, and it was dismissed about a year after it was filed. Advanced and Audax declined to comment.

One-Stop Skin Care

By buying up labs and adding specialists, private equity-owned dermatology groups get paid at every step of a patient's treatment.

Data: Estimated Medicare reimbursement rates for the Miami area, Sensus Healthcare sales presentation

Private equity-backed practices also try to increase revenue by adding more-lucrative procedures, according to doctors interviewed by Businessweek . In dermatology, this means more cosmetics, laser treatments, radiation, and especially Mohs surgeries -- a specialized skin cancer procedure that removes growths from delicate areas like the face and neck one layer at a time, to limit scarring. The surgery involves expensive equipment and specialized doctors, so some large medical groups keep costs down by assembling traveling Mohs teams, who fly in from other states. Others create mobile labs in vans that set up in clinics' parking lots.

Most dermatologists use outside labs and pathologists, but private equity-owned groups buy up existing labs and hire their own pathologists. Then doctors are encouraged to refer patients within the group and send biopsy slides to the company-owned labs, keeping the entire chain of revenue in-house. This takes advantage of a regulatory quirk that has made dermatology, and a handful of other specialties, attractive to private equity. Under the 1989 Stark Law, doctors aren't allowed to make patient referrals for their own financial gain. An exception was made for some fields because it's more convenient for patients, explains Dr. Sailesh Konda, a Mohs surgeon and professor at the University of Florida. "But that can be abused."

Step 3: Synergy

Now comes the cost-cutting. This is supposed to be the hallmark of private equity, and, done right, it can work to the benefit of doctors and patients. But there are pitfalls unique to medicine, where aggressive cuts can lead to problems, some of them merely inconvenient and some potentially dangerous.

A doctor at Advanced Dermatology says that waiting for corporate approvals means his office is routinely left without enough gauze, antiseptic solution, and toilet paper. Even before the great toilet paper shortage of 2020, he would travel with a few rolls in the trunk of his car, to spare patients when an office inevitably ran out. The company declined to comment.

At the country's second-biggest skin-care group, U.S. Dermatology Partners , a former doctor says a regional manager switched to a cheaper brand of needles and sutures without consulting the medical staff. The quality was so poor, she says, they would often break off in her patients' bodies. Mortified, she'd have to dig them out and start over. She complained to managers but couldn't get better supplies, she says. Paul Singh, U.S. Dermatology's CEO, says the company uses a "reputable, global vendor for medical supplies." "While our group may have standardized purchasing processes, individual providers have the autonomy to procure specific supplies that they need for a particular patient situation or patient population," he says in a statement.

Doctors who join a private equity-backed group generally sign contracts that state they'll never have to compromise their medical judgment, but some say that management began to intervene there, too. Dermatologists at most of the companies say they were pushed to see as many as twice the number of patients a day, which made them feel rushed and unable to provide the same quality of care. Others were forced to discuss their cases with managers or medical directors, who asked the doctors to explain why they weren't sending more patients for surgery. Multiple practices also encouraged doctors to send home Mohs surgery patients with open wounds and have them come back the next day for stitches -- or to have a different doctor do the closure the same day -- because that would allow the practice to collect more from insurers.

That's if doctors are performing the procedures at all. At Advanced Dermatology, several doctors say they were asked to claim that physician assistants, or PAs, were under their supervision when they weren't seeing patients in the same building, or even the same town. Because PAs are paid less than dermatologists, this allowed the company to keep costs low while growing the business. In a statement, Eric Hunt, Advanced's general counsel and chief compliance officer says that having PAs on staff enables the company to "provide access to quality dermatological care to more patients."

Step 4. Rolling Up the Roll-Up

Advanced Dermatology was sold in 2016 by Audax to Harvest Partners LP , following a pattern that's typical in the industry. At some point, after costs have been cut and profits maximized, most private equity-owned medical groups will be sold, often to another private equity firm, which will then try to somehow make the company even more profitable.

Having reduced most of the obvious costs, Advanced Dermatology began skimping on more important supplies, including Hylenex, according to doctors and other employees. The drug is an expensive reversal agent used when cosmetic fillers, which are supposed to make skin look plumper, go wrong. Not having enough is dangerous: Patients who get an injection that inadvertently blocks a blood vessel can be left with dead sections of skin or even go blind if they don't get enough Hylenex in a matter of hours. The company says that it stocks Hylenex in every office that performs cosmetic procedures, and that it "has no records of any provider being denied an order for this medication."

Advanced Dermatology also started giving even more authority to PAs, according to doctors and staff. Without enough oversight some were missing deadly skin cancers, they say. Others were doing too many biopsies and cutting out much larger areas of skin than necessary, leaving patients with big scars. Doctors who complained about the bad behavior say they saw PAs moved to other locations rather than fired or given more supervision. Hunt, the company's lawyer, says that all PAs get six months of training and are supervised by experienced doctors.

The staff coined a new medical diagnosis, "pre- pre- pre-cancer"

Advanced Dermatology also put more pressure on doctors to send biopsies to in-house labs. The move made sense financially, but some of the doctors didn't trust the lab. One of its two pathologists in Delray Beach, Fla., Steven Glanz, had a history of misdiagnosing benign tumors, which led patients to undergo surgeries that were later found to be unnecessary, according to doctors who worked with him. Dermatologists who warned that Glanz was a danger to patients say that their complaints to Dr. Matt Leavitt, the group's founder and CEO, were ignored. More procedures, doctors knew, brought in more money.

Glanz, who had been with the practice since its early days, was known to read slides under a microscope with a pistol on his desk. After he was arrested with a handgun, a folding knife, and a vial of methamphetamine crystals, he was fired and Florida's state medical board fined him $10,000, requiring him to complete a five-hour course on ethics before he could resume practicing. But his former colleagues were unsettled; they knew Glanz's signature was on years of reports that determined treatment for patients. Some slides were reevaluated, and pathologists noticed mistakes. Managers told some doctors and their staff that patients, even those who'd been misdiagnosed and had unnecessary procedures, were not to be told. Glanz pleaded guilty to stalking and a firearms violation and was sentenced to probation. When a reporter called his office and identified herself, the receptionist hung up. Further attempts to reach Glanz were unsuccessful. Advanced's Hunt says that he was "formally released from employment three years ago," but did not comment further.

Of course, some doctors pushed ethical boundaries long before private equity came into the picture. But critics of the industry, including doctors and investors, say management teams put in place by private equity firms tend to look the other way as long as a medical practice is profitable. Of the dermatologists with the highest biopsy rates in the country (between 4 and 11 per patient, per year), almost 25% were affiliated with private equity-backed groups, according to Dr. Joseph Francis, a Mohs surgeon and data researcher at the University of Florida.

Medical providers may have also been blurring ethical lines at U.S. Dermatology Partners, which was until recently on its second private equity owner, Abry Partners LLC . At four of the company's offices in Texas, a doctor and his PAs were doing more biopsies than necessary, according to employees. These employees say the staff routinely called patients with benign lichenoid keratosis, small brownish blotches that usually go away on their own, and told them the growths should be removed. Under instruction from the doctor, the staff coined a new medical diagnosis, "pre- pre- pre-cancer," and then talked patients into coming in for removal, employees say. Singh, the U.S. Dermatology CEO, says that the company trusts doctors to make the right decisions and that it monitors them through routine audits.

Step 5: Sell-Off

In some cases the cost-cutting either becomes impossible or leads to compromises in care too obvious to ignore. In 2016 a DermOne LLC office in Irving, Texas, had been using a faulty autoclave machine to sterilize surgical equipment -- the state and county health departments identified 137 patients that needed to get tested for blood-borne diseases such as HIV and hepatitis. By 2018, DermOne's backer, Westwind Investors, wanted out.

Westwind had been one of the earliest firms to build a big dermatology business -- with practices in five states -- but others had grown larger. After the debacle in Irving, the Nevada-based firm sold DermOne's medical records and patient lists, as well as some of its offices, to other groups. It dissolved the remaining offices, leaving some patients abruptly without care. Westwind did not respond to repeated requests for comment. Two other private equity-backed groups, TruDerm and Select Dermatology LLC, have also gone out of business in the past two years.

The surviving chains have been saddled with large piles of debt they're now struggling to repay. In January, U.S. Dermatology Partners defaulted on a $377 million loan, meaning the private equity backer, Abry Partners, had to hand over the keys to its lenders, Golub Capital , Carlyle Group , and Ares Management , which will now oversee a chain with almost 100 locations, receiving 1 million visits from patients a year. Abry did not respond to requests for comment .

For the medical groups that make it, the game plan is to eventually sell to the largest players, such as KKR , Blackstone Group , and Apollo Global Management . Pioneering investors, including Audax, are now buying practices in other fields -- a concerning development to critics who note that the areas that are currently attracting investment, such as urology, generally involve more invasive procedures. Should doctors performing vasectomies be thinking about the dollar-rate returns for KKR -- or any private investor?

"It's ultimately going to backfire," says Dr. Jane Grant-Kels, a veteran dermatologist and professor at the University of Connecticut School of Medicine. "There's a limit to how much money you can make when you're sticking knives into human skin for profit."

One paradox of the Covid-19 pandemic has been that even as the virus has focused the entire country on health care, it's been a financial disaster for the industry. And so, while emergency room doctors and nurses care for the sick -- comforting those who would otherwise die alone, and in some cases dying themselves -- private equity-backed staffing companies and hospitals have been cutting pay for ER doctors. These hospitals, like the big medical practices, make a large portion of their money from elective procedures and have been forced into wrenching compromises.

For investors with capital, on the other hand, the economic fallout from the virus is a huge opportunity. Stay-at-home orders have left small practices more financially strained than they've ever been. That will likely accelerate sales to private equity firms, according to Marc Cabrera, an investment banker focused on health-care deals at Oppenheimer & Co. Independent doctors or groups that previously rebuffed offers from deep-pocketed backers "will reconsider their options," he says.

Many doctors may ultimately come to regret cashing out, but it's hard to get out once you're in. As part of an acquisition, the private equity groups typically require doctors to sign yearslong contracts, with noncompete clauses that prevent them from working in the surrounding area.

As governors throughout the nation ease restrictions on businesses, Advanced Dermatology is opening its most profitable offices first. The company received an undisclosed sum under the Cares Act, as part of the government relief package intended for health-care workers. Hunt, Advanced's chief compliance officer, told employees in an email earlier this month that the money would be used for protective gear, such as masks, and to replace "millions of dollars" in lost revenue.

The group had closed most of its offices since the stay-at-home orders were issued in March, cutting pay for doctors and furloughing staff. With cities and states beginning to consider reopening, doctors and PAs say they've been told they should be prepared for a full schedule. Hunt says the company is following the appropriate safety measures, but employees fear it will be nearly impossible to keep patients apart in waiting rooms. Opening in a reduced capacity, they understand, is not an option.

Read more: Private Equity Ate Finance, and Now It's Taking Over the World

[May 12, 2020] Deadly Medicines and Organized Crime

May 12, 2020 | www.moonofalabama.org

Pft , May 12 2020 23:01 utc | 186

Interesting book "Deadly Medicines and Organized Crime " published in 2013 by PETER C GØTZSCHE

He points out "Science philosopher Karl Popper in "The Open Society and Its Enemies" depicts the totalitarian, closed society as a rigidly ordered state in which freedom of expression and discussion of crucial issues are ruthlessly suppressed. Most of the time, when I have tried to publish unwelcome truths about the drug industry, I have been exposed to the journal's lawyers, and even after I have documented that everything I say is correct and have been said before by others, I have often experienced that important bits have been removed or that my paper was rejected for no other reason than fear of litigation. This is one of the reasons I decided to write this book, as I have discovered that I have much more freedom when I write books. Popper would have viewed the pharmaceutical industry as an enemy of the open society.

Rigorous science should put itself at risk of being falsified and this practice should be protected against those who try to impede scientific understanding, as when the industry intimidates those who discover harms of its drugs. Protecting the hypotheses by ad hoc modifications, such as undeclared changes to the measured outcomes or the analysis plan once the sponsor has seen the results, or by designing trials that make them immune to refutation, puts the hypotheses in the same category as pseudoscience.

In healthcare, the open democratic society has become an oligarchy of corporations whose interests serve the profit motive of the industry and shape public policy, including that of weakened regulatory agencies. Our governments have failed to regulate an industry, which has become more and more powerful and almighty, and failed to protect scientific objectivity and academic curiosity from commercial forces."

Thats about it in a nutshell. Too bad the good scientists are all muzzled. Only the politicized fraudsters get the good press.

[May 12, 2020] PHARMA: Greed, Lies, and the Poisoning of America

May 12, 2020 | www.moonofalabama.org

karlof1 , May 12 2020 16:01 utc | 125

Renegade Inc interview with Gerald Posner the author of PHARMA: Greed, Lies, and the Poisoning of America is lively, timely, revealing, and very informative! An excellent 25 minute investment of your time today. In the book which was written well before the COVID-19 breakout, Posner did address the issue of pandemic which this article reported on along with other aspects of PHARMA . And there's much more at his website.

[May 01, 2020] ONE IN SEVEN Americans would avoid Covid-19 treatment for fear of cost, even as pricey new pill shows promise against virus

May 01, 2020 | www.rt.com

Some 14 percent of US adults would forgo medical care for Covid-19 symptoms because they couldn't pay for it, a new poll has found – yet oblivious health authorities act as if the epidemic will be solved by drugs alone. One in seven American adults would avoid seeking healthcare if they or a family member experienced symptoms of Covid-19, out of concern they would be unable to afford treatment, according to a Gallup poll published on Tuesday. Even if they specifically believed themselves to be infected with the coronavirus, nine percent would forgo care for financial reasons, the poll found. Their fears are well-founded – the average cost of coronavirus treatment in an intensive care unit runs over $30,000, according to a study released earlier this month by insurance industry group America's Health Insurance Plans. Even for those who avoid the ICU, American healthcare is the most expensive in the world, and stories of coronavirus patients being whacked with gargantuan medical bills are a dime a dozen two months into the pandemic.

Making matters worse is the unemployment crisis, as about 55 percent of Americans receive healthcare through their jobs. Upwards of 30 million have filed for unemployment in the last five weeks, adding an unprecedented number of families to the ranks of the uninsured – which were already estimated in December to include 27.5 million people, more than the population of Australia. Even those lucky enough to have kept their jobs and insurance may face steep co-pays or other surprise costs.

After a handful of highly-publicized cases in which Americans died of the virus after being turned away by hospitals for lack of money, President Donald Trump ordered hospitals to pay for the cost of Covid-19 treatment, and several large insurers promised at the beginning of the month to waive all co-pays for coronavirus testing for 60 days. However, those coverage pledges do not include other costs associated with hospitalization, like ambulance transportation; outpatient treatment; or treatment for non-Covid-19 patients. Individuals seeking treatment have been tested and received the good news that they don't have the virus – only to be hit shortly thereafter with the bad news that they're on the hook for thousands of dollars in costs. Low-income respondents were much more likely to report they would not seek care for financial reasons. Perhaps more troublingly, respondents with annual income under $40,000 were almost four times as likely as those with incomes over $100,000 to report that they or a family member had been turned away from a hospital for reasons related to overcrowding or high patient volume, the Gallup poll found.

[Apr 13, 2020] American health care, as we call it today, and for all its high-tech miracles, has evolved into one of the most atrocious rackets the world has ever seen. By racket, I mean an enterprise organized explicitly to make money dishonestly by James Howard Kunstler

Highly recommended!
Apr 13, 2020 | www.zerohedge.com

Authored by James Howard Kunstler via Kunstler.com,

The ruins of Mary McClellan Hospital stand on hill overlooking the village of Cambridge, New York, in what was a "flyover" corner of the country until the planes stopped flying. The hospital cornerstone was laid July 4 1917. The USA had entered the war against Germany a few months earlier. The "Spanish" flu pandemic kicked off in January, 1918. The hospital opened in January 1919. The flu burned out a year later. The hospital shut down for good in 2003.

I've lived around here for decades and never actually got a look at the place until I went up there on a blustery spring Saturday before Easter to look around. I like to read landscapes and the human imprint upon them. This one is a ghost story, not just of the bygone souls who came and went here, but of an entire society, the nation that we used to be and stopped being not so long ago.

This is the old main building today. It's astounding how quickly buildings begin to rot when the human life within them is gone. The style was Beaux Arts Institutional, seen everywhere across America in that period in schools, libraries, museums, and hospitals, an austere neoclassicism that radiated decorum in a confident and well-run society ­– because that is what we were then. Note especially, the entrance and the beautiful bronze marquee above it. The message is this: You enter through a portal of beauty to a place of hope and trust.

This is Mary McClellan Hospital not long after it opened.

The site itself, on its hill, with views east across the state line to the Green Mountains, speaks of authority and command.

The America of 1919 was a deeply hierarchical society. Today we regard hierarchy as a bane and a curse. The truth is, it is absolutely required if you expect to live in a well-run society, and proof of that is the disordered mess of bureaucratic irresponsibility we live in today, with virtually every institution failing – well before the Covid-19 virus arrived on the scene - and nobody called to account for anything anymore.

Hierarchy must be fit to scale to function successfully. In small institutions like this, everybody knows who is responsible for what. That's what makes authority credible.

These are the ruins of the nursing school associated with the hospital (and also associated with Skidmore College in Saratoga Springs, 25 miles west).

The nurses lived here, in Florence Nightingale Hall.

In the early 20th century, the profession favored young, unmarried women whose allegiance and attention to the patients would not be distracted by the needs of a family.

Was that exploitation? Or was it simply an intelligent way to organize a hospital subculture? The nurses lived here very comfortably. The institution cared for them, literally.

There's no record available of what exactly these buildings were for. The one in the foreground has a cut stone sign that says "The Junior" on it. I infer that this may have been where a couple of young, staff, resident physicians lived, young men probably, just out of their internships, close at hand and on-call for emergencies. The building in the background is a rather grand country cottage, possibly the residence of the chief surgeon or the hospital director. The hospital was, after all, a community unto itself, and it was important that authority have a visible presence there all the time. Both buildings display architectural grace-notes that humanized and dignify that resident authority. We no longer believe in grace-notes for the things we build, so is it surprising that we live in a graceless society?

This is the power plant for the whole operation, on the premises, ensuring that the electricity would stay on at all times. In the early 20th century, electric power was the new sine qua non of advanced civilization. America's rural electrification program really didn't get underway until the 1930s, so it's likely that many of the farms outside the village were not hooked up to a grid. The hospital generators must have been driven by coal, or perhaps oil. Somebody had to attend to all that machinery. The laundry ­– hospitals produce a lot of that – was also on-premises, as was all the meal preparation. The hospital maintained a large garden to furnish some of the food. All these tasks required crews of people working purposefully and getting paid. The hospital was a complex organism, a world within a nation within a world.

Things rise and self-organize beautifully into fully-formed systems and after while they run down, even while they over-grow; authority starts working more and more for its own sake and its own benefit; hierarchy breaks down into disrespect, lack of trust, fear; and then society loses its vital institutions, which is exactly what happened at Mary McClellan Hospital in little Cambridge, New York.

It dwindled and then quickly collapsed. The town lost a part of itself, the part that welcomed people in a particular kind of trouble and cared for them, as it cared for those who did the caring. By the way, in 1919, a private room was $7-a-day (a bed on a ward was $3). Imagine that! The town also lost a vital component of its economy. And that was all of-a-piece with its decline into the flyover place it became in our time.

American health care, as we call it today, and for all its high-tech miracles, has evolved into one of the most atrocious rackets the world has ever seen. By racket, I mean an enterprise organized explicitly to make money dishonestly. This is what we've become, and the fact that we seem to be okay with that tells you more about what we have become. The advent of Covid-19, along with the extreme economic disorders it has triggered, will probably be the beginning of the end of that racket. We have no idea how medicine will re-organize itself, but I'd guess that it will happen at a much more primitive scale ­– because that's usually what happens when human societies overshoot badly. Alas, history is not exactly symmetrical.

But read these photos and meditate on what we were once capable of putting together in this land, and maybe you will find some clues about what was truly admirable about the American condition before we stopped caring.

[Apr 06, 2020] Why Do Rural Hospitals Close

Apr 06, 2020 | angrybearblog.com

run75441 | April 5, 2020 8:15 pm

One of the serious issues with healthcare today is the lack of universal availability of it across the nation. In citified areas, the availability of it mostly meets the demand of the people requiring it and is in close proximity. If you travel one to two hours outside of the city, the availability of it begins to drop off until a person in need must travel hours to get to help. The resource in more rural areas begins to drop off in a precipitous manner. Not to make light of the healthcare situation, if you watch the move " Doc Hollywood ," small community with an aging doctor, a small clinic, staff nurse, a large number of patients, and a distant hospital. Dr. Ben Stone is on his way to LA in his 356 Cabriole (almost bought one in the eighties). The resources bypass rural America mostly for monetary reasons.

Here is a list of reasons:

Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure in rural markets. The addition of work requirements by states will negate much of the Medicaid's expansion gain.

You will hear many complaints about narrow insurance corridors. The result of Section 227 was Coops going bankrupt, insurance companies withdrawing, people having to find other plans, premiums increasing, etc. causing much of the narrowing. Rather than solve the issue, Republicans as led by Fred Upton of Michigan chose to use this in an effort to dismantle the ACA. The ACA Risk Corridor Program was to last 3 years and is similar to the Republican created Risk Corridor Program in Part D which is ongoing.

Medicare reimburses at much lower rates than does private insurance in my specialty. If you work in a place with a high percentage of Medicare (or Medicaid which is worse) like we do, you cannot come close to earning market salaries. So we, many years ago, ended up working 95th percentile or worse hours (over 70 per week) while earning in the 15th-20th percentile in income. We lost a lot of staff. The hospital had to make up the difference so that we could hire and retain people. We were fortunate that our hospital had the resources to do that.

Up north of us another hospital faced a similar situation, but they didn't have the resources to subsidize their staff. So they fired a good team and brought in another. Told them it was OK to not bill in accordance with what the hospital accepted, like the prior group did. That let the new group earn enough, for a while, to hire and retain people. Hospital eventually failed anyway and had to be bought out.

Mayo Clinic in Minnesota closed one smaller hospital and two clinics due to a lack of personnel and utilization. The result was people having to make a much longer trip to get to the hospital and staffing goes where the money is in many cases.

It is a problem begging for a solution.

More Rural Hospitals Closing in States Refusing Medicaid Coverage Expansion , Center for Children & Families (CCF) of the Georgetown University Health Policy Institute, Adam Searing, October 2018

The Quiet Crisis Of Rural Hospital Closures , Kaiser Health News, January 2020

170 Rural Hospital Closures , NC Rural Health Research Program

Michael Oder , April 5, 2020 8:51 pm

Another reason is that we've privatized our medical industry. Many hospitals used to be owned by counties and municipalities who had established them to provide healthcare for their citizens. Throughout the 90s and early 2000s, these were systematically privatized often to cover short-term budget crises. For-profit providers have different priorities in mind and providing effecting and available treatment is not at the top of the list.

Event before shuttering the hospitals they were already cutting services:
https://www.sciencedirect.com/science/article/pii/S109830151204154X

kwark , April 5, 2020 10:02 pm

This quote from the doctor sort of encapsulates what is wrong with our s0-called "system" of healthcare: "If you work in a place with a high percentage of Medicare (or Medicaid which is worse) like we do, you cannot come close to earning market salaries." Medicine has devolved into a scheme to extract absolutely the most money possible all the time regardless of the long-term outcome for society or, it appears, the short term outcome for the patient. Doctors were supposed to follow "first, do no harm" but nowadays they're forced to play with the definition of harm.

[Apr 06, 2020] What Wall Street Doesn't Want You to Know About Hospital Emergency Rooms

Apr 04, 2020 | www.nakedcapitalism.com
Yves here. We've written regularly on Eileen Appelbaum and Rosemary Batt's important investigations into how private equity has taken over more and more of hospital staffing, including of emergency rooms. This in turn has allowed them to override patient efforts to have only in-network doctors assigned to their case, as well as to engage in other practices that greatly inflate patient charges (so-called surprise billing).

The legal fig leaf that allows private equity firms like Blackstone and KKR to play doctor is that their deals are structured so that MD or group of MDs is the nominal owner of the specialty practice, even though the business is stripped of its assets and the operating contracts are widely believed to strip them of any say. The now-notorious incident of Blackstone's TeamHealth firing whistleblower Dr. Ming Lim confirms who is really in charge.

By Eileen Appelbaum, the Co-Director of the Center for Economic and Policy Research and visiting professor, School of Management, University of Leicester, UK and Rosemary Batt, the Alice Hanson Cook Professor of Women and Work, Cornell University ILR School. Produced by Economy for All , a project of the Independent Media Institute

Doctor Ming Lin is the first emergency room doctor to be fired for going public with his concerns about poor hospital emergency room safety practices and shortages of medical supplies and protective gear for health workers. He won't be the last.

Like many hospitals in the US, PeaceHealth St. Joseph Medical Center in Bellingham Washington, where Ming Lin worked for the past 17 years as an emergency room doctor, has outsourced the management and staffing of its emergency rooms. So, Lin works on-site at the hospital's emergency room, but he is employed by a physician staffing firm that runs the emergency room. These staffing firms are often behind the surprise medical bills for emergency room services that patients receive after their insurance company has paid the hospital and doctors, but not the excessive out-of-network charges billed by these outside staffing firms.

About a third of hospital emergency rooms are staffed by doctors on the payrolls of two physician staffing companies -- TeamHealth and Envision Health -- owned by Wall Street investment firms. Envision Healthcare employs 69,000 healthcare workers nationwide while TeamHealth employs 20,000. Private equity firm Blackstone Group owns TeamHealth, Kravis Kohlberg Roberts (KKR) owns Envision.

Care of the sick is not the mission of these companies; their mission is to make outsized profits for the private equity firms and its investors. Overcharging patients and insurance companies for providing urgent and desperately needed emergency medical care is bad enough. But it is unconscionable to muzzle doctors who speak out to advocate for the health of their patients and co-workers during the global pandemic that is rapidly spreading across the US.

Yet, that is what Blackstone-owned TeamHealth just did. Why would an experienced emergency room doctor be fired in the middle of a pandemic? One clue may be that Blackstone's CEO, Stephen A. Schwarzman, is part of President Trump's inner circle . He may not want to risk that relationship by allowing TeamHealth's doctors to inform the public about Washington's mishandling of the allocation of supplies and protective gear. The President might conclude that TeamHealth doctors didn't appreciate him enough, and where would that leave Schwartzman?

PeaceHealth St. Joseph Medical Center may have the distinction of being the first hospital to have a doctor outsourced from a physician staffing firm unceremoniously fired for telling the public the truth. But it won't be the last. Hospitals are now telling doctors treating coronavirus patients they will be fired if they speak to the press.

The American Academy of Emergency Medicine protested Dr. Lin's ouster and questioned how TeamHealth is allowed to provide hospital services when the law requires that physician practices must be owned by a licensed medical practitioner. TeamHealth skirts the law by owning all the assets of the physician practices it acquires -- the real estate, offices, equipment, supplies, inventory, and even accounts receivable.

On paper, the physician practices are owned by a doctor-led organization that TeamHealth has set up to comply with the law. But what does it mean to own a physician practice if the practice has no assets and no possibility to exist on its own?

The furor over patients hit by surprise medical bills revealed that TeamHealth controls the billing for the doctors it supplies to hospital emergency rooms. The firing of Doctor Ming Lin pulls back the curtain and reveals that TeamHealth controls the doctors as well.


sd , April 4, 2020 at 5:54 am

Private Equity = Non Essential

Furiouscalves , April 4, 2020 at 12:13 pm

So anyone who works for TeamHealth or Envision needs to stay home until the virus subsides Or until PE is out of ER. Right now is the time to be going after them hard. If they come out the other side of this with no changes to PE control of ER, it will be a missed opportunity to bring them to heel.

dan , April 5, 2020 at 8:54 am

Thats called group organizing. Our present gov. won't allow it. Or will they they don't seem to have much control over virus spreads.

Mel , April 4, 2020 at 12:53 pm

Way back when, an American banker named Paul Erdman tried to start an American bank in Switzerland, and wound up taken down, tried, and convicted under by a charge in Swiss law called (IIRC, this whole comment is IIRC basically) untreu Gesellshaftshandlung . He went on afterwards to write popular novels about what -- meanies -- Swiss bankers are. The one I read is really pretty good.
Anyway, although it would be really heavy lifting creating an American law against untreu Gesellshaftshandlung in the face of the modern American concept of business, a law like that could have excellent effects. It could penalize people who destroy the businesses they are pretending to manage. Think how wonderful that would be.

divadab , April 4, 2020 at 6:54 am

In what ethical system is profiteering on the sick and injured who are having a health emergency morally correct? What kind of people are these Blackstone owners? The kind of people who rob the dead and wounded on a battlefield, apparently. Ghouls. Morally depraved scum.

That Peace Health, which is owned by the Catholic Church, has contracted with these looters, is indicative of how low the Church has fallen in its mission in the world. They kicked out the nuns from any oversight of the hospital and brought in these Blackstone demons. Is it any wonder the moral authority of the Church is a thin thread when rather than supporting their flock they prey upon them? When did the Church start subcontracting to Satan?

ambrit , April 4, 2020 at 6:58 am

Oh for a reset. In olden times, often the victorious officers would mandate shoot on sight for looters caught on a battlefield.

Tom Doak , April 4, 2020 at 7:21 am

Yes, but unfortunately, that's what the "winners" in private equity are doing to us.

Off The Street , April 4, 2020 at 7:45 am

Gives new meaning to the Neo-Liberal 1-2 punch.
1. Because Markets.
2. Go Die.

hemeantwell , April 4, 2020 at 11:33 am

ambrit's suggested reset brought to mind another frame, the role of the tribunes in early Roman society. I've enthused about them before here, re their ability to block measures deemed harmful to the people, and the oath sworn to protect them, whereby anyone laying a hand on them would be hung by the rightfully enraged citizenry.

What we're seeing going on now between the administration and some of the governors is a loose fit. They are speaking out against the administration's deadly neglect and acting against it, while, hopefully, having a degree of immunity against reprisal. We'll see about a hanging, electoral or otherwise.

Billy , April 4, 2020 at 2:48 pm

Substitute " corporate board of directors ",
and or possibly, depending on the crime,
" upper level management "
for "looters."

allan , April 4, 2020 at 7:29 am

"What kind of people are these Blackstone owners?"

Steve Schwartzman is on the list of billionaires who supposedly urged Trump to reopen as soon as possible.
Given Blackstone's medical investments, that is quality talking-your-book.

NotTimothyGeithner , April 4, 2020 at 8:41 am

Start?

For the modern era, I would say john Paul II. He largely had free reign to control the bishop selection process (which for a long time was tied to local governance) and stamped out any opportunity for good or not heinous bishops to serve as counter examples or exist as threats to leadership.

tonycat , April 4, 2020 at 12:48 pm

Blackstone was a firm that was behind the stealing of houses from American homeowners in the foreclosure fraud heyday since 2008's financial crisis, I believe. I think they were owners of document-forging firms.

Ian , April 5, 2020 at 8:48 pm

tonycat,
I didn't think Blackstone had anything to do with document forgery, that was primarily the realm of LPS, ( lender processing services), who changed their name to Black Knight Services. Owned by Fidelity National , yes, the title insurance company.
Blackstone bought tens of thousands of foreclosed homes, the ones with irretrievably corrupted chains of title, formed a subsidiary to do so, and rented them all out.
If you could let me know who you have reason to believe Blackstone owned as far as document processors , or forgers, pls respond to me thanks-

Kirk Seidenbecker , April 4, 2020 at 1:21 pm

PeaceHealth . should be HealthGrift.

Billy , April 4, 2020 at 3:00 pm

Before the information is taken down, search for and file save
the board of directors. Save as a file on your hard drive. Guarantee that these same people will pop up like moles in future disasters and national looting.
https://www.blackstone.com/the-firm/our-people

Never (let them) forget.

That Peace Health, which is owned by the Catholic Church, has contracted with these looters, is indicative of how low the Church has fallen in its mission in the world. They kicked out the nuns from any oversight of the hospital and brought in these Blackstone demons."
How does the Catholic church contracting with them still allow their tax exempt status?
Care to comment?
PeaceHealth System Services
1115 SE 164th Avenue
Vancouver, WA 98683
360-729-1000

Knot Galt , April 4, 2020 at 3:21 pm

In what ethical system is profiteering on the sick and injured who are having a health emergency morally correct?

Isn't the answer obvious? It's called ObamaCare.

Am I wrong?

EoH , April 4, 2020 at 9:13 pm

Yes.

Procopius , April 5, 2020 at 6:36 am

When did the Church start subcontracting to Satan?

I believe it was around 325 A.D., when they made a deal with the Emperor Constantine. It may have been earlier, when the tax collector, Saul of Tarsus, said, "Can't get new converts? Hold my beer."

jackiebass , April 4, 2020 at 7:04 am

Where I live our local hospital emergency room is staffed by doctors and nurses that aren't hospital employees. They are employed by a private group. This has been the case for at least a decade. There are signs telling people that they will get separate bills from the doctors. My wife and I both are on traditional medicare and a supplemental policy. Fortunately this group is part of my supplemental network. Also the hospital sold its dialyses unit to a private company. They used to do their own laundry now it is done by a private company. The same is true for the janitor services. The head of the hospital used to be a doctor. Now the head is an MBA. This hospital is considered a nonprofit hospital. Since all of these changes has been happening I have noticed that care has become just another business transaction. Tho corporations own everything , even doctors who are now employees. If you need to see a doctor immediately you now have to go to one of two walk in clinics. Health care in my area has become just another money making business. This is a county in upstate NY with a population of about 100,000 people. There are only 2 corporations providing all of the care. Both operate with the same business plan. My doctor of 13 years decided to move out of the area. Instead of the health care organization hiring a replacement his patients were left out in the cold to find a new doctor. My wife has had 5 primary care doctors in the last 2 years. Health care has become just another money making business with no real competition.

Susan the other , April 4, 2020 at 1:11 pm

There are lots of dimensions to the outsourcing going on in American hospitals. My experience last summer is instructive. My husband (on Medicare) got sepsis from a carpet tack, he's diabetic so it was very dangerous and I took him to the ER on instructions from his podiatrist. The ER hemmed and hawed, tried to confirm with the podiatrist who just happened to turn off his beeper so the ER called Bill'r regular doctor. His regular doctor was playing the system like a violin: because he gets bonuses for any cost saving measures he achieves. This was one – so instead of getting Bill on an emergency IV, his doctor sent him home with some crappy antibiotics, which he threw up; we lost a good 24 hours which could have been the diff between life and death. I was furious and I called all the people I knew on the board of the new hospital to complain. We returned to the ER the next morning and I was already a cat-5 tornado. They got Bill on an IV and they literally hid from me. After 10 days he was cured but his nitwit doctor (to cover his own ass) recommended some expensive anerobic antibiotics for another 7 days – by mouth. The gave me a prescription to get filled. No pharmacy in town had the stuff – it was special order only and took up to 3 days. Long-short when I finally got my hands on the pills, I called the hospital complaint line and told them how inept they were to let a patient go from the hospital with an un-fillable prescription – and she told me that that was not hospital policy, that hospital policy was to send such a patient home with a 3 day supply for the interim. So I only wish I had had the phone number of the person paying Bill's doctor his bonus for endangering his recovery in such a callous and insouciant manner. I tried to get through to Medicare to complain about him but I was blocked every time. It's a shame because that's first class malpractice in my opinion – and the system that encourages it is unconscionable. All those cost cuts by the system are death by a thousand cuts for patients – and an equivalent amount of profits in the pockets of the corporation.

cnchal , April 4, 2020 at 7:17 am

>. . . But what does it mean to own a physician practice if the practice has no assets and no possibility to exist on its own?

Public sector pension funds are investors in Pirate Equity, in case anyone has forgotten, so you could ask them or at the Trump's press conference today, ask him. He would know.

JTMcPhee , April 4, 2020 at 11:00 am

Pensioners don't have much, if any, say in how the people who run the pension funds do what they do. The long look we have had at CalPERS gives some idea of the corruption and malfeasance that's going on, protecting the "fees" and extractions of the "advisers" who in turn get their spiffs from the "market."

Not sure what your point is. The structuring of the "deal" obviously seems to be to maximize all looting possibilities and to shed any possible "legal" avenues of either control or redress by any of the institutions of governance.

Bryan , April 5, 2020 at 9:21 am

Luring the public sector pension funds into private equity was the historical turning point. Private equity has now lashed itself to the ship of state, its main goal.

John , April 4, 2020 at 7:27 am

Private equity is too greedy and rapacious to be permitted to exist.

Tom Doak , April 4, 2020 at 8:26 am

Instead of calling them private equity "firms" and "executives ", we should start consistently labeling them in the same way The New York Times labels the dictators we don't like with unflattering terms.

Since they have a long and questionable history in medicine, I nominate the term "private equity leeches".

Billy , April 4, 2020 at 3:06 pm

Tom, Don't be such a easy going pushover, how about

"Health Criminals"
=
"War Criminals"

They should be identified, shamed and or prosecuted the same way authentic Nazis and Human Rights violators were, and are, in the U.S.

The Historian , April 4, 2020 at 7:32 am

A doctor in Boise was fired for wearing her own M95 mask that she needs because of her own health problems. Listen to the runaround she got! This doctor wasn't afraid to speak out because she works for herself!

https://www.ktvb.com/article/news/local/208/idaho-doctor-says-she-was-fired-after-trying-to-wear-a-mask-at-a-boise-hospital/277-008a2b17-fef4-4fc1-a070-672166c6286e

c_heale , April 4, 2020 at 10:29 am

This is happening in the UK too

https://www.theguardian.com/world/2020/apr/04/nhs-worker-quit-when-she-was-stopped-from-wearing-face-mask

JBird4049 , April 4, 2020 at 7:56 pm

"The list included: if you wear it, everybody will want to wear PPE and we don't have it,"

In her termination phone call, Buckalew asked to see the policy saying she couldn't wear a mask.

"I need to have it in writing that you are asking me to leave because I want to protect myself," Buckalew said.

Still, she said nobody has been able to show her that policy. She was informed though that she was officially labeled as insubordinate, incompetent, and unethical for her actions.

I wonder how the hospital would handle mass death? Financially of course seeing as ethics don't matter.

Paul Jurczak , April 4, 2020 at 10:00 pm

The most telling sign that we are firmly in the post-truth era is the non-response statement from Encompass Health:
"We are continuing to tap every resource available to provide personal protective equipment that meets the needs of our patients and staff [ bla, bla, bla]".
Corporate PR considers not addressing the issue and spewing some unrelated sugar coated BS a normal operating procedure these days. Before you think that corporations are bad people, think about bad people inside the corporations. There are thousands of middle class employees who are writing these kinds of statements on behalf of their paymasters. Humanity has a lot of rot in it.

Billy , April 4, 2020 at 10:12 pm

Call me "The Listmaster"

Keep every letter, every email, better yet, email them back and ask for clarification about who authorized, authored, directed the policy. If you phone, record the call. Look up the board of directors, save the webpage, their names.
This will be useful in the future for potential prosecutions at the judicial and activist level.

pricklyone , April 5, 2020 at 12:28 am

Sorry Billy, it IS good advice, but others have suggested similar, like "when signing the authorization for treatment, include a statement about in-network only ".
While logical, in every hospital, doctors office, clinic, etc, in my network, you sign all of these authorizations on a "signature pad" attached to a computer. No addendums or changes can be made by the patient, and the staff are not authorized to alter it either.
Anything you want as a hard copy, they tell you you can print from the "patient portal"
on the web THEIR version, of course, perhaps not the same as the one you signed.
In the case of any legal actions, their politically connected 18 lawyer team will select their preferred judge, who will promptly throw out all of your careful documentation
MBAs and automation/IT run amok.

Rod , April 4, 2020 at 8:20 am

With 8b$ in the bank a 'non-profit" Atrium compensates the top well:

Atrium Health 's top 11 executives made a combined $27.6 million in 2019, the Charlotte-based health system said on Friday. That's a nearly 15% jump from a combined $24.05 million in 2018. Atrium CEO Gene Woods was at the top of the list with $7.25 million in compensation in 2019.

Here's what Atrium Health's top executives earned in 2019
http://www.bizjournals.com/charlotte/news/2020/02/07/heres-what-atrium-healths-top-exe

Rod , April 4, 2020 at 8:40 am

Here's a trick they used to get to that Executive pay which was stopped in 2018–

The Department of Justice announced a settlement with Atrium Health, formerly known as Carolinas HealthCare System, that prohibits Atrium from using "anticompetitive steering restrictions" in contracts between commercial health insurers and its providers in the Charlotte, North Carolina metropolitan area. The settlement, revealed Thursday, also bans Atrium from seeking contract terms or acting in such a way as to prohibit, prevent, or penalize steering by insurers in the future.

KLG , April 4, 2020 at 9:32 am

Working link
https://www.bizjournals.com/charlotte/news/2020/02/07/heres-what-atrium-healths-top-executives-earned-in.html

jfleni , April 4, 2020 at 8:27 am

SUprise billing is just a pluticrat swindle that will increase by millions when Biden gets in; Bernie was right and every body knows
it. Consider every advanced country has medicare for all BUT not
here in plutocrat heaven; Bernie was totally right!!!

rd , April 4, 2020 at 5:34 pm

Other countries have systems different from Medicare for all, especially some of the European ones. But they are heavily regulated which eliminates all of the efficiencies and improvements you get with a free market .. I assume that is why we have such an inexpensive and effective system compared to the heavily regulated ones.

Noel Nospamington , April 4, 2020 at 10:38 pm

From a Canadian perspective I don't understand why the vast majority of Americans don't support political candidates which promote universal single payer healthcare.

Maybe healthcare isn't something most people think about until they have the misfortune of accidents or illnesses.

If there is one positive outcome from the current pandemic, it might be that many more Americans will be shown how badly broken their health care is, including the per capita death rate compared to other countries.

However right wing parties are masters of deception, and they are likely working on some dog whistle issues to change the focus away from health care after the pandemic settles down.

Jonathan , April 5, 2020 at 11:10 am

Because most have been brainwashed since birth and couldn't imagine better governance exists elsewhere.

From a Singaporean perspective, US is such a crappy place in terms of income versus overall cost of living + public safety + government efficiency + convenience that it makes me LOL whenever I hear Americans dissing us as "an authoritarian nanny state". Well, I say they have the freedom to keep believing whatever that floats their rotten boats.

rob , April 4, 2020 at 8:34 am

What is mind boggling is the dysfunction that can be wrought by lawyers.
It seems to me that the fulcrum under private equity's; arrogance,greed,uninhibited vile existence leading to the takeover of the public medical infrastructure ; rests on peoples ability to "BS" some excuse to a bunch of lawyers . and have it "cleaned" up into some legal footing that can be defended. Not because of the merit of the idea . but because of some standing granted to a "legal framework" of some kind.
The reality completely divorced from the effort to promote the scheme.
On all sides.
Not only the vile, morally repugnant private equity types.
But the people on the other side of the negotiation, who are enticed to make a quick buck ,by selling out the ship the passengers without a lifeboat, are floating on.
And all of this dealing is made "right" ,by lawyers .
Is it because there is some contagion in law school? that divorces people from "right and wrong" Or is it partly, sociopaths finding a setting where they fit right in?
Whether it is the prosecutors all over the country, "legally" screwing nominally guilty people of all kinds of things, making money for their systems by taking it from the general public
Or the ones who fight to allow every scumbag with a dollar to get non disclosure agreements , so they can "pay off" justice and continue to go about damaging society.
Or the ones who allow these medical ownership rule "work-arounds" by saying to private equity," now , we all know that you are looking to plunder a population but hey . we can just say "you're helping them on to their final journey" and "it all meets the requirements" . so sign here how about a round of golf ,down at the club?

Felix_47 , April 4, 2020 at 9:23 am

Great comment. That is the real cancer we are facing in this society. I note Joe Biden is a lawyer, I believe he said he was at the top of his class at Syracuse, and Sanders is not a lawyer. Americans seem to want lawyers as leaders because they know how to make everything look fine and they can keep a straight face saying it.

Schtubb , April 4, 2020 at 12:33 pm

Biden lies about his academic record:

https://apnews.com/cd977f7ff301993f7976974ba07c5495

"WASHINGTON (AP) _ Sen. Joe Biden claimed during a campaign appearance in New Hampshire last spring that he finished in the top half of his law school class, although records indicate he finished near the bottom."

sd , April 4, 2020 at 6:43 pm

Why am I not surprised.

DJ , April 4, 2020 at 10:55 am

Whatever else is going wrong, at the root we are experiencing a crisis of integrity. Such a word, "integrity." It requires that we say it like it is. "The state of being whole and undivided" the dictionary says. It is not, of course, a state that we, being human, can fully achieve. But it is something that we, as humans, must aspire to achieve. Our huckster society places no value on the simple virtue of telling the truth. It is a loser's creed, a false refuge of Pollyannas, we are told by the grizzled veterans of economic warfare. In fact, though, it is the lubricant that ensures the smooth functioning of all of society. We are awash in falsehood, victims of Bill Black's "Gresham's Dynamic." We can get back on course by punishing false representation, starting at the highest levels, where the greatest damage is done by those entrusted with the greatest responsibility, who should be punished accordingly. We should do this not out of a sense of retribution against the bad guys (a class which, in fairness, may include many of us), but as a necessary means of survival.

David in Santa Cruz , April 4, 2020 at 3:06 pm

Former SIGTARP Neil Barofsky was interviewed by Bill Moyers earlier this week. Barofsky expressed his concern that we have developed a culture of casual lying at every level of our society:

It is different. They lied then. They lied now. That hasn't changed. But the way those lies are perceived, and how people have their alternate realities, I think that's very different, and very scary as we go into this next crisis.

https://billmoyers.com/story/here-we-go-again/

The human race is entering its extinction event, and there is no longer any such thing as long-term thinking. Personal honor was the first casualty. Many people suddenly feel entitled to "get theirs" at the expense of everyone else.

I see this sort of casual lying every day now.

Billy , April 4, 2020 at 10:17 pm

That is a symptom of civic decay, not a cause. Once moral relativism is acceptable in "choices", then it becomes so in civics, then contracts then the entire society. You reap what others have sowed and you casually accepted.

eg , April 4, 2020 at 1:44 pm

Yup.

Read all about the history of this in Katharina Pistor's "The Code of Capital"

https://blogs.lse.ac.uk/lsereviewofbooks/2019/09/26/book-review-the-code-of-capital-how-the-law-creates-wealth-and-inequality-by-katharina-pistor/

pebird , April 4, 2020 at 8:57 am

Universal service
High quality
Profit

Pick 2 of 3

periol , April 4, 2020 at 2:53 pm

I'll take Universal Service and High Quality for $400, Alex

Answer: Daily Double

I'll risk everything.

Answer: How do we MAGA?

Jesper , April 4, 2020 at 9:17 am

Private equity might be leading the decline, however, the decline happens everywhere. In the public sector it might be seen less but it happens due to New Public Management (NPM): https://www.managementstudyguide.com/new-public-management.htm

As far as I can tell the story is:
Once an organisation gets large enough (private or public) then it starts to attract management accountants (often MBA degree holders). The management accountant believe they can improve efficiency using the tools that (often) worked in improving efficiency in manufacturing. Process flow-charts and statistical analysis leading to the use of Key Performance Indicators (KPI). Sadly the management accountants are often lacking in knowledge and they are often insecure so they don't dare to ask questions. Their understanding of statistics is either bad or they simply decide to torture data to get their preferred (or indeed any as they need an) answer.
The end result is often KPIs which are seldom Key and often not even Indicators of Performance.
(Their own KPI is billable hours which can and often does affect the quality/usefulness of their work)

In medicine then it might result in something like providing a doctor with a KPI of number of patients seen during a day. Seems reasonable, right?
The problem with that KPI is that the patients differ, some visits are short and some take longer. That might lead to a doctor deciding to call in patients who might as easily have been helped over the phone. The doctor needs the quick and easy visits to meet the KPI, the patient might end up with a two hour trip for something that might have been resolved over the phone but the doctor might have no choice but doing this to meet the KPI.
Or alternatively, if the KPI is about resolving queries over the phone then patients who needs to come to the office are instead refused to come in and instead treated/diagnosed (or as it happens, not) over the phone.

The drive for efficiency can lead to more waste and worse outcomes, when it comes to management accountants then my opinion is: A little knowledge (and that is all they have, a little) can be a dangerous thing. Their lack of knowledge has caused and is continuing to cause a lot of waste and a lot of problems for many people.

Oregoncharles , April 4, 2020 at 3:38 pm

What struck me about the story is that the hospital(s) are every bit as guilty as the PE's. Why would they sign these contracts? There must be some sort of kickbacks for them. Ultimately, it's nothing but a way to squeeze more blood out of the turnips – and that seems to be exactly the way they think of patients.

Technical question: are hospitals legally responsible for the quality of care and honesty of billing in their own emergency rooms? Seems to me that question should be settled by a big, expensive lawsuit by cheated patients.

Jesper , April 4, 2020 at 7:08 pm

My guess is that the hospital first tried outsourcing the canteen and the outsourcing of the canteen might have worked well so they then decided to outsource something else. Why the ER was chosen for the outsourcing might be related to wanting to be able to blame the outsourcer for things that might cause bad publicity. Surprise-billing in the ER might cause bad publicity. By outsourcing the ER the hospital might get more money from the ER and deflect blame for the surprise-billing to the outsourcer.
And I would not be surprised if another reason for signing those deals might have generated some personal benefits for the people who signed the agreement on behalf of the hospital. Probably not a common occurrence but there is a risk that it could happen.

jrkrideau , April 4, 2020 at 9:39 pm

I have worked for an industrial catering firm and properly managed by the contracting organization contracting out a peripheral function such as as food services can work well. Contracting out your key business is madness.

Billy , April 4, 2020 at 10:23 pm

Sodexo-Marriot has replaced many fine in house hospital cafeterias.

From "just OK, to excellent food" has become corporate, tasteless, expensive, profit wringing slop.

Boycott any place that tries to foist that off on you in a captive audience situation.

pricklyone , April 4, 2020 at 11:43 pm

I have been operating under the hypothesis that the escape from legal liability was key to these subcontracting deals.
I am not an insider and have not direct knowledge of such a mechanism, but JTMcPhee may have some insight, if he thinks about it for a few

JTMcPhee , April 5, 2020 at 10:45 am

There's probably no way a hospital, as a business entity, can avoid being sued In a malpractice situation. The law on this is murky and fact-driven. Plaintiffs' attorneys sue all deep pockets where there is a "colorable claim" and assets and insurance behind the defendant. The hospital corps have deep pockets that fund the best lawyers and expert opinion providers that money can buy. They can drown many victims in paper and procedure. So your lawyer can sue the hospital, but will have an uphill battle piercing through to the imposition of liability on the hospital.

Here's an article discussing the issue of entity liability in malpractice:

https://www.plaintiffmagazine.com/recent-issues/item/when-is-a-hospital-liable-for-a-physician-s-malpractice

Often a case against the hospital turns on whether "vicarious liability" can be established. As you note, the structure discussed is an effort to maximize the distance between the hospital entity and the physician. And of course the PE real-party-in-interest owners of the profitable part of the business are even further removed.

I've got to say, firing Dr. Lin was maybe unwise since it establishes a much closer link between the PE entity as controlling the physician's practice and thus makes it easier to establish agency, direct employee and vicarious liability by the PE entity. Though of course those snakes are very careful to revise their own trench-warfare defenses against personal liability in constructing their shells and disconnects.

Jeff , April 4, 2020 at 9:19 am

Yves, I don't get it. Why would a hospital not hire these docs in the ER and give up that revenue stream to a private company? If it's so profitable, why would a hospital just give that money away? I can see why a small rural hospital or single site facility might not have the consistent ER volume to justify multiple ER docs, but larger hospital groups can move er docs around in a geography to cover greater needs.

Felix_47 , April 4, 2020 at 9:55 am

As a doc the answer is management and cost control. If they have a lot of doctors they get a hefty discount on malpractice premiums which can be in the hundreds of thousands or they self insure with umbrella coverage. ER billing is a huge issue. It requires full time people and a lot of phone calls and follow up and tons of paperwork. Don't forget the insurance carriers see their job as looking for loopholes to not pay and the doctor groups see their job as bypassing those loopholes. If it is a large group and someone goes on vacation or is sick or can't make a shift coverage has to be maintained. A large pool of doctors makes that possible. A lot of ER doctors chose the specialty because they did not want to be tied down to an office and a business. They want to do the job and then have time off. For that they are willing to take a substantial cut in pay. Overhead costs could easily be over 50%. Pay for doctors has really not kept up with inflation over the last 30 years .unless they cheat .and the more the payers cut them the more that happens. And consider the risk of seeing children with fevers brought in to ERs by non English speaking people often without insurance at 3 in the morning. One case of meningitis, and a certain small percentage will have it, and you could be wiped out. The lawyers are all over it. Think about the two febrile kids who died with ICE a few months ago as they were brought over the border by the parents. Combining these sorts of high risk cases with our legal system is more than a single doc or small group can handle. For example, I alway saw the problem with the asylum wave to be more the legal risk of holding these folks than anything else. I think there were hefty settlements in those cases and I am sure the doctors did not do much wrong .just bad luck .but their careers might well have been significantly impacted. The only answer is a national health system with significant tort reform in medicine. Doctors should be on government salary just like firemen. There is no reason the payment structure should change between the most important moments of care like 911 and the next part after you go through the swinging doors of the ER. If health care is a government guaranteed right then it should be free of profiteering and should be provided by the government and that goes for the pharma and hospital industry as well. The recent primary suggests that Americans like the health care they have and the way it is done. It is no accident the health insurance stocks bumped up to 30% the day after Super Tuesday.

Rod , April 4, 2020 at 10:47 am

thanks for this insight overall.
You state the bottom line:

The only answer is a national health system with significant tort reform in medicine.

rd , April 4, 2020 at 12:21 pm

Canada

UK-NHS is similar but way underfunded compared to Canada.

Societal Illusions , April 4, 2020 at 10:11 pm

I'm not convinced the "only" answer is the one you provide – national healthcare with significant tort reform.

that said, it certainly is one answer. i wonder if most any answer could be worse than what we have currently.

wonder how the super tuesday voting would have changed if done over now?

lyman alpha blob , April 4, 2020 at 10:23 am

I had no idea that hospitals did this. Just when you think you can't get any more cynical

cripes , April 4, 2020 at 10:08 pm

lyman alpha blob:

I commend your healthy lifestyle choices that have kept you from an ER visit over the past 10 years or so and from the out-of-network double billing that is now endemic. Everywhere.

vegeholic , April 4, 2020 at 10:24 am

People have developed an exquisitely tuned sensitivity to some swindles, such as when the oil companies collude to increase gasoline prices, with or without justification. They even invented a phrase to describe the practice called "price gouging", and demand action from their elected representatives. Everyone becomes a raging, full-throated socialist when being squeezed by this particular variety of market leverage. Yet when faced by other, even more egregious looting, such as described in this post, they fall in line like compliant sheep being led to the slaughter. I don't get it. Maybe someone can explain this.

a different chris , April 4, 2020 at 11:25 am

I am not going to claim to be able to explain it, but:

I *think* it's the horrible cross-pollination of the complexity issue vs the dire outcome of the wrong choice.

You can, although most won't, find a way to save gas. It's pretty understandable, your vehicle gets X MPG and you drive so many miles. You can adjust the second usually, and also occasionally adjust the first. You have a chance (even if your in negative territory you can buffer that period with a credit card) to somehow buy time while you make the adjustments.

How the heck do you figure out if you really need to be cut open (your GP choice), who to actually cut you open (references?) and where to have him/her do it (if the surgeon works across hospitals).

And if the GP is right, the clock is ticking .

Oregoncharles , April 4, 2020 at 3:44 pm

Medicine is a massive example of market failure, for the reasons your example outlines. So all that stuff about "choice" and "markets" is just self-serving BS.

K teh , April 4, 2020 at 10:27 am

The University Hospital Complex system is the most corrupt part of the economy, and as we now see it is the weapon being employed. The curtain comes down.

Government essentially guarantees private corporate revenue, so those corporations can focus on minimizing costs, which are labor. The non-profits sow up the trap with legal exemptions, generating profit that is not taxed. The three-headed hydra is the least common denominator of herd behavior, distilling labor.

That money supply chart is essentially an implosion ripe for explosion. You want to harness that and direct parts of that energy toward some useful function.

K teh , April 4, 2020 at 10:31 am

If you gotta go, talk to the overnight secretary and get the best nurse and PA to keep an eye on you.

The doctors signed their life away when their education began.

Dean , April 4, 2020 at 10:46 am

Is there a place on the web where these relationships and transactions are published / researched? State boards of medicine? State Attorney's General? Or is this another opaque backwater where the details don't see the light of day?

jef , April 4, 2020 at 11:08 am

Private equity is like someone standing between you and the milk at the grocery store where you say "excuse me I need to get a gallon of milk" and he says "Ok, that will be six dollars" and you say "but it says four dollars right there" he says "well I say six dollars is the new price take it or leave it".

It's about time we told these a$$hole$ to get the hell out of the way.

JTMcPhee , April 4, 2020 at 11:31 am

A little anecdote from my Army basic training experience that might be a potential scenario as all this goes "healthSouth:"

Troop barracks used to be these two-story buildings with "Open plan" layout -- ten double bunks down each side, a latrine (bathroom facilities with a row of unenclosed toilets and sinks and gang showers.) If you have seen "Full Metal Jacket," you remember the drill. In any event, forty males on each floor sharing everything including microbes.

My experience was at Ft. Leonard Wood ("Fort Lost-In-The-Woods, in the state of Misery",) in the fall and early winter of 1966. Meningitis started in the troop population, so the Commanding General mandated that all the windows were alternately to be kept open 9 inches, top and bottom, to air the place out. This with outside air temps being in the 20s.

So despite the window-open attempts to limit the spread of this infectious disease in a pretty bad kind of social propinquity situation, one of the guys in in my barracks, a draftee farm kid from Iowa, started having really bad headaches and a stiff neck. He was finally allowed to go to "sick call" at the dispensary, the equivalent of the Emergency Room. He went, they gave him Tylenol, and sent him back to duty. This was repeated for three days.

On the morning of the fourth day, his squad members found him in convulsions with a raging fever and he was carted off by a GI ambulance. He died that night in the base hospital, from meningitis. We troops were then made to remove his gear and bedding which was burned, and also to "GI" ("deep clean") the whole barracks with some nasty disinfectant from a 55-gallon drum in GI green.

A week or so later, the guy's father showed up with a shotgun. He'd collected his son's body Earlier, but someone had told him about his son's failed efforts to get treatment. He wanted to find the NCOs, officers and the sick bay doctor and staff that were responsible. The MPs showed up in force and hauled him off to the stockade (jail).

I wonder if there have been episodes like this happening in our current looting-based system? For sure, they are not likely to be reported very widely.

And the corporate scum have done a pretty good job of insulating themselves from visibility, let alone responsibility and liability. Kind of unfair to shoot the ER doctor or the mope in the billing department that was "just following orders."

flora , April 4, 2020 at 11:59 am

Thanks. Yep, and the higher ups who allowed that probably got promoted. Whereas commanders (and now doctors and nurses) who do the right thing to save lives get fired.

Capt. Crozier.

https://twitter.com/mccaffreyr3/status/1246146257480908801

The heros are the one's doing the right thing in the face of threats and retaliation. Crozier is a hero. So are the ER docs.

https://www.nytimes.com/2020/04/03/opinion/coronavirus-crozier-roosevelt.html

rd , April 4, 2020 at 12:25 pm

Expect COVID-19 case numbers to spike upwards soon along with deaths attributed to it. Trump rejected re-opening Obamacare and therefore hospitals will rely on Federal CARES dollars for reimbursement of Covid testing and care. So they will have every incentive to test everything but a dog or cat that walks through their door to ensure they will get paid because they will only be assured of being paid by the Feds if it is Covid.

ambrit , April 4, 2020 at 1:35 pm

They can also test cats and dogs, since, supposedly, they can catch it from humans, and bill it to the Agriculture Department.

Knot Galt , April 4, 2020 at 3:12 pm

PPE, NOT PE.

antidlc , April 4, 2020 at 3:35 pm

About a third of hospital emergency rooms are staffed by doctors on the payrolls of two physician staffing companies -- TeamHealth and Envision Health -- owned by Wall Street investment firms. Envision Healthcare employs 69,000 healthcare workers nationwide while TeamHealth employs 20,000. Private equity firm Blackstone Group owns TeamHealth, Kravis Kohlberg Roberts (KKR) owns Envision .

Anybody know if these guys have anything to do with Envisionrx?
https://envisionrx.com/

mtnwoman , April 4, 2020 at 3:51 pm

This got a hearty Amen! from me:

Stop Silencing Doctors: A Clinical Manifesto

https://www.youtube.com/watch?v=Mvlqh0JN55M&feature=youtu.be&app=desktop

antidlc , April 4, 2020 at 5:40 pm

About a third of hospital emergency rooms are staffed by doctors on the payrolls of two physician staffing companies -- TeamHealth and Envision Health -- owned by Wall Street investment firms. Envision Healthcare employs 69,000 healthcare workers nationwide while TeamHealth employs 20,000. Private equity firm Blackstone Group owns TeamHealth, Kravis Kohlberg Roberts (KKR) owns Envision .

Same Envision as envisionrx -- or is envisionrx owned by something else?
https://envisionrx.com/

Carla , April 4, 2020 at 6:13 pm

The whole story here is that for-profit medicine won't work. And in the U.S. of A., ALL medicine is for-profit, including our beloved (which has always required supplemental insurance, and now with "Advantage" plans is increasingly crapified) Medicare system.

Capitalism and Caring Cannot Co-Exist.

Give it up!

CanCyn , April 4, 2020 at 6:17 pm

As a Canadian, I had to stop reading this article when I got to the paragraph about Dr. Ming Lin working for a staffing company. I. Can't. Even.
The entire US healthcare system is complete and utter insanity! I don't know how anyone can even try to have a rational discussion about it.
Privatization and for profit craziness is creeping around the edges of Canada's system and has f'd up our long term care system (certainly in Ontario where I live). It scares the bejeezus out of me to think that anyone in Canada would want to go down the US road and I hope I never live to see the day.
The head or our provincial, Conservative, gov is quite to the right (fun fact : he is the brother of the crazy Toronto drug using mayor, Rob Ford, whose notoriety some of you may remember from a few years back) his mother-in-law is apparently in long term care, where Covid is hitting hard here in Canada and Ontario. I am hoping (faint though the hope might be) that this personal experience wakes him up to the complete and utter wrong that is profit in healthcare.

jrkrideau , April 4, 2020 at 9:51 pm

It's hard to tell but I almost get the feeling Doug is growing up. I think the Covid-19 pandemic was a real awake call for him.

Once we are out of the worst of it he probably go back to being an ***hole but I hope a better one.

BTW, we should be able to get Dr. Ming Lin an expedited visa and provisional licensing in no time.

Tom Stone , April 4, 2020 at 10:00 pm

I have long been aware that the only way the American Healthcare system could be reformed was if it totally collapsed, which is happening now.
Lots of unnecessary pain and death.

As many of you know I have in excess of $300K in medical debt accrued in roughly 18 months, the last trip to the Hospital ran $88K and change for a 32 hour stay.

If I had any easily ascertainable assets I'd have been sued multiple times already.
Fortunately every spare penny for the last 5 years has gone to my Daughter Rosetta's 529 plan, between that and a very nice scholarship she will graduate debt free.
And yes, that really is her name.
She's cool with it and we're planning to get matching Mohawks when I'm done with Chemo, I'll likely go with the same cobalt blue I did when I knew Chemo was on the way.
A man's gotta do

Jonathan , April 5, 2020 at 1:16 pm

All of that medical debt would be $0 if you lived in Singapore and opted in to pay ~USD300 per year in cash premiums for upgraded govt insurance, assuming you are in the 30-40 age bracket Even if you didn't opted in and without employer insurance, you most likely won't fork out more than USD 20K cash copay cash after all is said and done.

Also, you would probably pay only <1% of your total yearly income in income taxes and not be blowing some USD 2-3K in rent every month.

So frankly I have NO idea how you Americans can tolerate living in that "exceptional" sh!thole called the US.

mrtmbrnmn , April 5, 2020 at 12:53 am

In Pagan days human sacrifices were thrown into the fiery pits to appease the Mad Gods & Big Nature. We may want to revisit that in the present terrible circumstances. High on the list of nominees would be the Werewolves of Wall Street & all those Hedge Fund Hooligans.

Sound of the Suburbs , April 5, 2020 at 4:47 am

In Europe, doctors are facing difficult life and death decisions they are not prepared for.
US doctors are fully prepared to make difficult decisions.
Do you have health insurance?
If not, get lost.

That's what I like to see.
Markets forces at work.
If you can't afford it, you get nothing.

[Apr 05, 2020] Drug Wars How Big Pharma Raises Prices and Keeps Generics off the Market - Kindle edition by Feldman, Robin, Frondorf, Evan. P

Apr 05, 2020 | www.amazon.com

While the shockingly high prices of prescription drugs continue to dominate the news, the strategies used by pharmaceutical companies to prevent generic competition are poorly understood, even by the lawmakers responsible for regulating them. In this groundbreaking work, Robin Feldman and Evan Frondorf illuminate the inner workings of the pharmaceutical market and show how drug companies twist health policy to achieve goals contrary to the public interest. In highly engaging prose, they offer specific examples of how generic competition has been stifled for years, with costs climbing into the billions and everyday consumers paying the price. Drug Wars is a

... ... ...

Price increases had occurred across the board, on everything from gallstone treatments to, A shocking Wall Street Journal piece revealed that between 2010 and 2014, U.S. prices for the thirty best- selling drugs rose four times faster than prescription volume, and eight times faster than inflation. 24 Put another way, 80 percent of the growth in profits of the twenty largest drug companies in 2015 resulted from price increases. 25 Put still another way, customers of CVS Health spent 12.7 percent more on drugs in 2015 than in the previous year, and more than 80 percent of that additional spending was the result of price increases. -- U.S. President Barack Obama even got into the academic mix, publishing a paper in the Journal of the American Medical Association that, in part, called attention to rising spending on prescription medication. 22 And in the days before his 2017 inauguration, the next U.S. president, Donald Trump, sharply criticized the pharmaceutical industry. "We have to . . . create new bidding procedures for the drug industry because they're getting away with murder. . . . Pharma, pharma has a lot of lobbies and a lot of lobbyists and a lot of power." --

The brunt of the pain is felt by U.S. citizens - one drug that costs less than $400 a year in some countries has a list price around $300,000 in the United States. 24 The rest of the world, however, has not been immune to the plague of skyrocketing prices...

[Mar 29, 2020] Medical Expert Who Corrects Trump Is Now a Target of the Far Right

Money quote " There is this sense that experts are untrustworthy, and have agendas that aren't aligned with the people"
That was always true about neoliberal economists. So it might well be true about mecuacl bureaucrats like Fauci. Did he disclose his stock holdingd and financial interests? Is he a part of neoliberal "medical-industrial complex" which wants to rake profits at the expense of people health?
His email to Hillary suggest that he is medical professional but a politician.
Actually any top medical honcho in Washing is compromised as they did nothing to stop "balance billing" fraud and too over of ambulance business by private equity sharks.
Notable quotes:
"... There is this sense that experts are untrustworthy, and have agendas that aren't aligned with the people ..."
"... In the email, Dr. Fauci praised Mrs. Clinton for her stamina during the 2013 Benghazi hearings. The American Thinker falsely claimed that the email was evidence that he was part of a secret group who opposed Mr. Trump. ..."
Mar 29, 2020 | www.nytimes.com

Adding that Dr. Fauci is bearing the brunt of the attacks, Mr. Bergstrom said: " There is this sense that experts are untrustworthy, and have agendas that aren't aligned with the people . It's very concerning because the experts in this are being discounted out of hand."

... ... ...

Anti-Fauci posts spiked, according to Zignal Labs. Much of the increase was prompted by a March 21 article in The American Thinker, a conservative blog, which published the seven-year-old email that Dr. Fauci had written to an aide of Mrs. Clinton.

In the email, Dr. Fauci praised Mrs. Clinton for her stamina during the 2013 Benghazi hearings. The American Thinker falsely claimed that the email was evidence that he was part of a secret group who opposed Mr. Trump.

... ... ...

In an interview, Mr. Fitton said, "Dr. Fauci is doing a great job." He added that Dr. Fauci "wrote very political statements to Hillary Clinton that were odd for an appointee of his nature to send."

...One anti-Fauci tweet last Sunday read: "Dr. Fauci is in love w/ crooked @HillaryClinton. More reasons not to trust him."

[Mar 28, 2020] Neoliberalism and medicine

Mar 28, 2020 | www.unz.com

JackOH , says: Show Comment March 27, 2020 at 12:06 pm GMT

Pepe, thanks.

As I've seen it, America's medical establishment enjoys extraordinary powers of initiative and veto in its engagement with the public, and much of that originates in the asymmetric doctor-patient relationship, the bad consequences of which were noticed by Hippocrates 2500 years ago when he tried calling physicians to their better instincts with his oath.

Good health is indeed a very important factor in Big Medicine's public engagement. So, too, revenues and profits, autonomy of practice, fee for service, overwhelming influence and downright control of the distribution of medicine for its own purposes, etc. Will elements of Big Medicine sacrifice good health for those other factors?

Yes. But you have to look at discrete instances to see how Big Medicine's players are tempted to go outright criminal. See, for example, the oxycodone killings.

I can't speak to the specifics of your article, Pepe, but it sure as hell meets some minimum threshold of plausibility to warrant further investigation in my opinion. Thanks again.

[Mar 28, 2020] The best book on big pharma criminality

Mar 28, 2020 | www.unz.com

tomo , says: Show Comment March 27, 2020 at 12:44 pm GMT

@Mustapha Mond this is the best book on big pharma criminality I have ever seen (written by an English doctor who writes for the Guardian )
You will not believe what's 'legal' for them to do in their 'research'
It's beyond criminal – but they obviously got their politicians/friends to change laws to allow what they are doing to proceed – it's really almost unbelievable
and it seems to be even worse in Europe than in the US (another thing I initially found hard to believe)

https://read.amazon.com/kp/card?preview=inline&linkCode=kpd&ref_=k4w_oembed_h8hKOfsbUkiUQn&asin=B008RLTUUA&tag=kpembed-20

[Mar 04, 2020] Why Are We Being Charged? Surprise Bills From Coronavirus Testing Spark Calls for Government to Cover All Costs by Jake Johnson

Highly recommended!
Notes of disaster capitalism in action...
Notable quotes:
"... The Centers for Disease Control and Prevention (CDC) is not billing patients for coronavirus testing, according to Business Insider . "But there are other charges you might have to pay, depending on your insurance plan, or lack thereof," Business Insider noted. "A hospital stay in itself could be costly and you would likely have to pay for tests for other viruses or conditions." ..."
"... Congress needs to immediately pass a bill appropriating funding to cover 100% of the cost of all coronavirus testing & care within the United States. We will not have a chance at containing it otherwise. @tedlieu - as my rep, can you please ensure this is brought up? ..."
"... In the case of the Wucinskis, Kliff reported that "the ambulance company that transported [them] charged the family $2,598 for taking them to the hospital." ..."
"... Last week, the Miami Herald reported that Osmel Martinez Azcue "received a notice from his insurance company about a claim for $3,270" after he visited a local hospital fearing that he contracted coronavirus during a work trip to China. ..."
"... Did anyone expect the unconscionable greed of capitalism to cease when a public health crisis emerges? This is just testing for the virus, wait until a vaccine has been developed so expensive that the majority of the US populace can not afford it at all and people are dropping like flies. Wall Street, never-the-less, will continue to have its heydays ..."
"... The very idea that the defense and "Homeland" security budgets are bloated and additional funding approved year after year but the citizens of this country are not afforded 100% health coverage In a time of global health crisis that could become a pandemic. ..."
Mar 03, 2020 | www.commondreams.org

"Huge surprise medical bills [are] going to make sure people with symptoms don't get tested. That is bad for everyone." by Jake Johnson, staff writer Public health advocates, experts, and others are demanding that the federal government cover coronavirus testing and all related costs after several reports detailed how Americans in recent weeks have been saddled with exorbitant bills following medical evaluations.

Sarah Kliff of the New York Times reported Saturday that Pennsylvania native Frank Wucinski "found a pile of medical bills" totaling $3,918 waiting for him and his three-year-old daughter after they were released from government-mandated quarantine at Marine Corps Air Station in Miramar, California.

"My question is why are we being charged for these stays, if they were mandatory and we had no choice in the matter?" asked Wucinski, who was evacuated by the U.S. government last month from Wuhan, China, the epicenter of the coronavirus outbreak.

"I assumed it was all being paid for," Wucinski told the Times . "We didn't have a choice. When the bills showed up, it was just a pit in my stomach, like, 'How do I pay for this?'"

The Centers for Disease Control and Prevention (CDC) is not billing patients for coronavirus testing, according to Business Insider . "But there are other charges you might have to pay, depending on your insurance plan, or lack thereof," Business Insider noted. "A hospital stay in itself could be costly and you would likely have to pay for tests for other viruses or conditions."

Lawrence Gostin, a professor of global health law at Georgetown University, told the Times that

"the most important rule of public health is to gain the cooperation of the population."

"There are legal, moral, and public health reasons not to charge the patients,"

Gostin said.

Congress needs to immediately pass a bill appropriating funding to cover 100% of the cost of all coronavirus testing & care within the United States. We will not have a chance at containing it otherwise. @tedlieu - as my rep, can you please ensure this is brought up?

-- William LeGate (@williamlegate) March 2, 2020

In the case of the Wucinskis, Kliff reported that "the ambulance company that transported [them] charged the family $2,598 for taking them to the hospital."

"An additional $90 in charges came from radiologists who read the patients' X-ray scans and do not work for the hospital," Kliff noted.

The CDC declined to respond when Kliff asked whether the federal government would cover the costs for patients like the Wucinskis.

The Intercept 's Robert Mackey wrote last Friday that the Wucinskis' situation spotlights "how the American government's response to a public health emergency, like trying to contain a potential coronavirus epidemic, could be handicapped by relying on a system built around private hospitals and for-profit health insurance providers."

We should be doing everything we can to encourage people with #COVIDー19 symptoms to come forward. Huge surprise medical bills is going to make sure people with symptoms don't get tested. That is bad for everyone, regardless of if you are insured. https://t.co/KOUKTSFVzD

-- Saikat Chakrabarti (@saikatc) March 1, 2020

Play this tape to the end and you find people not going to the hospital even if they're really sick. The federal government needs to announce that they'll pay for all of these bills https://t.co/HfyBFBXhja

Last week, the Miami Herald reported that Osmel Martinez Azcue "received a notice from his insurance company about a claim for $3,270" after he visited a local hospital fearing that he contracted coronavirus during a work trip to China.

"He went to Jackson Memorial Hospital, where he said he was placed in a closed-off room," according to the Herald . "Nurses in protective white suits sprayed some kind of disinfectant smoke under the door before entering, Azcue said. Then hospital staff members told him he'd need a CT scan to screen for coronavirus, but Azcue said he asked for a flu test first."

Azcue tested positive for the flu and was discharged. "Azcue's experience shows the potential cost of testing for a disease that epidemiologists fear may develop into a public health crisis in the U.S.," the Herald noted.

Sen. Bernie Sanders (I-Vt.), a 2020 Democratic presidential candidate, highlighted Azcue's case in a tweet last Friday.

"The coronavirus reminds us that we are all in this together," Sanders wrote. "We cannot allow Americans to skip doctor's visits over outrageous bills. Everyone should get the medical care they need without opening their wallet -- as a matter of justice and public health."

Last week, as Common Dreams reported , Sanders argued that the coronavirus outbreak demonstrates the urgent need for Medicare for All.

The coronavirus reminds us that we are all in this together. We cannot allow Americans to skip doctor's visits over outrageous bills.

Everyone should get the medical care they need without opening their wallet -- as a matter of justice and public health. https://t.co/c4WQMDESHU

-- Bernie Sanders (@SenSanders) February 28, 2020

The number of confirmed coronavirus cases in the U.S. surged by more than two dozen over the weekend, bringing the total to 89 as the Trump administration continues to publicly downplay the severity of the outbreak.

Dr. Matt McCarthy, a staff physician at NewYork–Presbyterian Hospital, said in an appearance on CNBC 's "Squawk Box" Monday morning that testing for the coronavirus is still not widely available.

"Before I came here this morning, I was in the emergency room seeing patients," McCarthy said. "I still do not have a rapid diagnostic test available to me."

"I'm here to tell you, right now, at one of the busiest hospitals in the country, I don't have it at my finger tips," added McCarthy. "I still have to make my case, plead to test people. This is not good. We know that there are 88 cases in the United States. There are going to be hundreds by middle of week. There's going to be thousands by next week. And this is a testing issue."

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Harry_Pjotr 13h

Did anyone expect the unconscionable greed of capitalism to cease when a public health crisis emerges? This is just testing for the virus, wait until a vaccine has been developed so expensive that the majority of the US populace can not afford it at all and people are dropping like flies. Wall Street, never-the-less, will continue to have its heydays

Smerl fern 12h

A wall street bank or private predator may own your emergency room. A surprise bill may await your emergency treatment above insurance payments or in some instances all of the bill.

An effort was made recently in congress to stop surprise billings but enough dems joined repubs to kill it. More important to keep campaign dollars flowing than keep people alive. fern Smerl 12h I know emergency rooms are being purchased by organizations like Tenet (because they are some of the most expensive levels of care) and M.D.s provided by large agencies. I'm not as up on this as I should be but a friend of mine tells me that some of this is illegal. I have received bills that were later discharged by challenge. This is worth investigating further. Atlas oldie 11h Hmmmm A virus that overwhelmingly kills the elderly and/or those with pre-exisitng conditions.

Sounds like a medical insurance companies wet dream. As well as .gov social security/medicare wet dream.

Just sayin'

Ticki 11h

The very idea that the defense and "Homeland" security budgets are bloated and additional funding approved year after year but the citizens of this country are not afforded 100% health coverage In a time of global health crisis that could become a pandemic. And as has been stated, the unconscionable idea suggested that a possible vaccine (a long way away or perhaps not developed at all) might not be affordable to the workers who pay the taxes that fund the government? That's insane.

leftonadoorstep 11h

Another example of "American Exceptionalism." China doesn't charge its coronavirus patients, neither does South Korea. I guess they are simply backward countries.

Barton 11h

I own my own home after years of hard work paying it off. It's the only thing of value, besides my old truck, that I have. If I get the virus, I will stay home and try to treat it the best I can. I can't afford to go to the hospital and pay thousands in medical bills, with the chance that they'll come after my possessions. America, the land of the _______. Fill in the blank. (Hint: it's no longer free).

fern 1 Barton 11h

There are other ways to protect your home. Homesteading or living trust. I'm not good at this but I know there are ways to do it. Hopefully, it would never come to that but outcomes are not certain even with treatment in this case.

Giovanna-Lepore oldie 11h

As someone who lost a mother at 5 years old I can sympathize with your grief in losing a daughter-in-law and especially seeing her four children orphaned. However, I think you miss the point here: This is about we becoming a society invested in each others welfare and not a company town that commodifies everything including the health and well being of us all.

fern 1 Giovanna-Lepore 11h

I'm going by: https://www.congress.gov/bill/116th-congress/senate-bill/1129/text

As a revision it is better but flawed. It is a cost containment bill based on the same research as the republican plan with global budgets and block grants.

Edited: I encourage you to read this:
-ttps://www.rand.org/blog/2018/10/misconceptions-about-medicare-for-all.html Giovanna-Lepore 10h oldie:

Part D

Higher education is not free but they do need to become free for the students and payed by us as a society.

Part D is a scam, a Republican scam also supported by corporate democrats because of its profit motive and its privatization

Medicare only covers 80% and does not cover eye and dental care and older folks especially need these services. Medicaid helps but there are limits and one cannot necessarily use it where one needs to go. Expanded, Improved Medicare For All is a vast improvement. because it covers everyone in one big pool and, therefore, much more dignified than the rob Paul to pay peter system we have.

Social Security too can be improved. Why should it simply be based on the income of the person which means that a person working in a low paying job in a capitalist system gone wild with greed will often work until they die.

Pell grants can be eliminated when we have what the French have: publicly supported education for everyone.

The demise of unions certainly did not help but it was part of the long strategy of the Right to privatize everything to the enrichment of the few.

Yunzer SuspiraDeProfundis 10h

Thank goodness for the "/s". Poe's Law you know

The overall competence that Canada is handling this outbreak, compared to the USA, is stark. First world (Canada) versus third-world (USA). Testing is practically available for free, to any suspect person, sick or not, as Toronto alone can run 1000 tests a day and have results in 4 hours. That is far more than all the US's capacity for 330 million people.

I wonder how long before Canada closes its borders to USAns? Me and my wife (both in a vulnerable age/medical group) should seriously consider fleeing to my brother's place in Toronto as the first announced cases in Pittsburgh are probably only days away. What about our poor cat though? We could try to smuggle her across the border, but she is a loud and talkative kitty

Greenwich 10h

Don't want to discourage anyone from any protective measures – but the "low down" from my veggie store today was that a lot of health professionals shop there and they think it's being hyped by media. Did get this from my NJ Sen. Menendez –

Center for Disease and Control and Prevention (CDC)

There is currently no vaccine to prevent coronavirus disease 2019 (COVID-19). The best way to prevent illness is to avoid being exposed to this virus. However, everyday preventive actions can help prevent the spread of respiratory diseases:

  • Wash your hands often
  • Avoid close contact with people who are sick.
  • Avoid touching your eyes, nose, and mouth.
  • Stay home when you are sick.
  • Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
  • For more information : htps://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html
  • How it spreads : The virus is thought to spread mainly from person-to-person. It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads. [Read more.]
    https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html )
  • Symptoms : For confirmed coronavirus disease 2019 (COVID-19) cases, reported illnesses have ranged from mild symptoms to severe illness and death. Symptoms can include fever, cough, and shortness of breath.
Seeker 9h Greenwich:

Don't want to discourage anyone from any protective measures – but the "low down" from my veggie store today was that a lot of health professionals shop there and they think it's being hyped by media.

I agree it is being hyped by the media to the point of being fear mongering. At the same time it is being ignored by the administration to such an extent that really little almost nothing is being done. At some point the two together will create an even bigger problem.

It is like the old adage: "Just because you are paranoid doesn't mean they aren't out to get you." Each over/under reach in considering the reality of the situation has its own problem, which multiply when combined. Every morning when I wake up I say a little atheistic prayer to myself before I get out of bed: "Another day and for better or worse...".

Seeker 8h

Well, two reported here in Florida tonight. One in my county, one in the county next door. And more of the "we already knew, but told you late". One person checked into the hospital on Wednesday. We hear it Monday night. Both were ignored far a long time it seems, and 84 in particular are being watched (roommates, friends, hospital workers not alerted for several days, the usual). But no one knows every place they had been since becoming infected.

Oh, and they have tested a handful of people. No worry?

I can't see anyway that this level of incompetency is an accident. Spring break is just starting usually a 100's of thousand tourist bonanza.

So the question is do they want to kill us, or just keep us in fear?

I think the later. But the end result is a crap shoot. So once again, it is a gamble with our lives.

Archie1954 7h

The business of America is business. Sometimes that can go too far and this is one of those times. Making money from the loss, distress, harm and suffering of others is perverse beyond belief.

[Mar 03, 2020] Coronavirus Systems Fragility by Rod Dreher

Highly recommended!
Notable quotes:
"... I have been a physician now for almost 30 years. It has been a career spanning the very end of the "Marcus Welby" era, and then piece by piece the complete dismantling of the medical profession by the insurance companies and now "non-profit" corporations. When I was young, the leadership structure in the hospitals was completely and utterly controlled by three groups: the physicians, the nurses, and in the case of Catholic hospitals, the church and the nuns, or in non-Catholic hospitals, philanthropic community leaders. ..."
"... There were no four-star mahogany and marble lobbies. There were no 2 million dollar annual salaries for the hospital CEOs. There were no non-profit corporate boards extracting every bit of wealth from the patients to maintain multimillion dollar salaries for the board members and the middle managers. ..."
"... In further conversation, the doctor said that we should be thinking about a world in which a large number of health care workers can't come to work because they are in quarantine or sick with the virus. We are looking at this problem right now. ..."
Mar 02, 2020 | www.theamericanconservative.com
Here's a link to an unrolled Twitter thread by former USAID official Jeremy Konyndyk. It begins:

Later in the thread:

Read the whole thread. His basic point is that the US Government did not want to see data that would indicate community transmission, so it didn't look for that. What do you think? I'm especially interested in what medical professionals in this blog's readership have to say.

I received this e-mail from Wyoming Doc a couple of days ago, and have his permission to post it:

I have just learned of the first Coronavirus Death in the USA. It is now getting real.

I would point you to the following links -- I am seeing myself -- but to a greater degree hearing about rather concerning things happening in our hospitals across the country.
The first is this video:

https://www.youtube.com/watch?v=5iz0dQbGLbE

The second is this website I showed you the other day:

https://www.oftwominds.com/blog.html

I would start first with a little background. I have been a physician now for almost 30 years. It has been a career spanning the very end of the "Marcus Welby" era, and then piece by piece the complete dismantling of the medical profession by the insurance companies and now "non-profit" corporations. When I was young, the leadership structure in the hospitals was completely and utterly controlled by three groups: the physicians, the nurses, and in the case of Catholic hospitals, the church and the nuns, or in non-Catholic hospitals, philanthropic community leaders.

The focus at the time was mostly on taking care of the most patients the best that could be done in a compassionate way with the resources available. And believe it or not, in my opinion, the care that was given in that time was far superior than what is going on now. The leaders of the hospitals were community leaders, and so was the medical and the nursing staff. To put it succinctly: they cared about their neighbors. Many, many nights while on call I would see the nuns right along side the nurses and physicians working themselves to death to take care of sick patients. These hospitals were never in debt -- the resources and the donations coming in were used for the expenses going out. There were no four-star mahogany and marble lobbies. There were no 2 million dollar annual salaries for the hospital CEOs. There were no non-profit corporate boards extracting every bit of wealth from the patients to maintain multimillion dollar salaries for the board members and the middle managers.

When I was a young medical student, a very old professor taught a course in medical ethics. In one of his most pressing lectures, he discussed the fact that the goals and ideals of medicine and public health were a complete 180 degrees from the wants and desires of a free market. He added that every time combining public health/medicine and free markets had been tried in history it ended in tears -- usually bankrupting the society. It was his fervent desire that we not allow this to happen to the profession as we entered its ranks, and to keep an eye out for this at all times.

Well, as everyone knows by now, his worst fears have been realized. Many, probably not most, members of my profession -- especially the procedure-based specialists and surgeons -- in the past 10-15 years have completely lost sight of the public well-being. Their sights are now on lucre. The one desire for many of them has been how to make more money more quickly. They have been aided and abetted by the governing agencies and Boards of all the various medical specialties. These national leadership organizations have made all the activities of being a physician so onerous and the billing so difficult that the vast majority of physicians have no choice but to become employees of these mega-corporations. The physicians have made a deal to take a back seat to these "businessmen" to keep the cash coming. The leadership of our hospital systems are no longer physicians, nurses, nuns, and philanthropists. Nope –it is all MBA all the time. Even the physicians who are nominally in charge -- ie the ubiquitous Chief Medical Officers of the corporations -- do not get considered for the jobs unless they have an MBA after their name. And the credentialing of the leadership teams are just absolutely ridiculous. Look at the websites of your local hospital and its leadership. It is usual to see things like this: John Doe, MD MBA FACP PhD FACC. The non-MD credentialing is even more hilarious -- I have no idea what 95% of these abbreviations mean -- but they have to puff themselves up anyway. The hubris and the arrogance would be hilarious, but now the crisis is upon us.

About 10-15 years ago, the change began in earnest. One by one, the physicians in charge were replaced with MBA bureaucrats. The usual committee structure in the hospital -- "Pharmacy & Therapeutics", "Patient Care Committee" etc -- had their physicians, nurses and pharmacists replaced with bureaucrats. Some of these bureaucrats were MDs and RNs -- the paycheck was awesome -- and they turned their backs on their duties and their colleagues and patients on the ground to keep the cash coming. I even lived to see the day when one of my hospitals fired the MD and RN leadership of the Medical Ethics Committee and replaced them with an MBA.

Suddenly, the only ethical thing to do was whatever was needed to maximize cash flow. And any MD or RN who did not like it? Well, you're fired -- see you later. We began to completely corporatize medical care. Advertisements and billboards everywhere, customer service feedback surveys flowing in the mail, the list is endless. Public health concerns began to be confined strictly to things that would boost revenue: colonoscopies, mammograms, labs, vaccinations, bone density studies, etc. Things that have no revenue flow -- like mental health issues, opioid abuse, elder care -- well, who cares about that? Very soon, the hospitals began to merge into gigantic corporations and then they began to collude to control the health care costs in the community. Our health care systems in all our big cities are gigantic monopolies. This despite the fact that this kind of behaviour is illegal under federal statutes. And please note: this is why insurance costs are so enormously high in this country -- and getting higher every year. Obamacare did NOTHING to stop this; it actually in many ways has made it much easier to pull off.

Because of this situation and for many other reasons, I decided to make a change in my life a few years ago. I have now moved to a very small hospital in rural America. In my life now, the corporate board has now been replaced by a board elected by the taxpayers: they are truly leaders of the community and do everything in the spirit of what the people need and are counting on from their hospital. The hospital is led by an MD -- and there are administrators -- but they too are members of the community. There is an obvious care about the community and its needs. I have spoken to colleagues across the country this week -- some big hospitals have done nothing at all to prepare for the crisis. It is no surprise to me that people in all levels at my current hospital have gone to enormous lengths to make sure everyone here is ready to go. I feel like I have stepped back in time twenty years. It is a very good feeling.

In the big city, I had become very accustomed to going to important meetings in the hospitals -- all controlled by the business leadership now -- and no medical facts or issues being discussed at all. Anything medical is distilled down to number crunching, revenue cycles, and "profit centers." Never a word is said about medical facts, public health, impact on patients, or morality like it used to be -- at least most of the time. Anyone who voices dissent is ostracized, and finds themselves disinvited and even dismissed from employment.

So the Youtube video is old hat to me. The people in charge of these critical things in our world often look like Barbie and Ken. They are cool cucumbers. They know all about branding, deceptive advertising, maximizing revenue, hiding truths, sucking up. But when actually asked questions that are critical to the issue at hand -- they often know nothing. And because they know nothing, nothing gets done. I have seen it many times before and am sure I will see it again. I read commentary online that people were shocked by that DHS Chief's answers to questions. I am not shocked -- I am very accustomed to it. Please note: our entire corporate health care system at the local hospital level in the big cities is now under the control of people just like him. They are looking for every way they can to defuse this crisis with calming advertising, words, pleasantries, smiles, and soothing statements. I am sure that they are also looking for any way they can profit financially from it as well. All I can say is: Good Luck.

A case in point was the following interaction I was told about yesterday by an old student of mine who is now a fellow at a major medical center on the East Coast. I heard the same exact recollection of the story from someone else in the room.

This was a meeting with the upper administration of the hospital system and heads of departments and multiple physicians and nurses. It occurred between the CEO and a DOC who is older and near retirement and who is an infectious disease specialist. The discussion about the current crisis went something like this:

CEO: I am not sure that we need to be preparing like this – this is obviously overblown – and is really going to damage our budget projections. The HHS seems to think this is going to go away in the spring anyway.
DOC: Why in God's name would you want it to go away in the spring?
CEO: (chuckling) What the hell are you talking about? We all want this thing to go away as soon as possible.
DOC – Historically, when pandemics are spread by aerosol droplets, and are as infectious as this one seems to be, they may recede in the spring -- but then come back in the fall with horrific fury. Remember the last one -- the Spanish Flu? The first wave was nothing, but the second and third waves turned the planet into a funeral home.
CEO: Oh for God's sake – don't you get it? That will give us time to get a vaccine -- we will not need to worry about it in October.
DOC: A vaccine? you must be kidding. It is never a good idea to rush a vaccine. Remember the first polio vaccine was rushed to market. It did not work and actually harmed many children. Remember the swine flu vaccine in the 1970s? It was not properly tested. Very few died from the swine flu. Hundreds and thousands were maimed or killed by Guillain Barré Syndrome because of it. And I doubt that half of our population would be even willing to take it. You do not understand.

CEO: Oh I understand way more than you obviously do. There is already an antiviral -- we will have that as well.

DOC: Really? Again, not really fully tested. And have you looked at the cost? Even a conservative estimate at the dosing they are using it would be $5000 a day. What is that going to do to your budget projections when you have 100 people in here in the hospital on that drug? Do we even have enough in the country for a sudden mass need? I do not know.

And then CEO looked DOC in the eye and just moved on to something else.

And DOC found out later that he would no longer be welcome at any of these meetings.

Please know this: viruses are not Republicans, they are not Democrats. Viruses are not going to respond to advertising, sweet words, or revenue cycles. They are going to accomplish their mission, and that alone. There may be things we are able to do, but we will need all the medical wisdom in the world focusing on our country as a whole and our local communities. That is just not happening to the extent it should be. We are going to fight this one with business school principles.

I again pray all the time that this virus will burn out -- that it will stop, that it will not get worse. I pray that God will have mercy and allow this to be a close call. But I am afraid that we have let our society crumble in so many ways –not just medicine -- that it is going to take a punch in the face to get our attention. This coronavirus may very well be the brass knuckles.

A follow-up e-mail from him:

This has been one of the most harrowing weeks in my career. The patients are really wigged out. Multiple times this week, I have seen patients with a cough or fever -- and we cannot ID a pathogen. That has caused a constant boogeyman to be sitting on my shoulder: fear. I can see the fear in my staff's eyes, and then on Friday, a nurse suddenly after lunch developed a 101 fever and a bad cough -- again no pathogens. I have a feeling this is happening in many other places in this country.

We have no way to test these people. I can offer little if any hope. I am telling them to stay at home, and I can see the horror in their eyes. I am now at the same level of those physicians in Milano 700 years ago –

So when I get this kind of soul crushing fear in my life, I always call one of my elder family members. My parents and grandparents are all gone now. The only one left is my 92 year old Auntie Marina. She lived through hell in Greece during the Nazi occupation and immediately thereafter. She is an amazing woman. And this is what she said to me.

"My dear, I was there when your parents handed your life and everything you are over to God. I was right on the front row. He has been preparing you every day of your life since you were a baby for the duties that you must now perform. Be brave, and sturdy, and do everything in His name. He will surround you with courage -- and fear not, if he decides this is your time to go, you will be welcomed by all the saints and angels. But here in our house, we are going to be lifting you up in prayer, multiple times a day. And I am certain that your parents are looking down and are very very proud of you."

I am a member of my community and my church. I cannot leave my post -- and I would ask that you pray for me and my staff for the bravery to continue on. I know that is a lot of drama, but we are really having fear here on the front lines. I would ask that you keep all the health care workers in America in your prayers right now.

In further conversation, the doctor said that we should be thinking about a world in which a large number of health care workers can't come to work because they are in quarantine or sick with the virus. We are looking at this problem right now.

He also recommends that people follow the coronavirus Reddit, which he says is well-moderated, and a source of solid information: https://www.reddit.com/r/Coronavirus/

[Feb 21, 2020] Private Equity's War to Preserve Surprise Billing

Notable quotes:
"... If you want proof that private equity is predatory, you need go not further than its concerted efforts to extend and intensify the devastating practice of surprise billing. ..."
"... Physicians' groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want. ..."
"... This has made physicians' practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms . ..."
"... Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not operate like an ordinary marketplace. Physicians' practices in these specialties do not need to worry that they will lose patients because their prices are too high. ..."
"... It's not only patients that are victimized by unscrupulous physicians' groups. These doctors' groups are able to coerce health insurance companies into agreeing to pay them very high fees in order to have them in their networks. ..."
"... and it needs to be annual ..."
Feb 21, 2020 | www.nakedcapitalism.com

If you want proof that private equity is predatory, you need go not further than its concerted efforts to extend and intensify the devastating practice of surprise billing.

Bad enough that patients develop afflictions or have accidents that land them in the hospital. Recovering physically is hard enough. But to then have the stress and financial damage of large and unexpected bills, which are exercises in rent extraction, is the sort of thing that creates Madame DeFarges.

Private equity experts Eileen Appelbaum and Rosemary Batt did the sleuthing to document how private equity has greatly extended and profited from this abuse. What most people do not realize is the degree to which hospitals have outsourced what most people would assume were core functions provided by doctors on the hospital's payroll, such as emergency room doctors. With many large nominally not-for-profit hospital groups run by MBAs out to justify higher pay packages for themselves, many practice areas are in fact outsourced. Private equity has hoovered up these groups. They, and not the hospital, provide the personnel for a particular case, and they make sure to get some out of network practitioners on the team to pad the bills.

One metric: a Stanford study determined that the odds of getting a surprise bill had increased from 32% in 2010 to 43% in 2016, and the average amount had risen over that time period from $220 to $628. A new study in Health Affairs found that this out of network billing raises health care costs by $40 billion per year .

Appelbaum gave a high-level overview in a op-ed in The Hill last May :

Physicians' groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians' practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms .

Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not operate like an ordinary marketplace. Physicians' practices in these specialties do not need to worry that they will lose patients because their prices are too high.

Patients can go to a hospital in their network, but if they have an emergency, have a baby in the neonatal intensive care unit or have surgery scheduled with an in-network surgeon, they are stuck with the out-of-network doctors the hospital has outsourced these services to .

It's not only patients that are victimized by unscrupulous physicians' groups. These doctors' groups are able to coerce health insurance companies into agreeing to pay them very high fees in order to have them in their networks.

They do this by threatening to charge high out-of-network bills to the insurers' covered patients if they don't go along with these demands. High payments to these unethical doctors raise hospitals' costs and everyone's insurance premiums.

Appelbaum cited Yale economists who'd examined what happened when hospitals outsourced their emergency room staffing to the two biggest players, EmCare, which has been traded among several private equity firms and is now owned by KKR and TeamHealth, held by Blackstone:

.after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded.

The study also described how TeamHealth extorted insurers by threatening them with high out-of-network charges for "must have" services:

in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates.

California and the Federal government tried to pass legislation to curb surprise billing. As we noted, the California bill was yanked suddenly and no one felt compelled to offer an explanation. The bi-partisan Federal effort also failed.

Appelbaum and Batt, in a new article at CEPR, explain how private equity has been throwing money at astroturf group to keep its scam going :

Early in the summer of 2019, Congress appeared poised to protect consumers from surprise medical bills and to hold insured patients financially harmless in situations where they were unable to choose their doctor .

Two solutions, both of which take surprise charges to patients out of the equation, have been put forward. Employers, patient advocates, and insurance companies favor paying out-of-network doctors a rate "benchmarked" to rates negotiated with in-network doctors to hold down health costs. Not surprisingly, this solution is opposed by large physician staffing companies and specialist physician practices that want to continue to charge prices higher than the in-network fees. These doctors' practices, some backed by private equity firms, have been lobbying intensively for a second option that would allow doctors dissatisfied with a negotiated rate to seek a higher fee via an arbitration process that they believe will ensure higher physician pay and higher company revenues and profits.

The campaign by Physicians for Fair Coverage, a private equity-backed group lobbying on behalf of large physician staffing firms, launched a $1.2 million national ad campaign in July to push for this second approach.8 The lobbying campaign bore fruit. In July, [sponsors of the House bill] Pallone and Walden accepted an amendment to allow arbitration, but only in special cases, and it required the arbitrator to use negotiated rates instead of provider charges when deciding on disputes over payment.9 But the private equity-owned physician staffing companies were not satisfied. In late July, a mysterious group called Doctor Patient Unity launched a $28 million ad and lobbying campaign (now up to nearly $54 million) aimed at keeping any legislation to protect patients from surprise medical bills from passing. In mid-September, a representative for Doctor Patient Unity finally revealed what many observers already suspected -- that PE-owned doctor staffing firms Envision Healthcare and TeamHealth were behind the campaign

Agreement on a joint House and Senate bipartisan bill by Senators Alexander and Murray and Congressmen Pallone and Walden nearly made it into the omnibus continuing resolution that passed in December 2019. It was stymied when Massachusetts Congressman Richard Neal, Chair of the House Ways and Means Committee, offered a last-minute alternative. The Neal bill protects consumers from surprise medical bills but requires disputes between providers and insurance companies to be resolved through arbitration. This, of course, is what the PE-owned staffing firms and the doctors' practices they own lobbied for. Lack of support from the Democratic leadership in the Senate and the House delayed passage of the legislation. In his September 2019 fundraising report, Neal reported receipt of $29,000 from Blackstone, owner of TeamHealth.

The entire article is very much worth reading , since it offers more detail on how the private equity firms tightened their grip on these chokepoints. And the threat of legal curbs has had an impact. As the piece also explains, the value of the debt on Envision, the parent of EmCare, and TeamHealth both fell into junk terrain and rebounded a bit when the bills were sidelined for 2019, but remains distressed:

Appelbaum and Batt are pessimistic that anything will get done in 2020:

In the current legislative session, Congress is again working to pass legislation to protect patients from surprise medical bills. But the disagreements in Congress remain unresolved Chances of a compromise bill emerging in this session of Congress do not look good as of this writing (mid-February 2020), and relief for insured patients from unexpected medical bills does not appear to be on the horizon.

However, bond investors clearly think there's still a risk of legislation with some teeth, although the earliest possibility is 2021. Keep your fingers crossed.


jackiebass February 21, 2020 at 6:31 am

Where I live the emergency room doctors are contracted out to a private group. This has been the practice for over a decade. Recently the local hospital got rid of their dialysis services by selling it to a private company. When a person is sick they don't think about asking if the provider is in their network. They simply want treatment to help recover.Another problem is in many areas there isn't a choice. Expensive services can have only one or no providers. That means you have to go out of you area and probably your network. I'm on medicare and chose to be on traditional medicare. You aren't locked into a small network of providers. My supplemental is through my former employer. Unfortunately it's network plan. Occasionally I have services not paid because they are out of network, even though medicare covers 80%. The deductible for out of network is so high that I end up with paying the 20%. I believe there is only one reason for network heart care. It's to increase profits and has little to do with reducing costs.

Shiloh1 February 21, 2020 at 8:02 am

If Al Capone was around today he would be in this criminal enterprise.

Criminal prosecution is the solution. Not "single payer for racketeering" or "mob protection for all".

Best government money can buy.

human February 21, 2020 at 1:05 pm

Capone famously once answered a reporter that, "Capitalism is the legitimate racket of the ruling class."

flora February 21, 2020 at 4:11 pm

I was thinking of Al Capone and his almost untouchable Chicago 'enterprise'. He was untouchable in Chicago because his racket paid off the judges, prosecutors, aldermen, and politicians. It took the feds stepping in to shut Capone down.

How many more people will go bankrupt, or avoid going to the doctor or hospital for fear of bankruptcy because of this PE surprise billing racket? Several state leges are passing or trying to pass legislation to block surprise billing.

Thanks for this post.

hoonose February 21, 2020 at 9:51 am

I hope that you've been negotiating your out of network billings! A third or half off may not be unreasonable. Heck, the hospital only collects about 25% of its total billings!

flora February 21, 2020 at 4:24 pm

This is one reason we need traditional M4A. Traditional Medicare has payment limits that the provider has to accept if they bill Medicare. (Medicare fraud is a problem, but it is tracked and prosecuted.)

Note: Medicare Advantage plans do not have this surprise billing limits protection. see:
https://pnhp.org/news/kathleen-sebelius-and-bill-frist-digging-for-the-medicare-advantage-gold/

John Anthony La Pietra February 21, 2020 at 6:34 am

Maybe I'm missing something, but offhand I don't see how this can even be a thing under a single-payer health-care system. If someone knows better otherwise, please enlighten me.

If I've got that much right, could this be another part of the motivation against M4A?

human February 21, 2020 at 7:35 am

Of course it is. A single-payer system will have massive leverage to achieve fair pricing and compensation.

hoonose February 21, 2020 at 11:34 am

Of course providers are all worried that compensations will be too meager and oppressive. For instance if the docs' income expectations go unmet, then they will certainly buck!

Yves Smith Post author February 21, 2020 at 4:58 pm

But the "providers," as in the MDs, are not the beneficiaries, or at least not much. It's the companies that own the practices .which are owned by PE funds.

Cripes February 21, 2020 at 7:05 am

This reminds me of the TV ad running lately featuring a nice young couple opening their cable bill and declaring "Its a ransom note!" as if its the height of comedy that we are living in a kleptocracy where everyone is constantly subject to "your money or your life" banditry we pretend were left behind in central park muggings of the 1970s.

I have recently had multiple occasions that I needed to write on patient responsibility forms that out of network and balance billing is refused, followed with letters citing applicable state laws and CMS contracts barring conduct in my state. It's insane.
Still I have stacks of collection notices I must beat back and win every time. They only need to win once to destroy someone. Have we no prisons?

The rapine and dispossession of late-stage American crapitalism (can we finally get to End Stage?) always exceeds our worst expectations.
Crime-infested swamp of a country.

Dare we hope a movement can coalesce and endure after a decent man in his waning years is thrust into an historical opportunity to move this train wreck from disaster?

He's the community organizer Obama never was and the new dealer FDR never quite was.

In the flatness of our current political terrain, Bernie's grandfatherly menscheism makes him a moral colossus next to the sniveling careerists and the nefarious old crassus.

1776, 1860, 1932, 1968. What will we make of this year?

On to Milwaukee

John Anthony La Pietra February 21, 2020 at 7:29 am

Can you put the rebuttal into your own easily reproducible form? Either a neat page to staple thoroughly to the bills (copied/printed in needed quantities) or a big rubber stamp with blanks to fill in if applicable?

Yves Smith Post author February 21, 2020 at 5:01 pm

Yes, if you can provide it, I would make it a post. Your version with your state's language and how to find similar language in other states. This is VERY important.

Note I have heard one reader say that their doctors said they wouldn't schedule the surgery if she made an issue out of out of network MDs, that she needed to go elsewhere. So those doctors were completely on board with this practice.

DHG February 21, 2020 at 7:22 am

Anyone who has not made themselves judgment proof really is the fool. No assets, nothing for them to get.

floyd February 21, 2020 at 8:23 am

Disagree -as Chris Hedges says, those people have value as prisoners where they can generate $40K+/yr for some private prison.

flora February 21, 2020 at 5:35 pm

Yep.

"You wouldn't think you'd go to jail over medical bills": County in rural Kansas is jailing people over unpaid medical debt

https://www.cbsnews.com/news/coffeyville-kansas-medical-debt-county-in-rural-kansas-is-jailing-people-over-unpaid-medical-debt/

fnx February 21, 2020 at 1:48 pm

Doesn't mean that can't get a judgment against you! Then you spend the rest of your life trying to avoid having people send money via Paypal or other services direct to your bank account since they can take it. Or winning the lottery or buying a new car the list is endless.

TG February 21, 2020 at 12:14 pm

I am currently visiting some old colleagues in Denmark. I told them about the new practice in the United States of "surprise medical billing."

They were shocked. "Sure that's something Trump would do, but surely the Democrats would stop it?"

Hahahaha.

Susan the other February 21, 2020 at 12:48 pm

As in "Privatize Sovereignty, Socialize Property" by David Cieplay, Blackstone and its ilk have this very business model. In this case they are buying up emergency room doctors' practices – with the promise they will make more money – and passing the cost on to insurance companies (poetic justice) and the state and federal gov. Because we have no laws against this sort of corporate privateering (heaven forbid congress should suddenly remember how and why to legislate), all the costs of health care are socialized and because the PE funds are untouchable they have effectively privatized sovereignty. When we all realize their useful function in this scam is one big nothing burger, congress will have to act. It's just another testament to how venal, immoral, lazy and rotten congress is. I can smell it from here.

Howard February 21, 2020 at 1:37 pm

Besides PE, it also makes sense that the real estate sector in general would be opposed to anything that reduces financial burden (particularly anything that would lessen medical debt) on middle- and lower-middle-income households, because foreclosures and desperation fire sales would then dry up.

TimH February 21, 2020 at 1:59 pm

Here's the California situation, from https://www.dmhc.ca.gov/Portals/0/HealthCareInCalifornia/FactSheets/fsab72.pdf

The law protects consumers from surprise medical bills when:
An enrollee goes to an in-network facility such as a hospital, lab or imaging center, but services are provided by an out-of-network health provider.

An enrollee receives emergency services from a doctor or hospital that is not contracted with the patient's health plan or medical group.

JCC February 21, 2020 at 4:13 pm

Yet another anecdote

I've been a relatively healthy individual and so rarely use my insurance. I used it for the first time in 20 years for a full yearly physical (just because it was "that time", not for any health problems). The annual full checkup is, supposedly, fully covered, and I chose a local clinic in my network.

The various clinics involved ended up billing me directly, so far, for over $3500.00, and that was before the colonoscopy bill which still hasn't arrived. I checked my Insurance Portal and, sure enough, the supposed covered charges were listed as "Denied".

So, considering all these costs were supposed to be covered, I took a full day off work (6 solid hours on various phone calls) to get it straightened out. While going through all these bills and working through each charge I discovered 1 bill for a clinic appt (a subsidiary of CVS) that never happened and 1 very high bill for standard blood tests (Quest) that never happened due to a screwup initiated by the CVS-owned clinic. We'll see what happens.

But while talking with one of the Insurance Co. reps she told me a classic surprise billing horror story that happened to her. She gets occasional nosebleeds and one day got a serious one while on the highway before her exit. A CHP officer pulled up behind her after she pulled over to take care of the situation and refused to let her continue on without going to the nearest Emergency Room, so she went.

Her visit lasted 1/2 hour. She was handed a bucket of clean water and a towel. After cleaning up, she waited around for awhile, gave up waiting, washed the towel out, cleaned the bucket out and left. She went on to tell me that 30 days later she recieved a bill from the Emergency Services group at the hospital for $45,000.00. For a towel and a bucket of water.

It took her two days of unpaid time off to get it straightened out and the bill removed.

She then told me she's voting for Sanders, too.

So I've learned three lessons from this; 1) even with insurance things go wrong far too often when it comes to billing issues, and 2) Surprise Billing is far more common than I was led to believe, and 3) Health Insurance/care in this country is riddled with fraud and outright criminality.

Yves Smith Post author February 21, 2020 at 5:07 pm

Hate to tell you, but with a colonoscopy, the exam is covered by Obamacare, but any snipping of polyps is not, and that can easily run to $1000.

The US Is the only advanced economy where colonoscopies are recommended for everyone over 50. In other countries, they are recommended only for people in high risk groups.

If you get an annual ( and it needs to be annual ) fecal occult blood test (easy and cheap, MD puts gloved finger in you, wipes test panel, and tells you right there), the results in terms of detection are on par with colonoscopies.

[Feb 19, 2020] Suprise Billing To Be Resolved in February 2020 to be Enacted in 2022 by run75441

Feb 18, 2020 | angrybearblog.com

Suprise Billing To Be Resolved in February 2020 to be Enacted in 2022

run75441 | February 18, 2020 11:40 am

Healthcare I had wondered why the Senate (Schumer) had backed off on legislation controlling surprise billing. It turns out there is a House bill also and I am sure they are going back and forth on this. Recently, two bills have emerged in the House and one from the Senate. Medscape , "House Committees Advance Bills to Address Surprise Billing."

Of course if Congress's butt was on the line, a solution would have been found quickly and enacted in 2020. At the end, see which one I would back.

The House Ways and Means Committee bill passed by a voice vote bipartisan bill. It seeks to establish more use of third-party negotiators ( arbitration) for settling certain disputes about payment for out-of-network care. This bill has the support of the American Hospital Association and the American College of Emergency Physicians. The American Medical Association also praised the committee's reliance on mediation for disputes on bills.

The House Education and Labor Committee advanced a hybrid proposal seeking to use established prices in local markets to resolve many disputes about out-of-network bills. Key to this bill is the use of arbitration above a certain cost. Bills greater than $750 or in the case of air ambulance services $25,000; clinicians and insurers could turn to arbitration for an independent dispute resolution. House Education and Labor passed this bill in a 32-13 mixed vote with some Republicans and Democrats opposing and in favor.

The latest Senate Health, Education, Labor and Pensions (HELP) Committee of legislative proposals also addresses surprise medical billing. The HELP bill called for mandating that insurers reimburse out-of-network costs on the basis of their own median rates for in-network providers.

The Education and Labor Committee bill is estimated to save $24 billion, the Senate HELPS bill is estimated to save $25 billion, and the Ways and Means' bill would save almost $18 billion all over 10 years. It is suggested the greater use of arbitration in the Ways and Means' bill will result in less savings.

Read on about the private equity involved and providers.

Outside Opponents of Legislation

The American Hospital Association : "Setting a rate in statute gives insurers few incentives to develop robust networks with hospitals and physicians, and paying for emergency care at the median in-network rate would surely underpay for these services and create an incentive for insurers to avoid paying fair reimbursement for these services. This approach is an obvious windfall for the insurance industry without any assurance that health plans will pass these savings on to consumers through lower premiums."

Other physician organizations have joined the fight to make balance billing appropriate; the American College of Emergency Physicians, Envision Healthcare, US Acute Care Solutions and US Anesthesia Partners -- gave roughly $1.1 million in 2019 to members of Congress, according to a Kaiser Health News analysis of Federal Election Commission records.

Doctor Patient Unity : "We support a federal solution to surprise medical bills that makes insurance companies pay their fair share and supports patients' right to quality medical care."
"We oppose insurance-industry-backed proposals for government rate setting that will lead to doctor shortages, hospital closures and loss of access to medical care, particularly in rural and underserved communities."

Early on in 2019, Doctor Patient Unity spent more than $28 million on ads opposing legislation without disclosing its staff or its funders. It was later revealed its largest financial backers are two private equity backed firms Team Health and Envision Healthcare. Together they own physician practices and staff emergency rooms around the country according to spokesperson Greg Blair. Blackstone Group owns Team Health and KKR owns Envision Healthcare

As is typical of political ads being run to influence people, they do not tell the whole story and omit references to surprise bills. Instead, they warn of "government rate setting" harming patient care and doctor/patient relationships.

The Direct Providers

ER doctors, anesthesiologists, radiologists and other specialists who typically charge out-of-network prices are among the highest-compensated practitioners. I have found this to be true during my hospital visits. Doctors, 3rd party contracting companies, and hospitals complain Healthcare Insurance Companies have the upper hand due to size and can pay the increased costs of out-of-network pricing.

The argument by doctors, the 3rd party contracting companies, and hospitals has been made the healthcare insurance companies control the market and are able to secure better pricing from providers which is not passed along to the insured. In markets where both providers and insurers are highly concentrated, insurers have bargaining power to reduce prices for hospital admissions and visits to certain physician specialists. The Market Concentration chart for insurers and providers reveals the concentration (concentration chart) for providers is greater than it is for insurers overall. Furthermore and if we are talking about ACA policies, additional moneys gained must be used for treatment or the excess beyond 15 and 20% overhead and profit is refundable. It can be said also, when the total cost goes up, the portion (15 or 20%) of the total price increases in real dollars.

ER doctors, anesthesiologists, radiologists and other specialists who typically charge out-of-network prices are among the highest-compensated practitioners. I have found this to be true during my hospital visits. If the insurance company can not convince them to take a lesser rate, you are stuck will the bill. I have been tempted to ask at the time of need whether they are all in network and employees of the facility I am visiting that day. Countering the argument by insurance, doctors, and hospitals complain healthcare insurance companies have the upper hand due to size and market control and can pay the increased costs of out-of-network pricing. As shown chart 1, their claims are not precisely true and the market for healthcare has become less competitive as hospitals and ACOs buy up the competition.

"Providers are more concentrated than insurers in almost 60 percent of US metro areas . Health plans hold an edge in only 6 percent of local markets. National and state level studies reveal a steady rise in concentration among specialist physicians, primary care providers, and hospitals alike. As Brent D. Fulton notes, concentration of insurers fell slightly from 2010 to 2016, while concentration rose for both specialist physicians and hospitals. The evidence suggests provider organizations will retain significant bargaining leverage even after out-of-network billing reform, leaving little scope or incentive or capability for insurers to push prices down sharply. "

Meanwhile, the naysayers are battling constructive resolution with $millions in countering ads and intense lobbying of Congress to delay and/or deny resolution of overpriced surprised billing of patients of which had no choice, many more are still being hit with bills there is little explanation for except greed. We do need Single Payer. Nough said . . .

Congress has till February 22nd to resolve the deadlock before the current temporary bill expires. I would take the Education and Labor approach, which is also backed by the House Energy and Commerce Committee, and the Senate Health Committee. It would set the payment rate based on the median amount paid for that service in the geographic area with the option of going to arbitration for some higher-cost bills. It result in greater savings.

steve , February 18, 2020 5:25 pm

We (anesthesiology) are par with everything that our network accepts. I am not a fan of surprise billing, but I dont think you grasp all of the issues here. Medicare reimburses at much lower rates than does private insurance in my specialty. If you work in a place with a high percentage of Medicare (or Medicaid which is worse) like we do, you cannot come close to earning market salaries. So we, many years ago, ended up working 95th percentile or worse hours (over 70 per week) while earning in the 15th-20th percentile in income. We lost a lot of staff. The hospital had to make up the difference so that we could hire and retain people. We were fortunate that our hospital had the resources to do that.

Up north of us another hospital faced a similar situation, but they didn't have the resources to subsidize their staff. So they fired a good team and brought in another. Told them it was OK to not bill in accordance with what the hospital accepted, like the prior group did. That let the new group earn enough, for a while, to hire and retain people. Hospital eventually failed anyway and had to be bought out.

I think most of the groups that I know are surprise billing are pretty greedy and sleazy, so I stay away from them. However, there are other cases where groups are in a tough situation and pretty desperate. Especially smaller rural hospitals that have trouble finding staff to begin with.

Steve

[Feb 16, 2020] Doctor Surprise Billing: this is the same price inflation dynamic that we observe in body shops and car insurance companies. Kind of evil symbiosis that develops

Feb 16, 2020 | angrybearblog.com

likbez , February 16, 2020 11:48 am

run75441,

Thank you for this post. This is an important topic that needs to be discussed.

Again Dr. ZDogg: "Guess what's going to happen to her insurance premiums next year? They're going to go up by 10%, 15%, 20 percent. And what will happen at employers around the country who are paying most of the bill? They're going to drop or keep wages flat (happening today). Healthcare becomes a financial albatross with collusion between healthcare providers charging a bunch of money and insurance companies paying it, hospitals overbuilding, overcharging, and doing stuff we don't even need. The results of these money games are a minority of people getting rich and everybody else's wages staying stagnant. 1 in 5 Americans have collection agencies coming after them for medical bills that are inflated and unnecessary.

BTW this is the same price inflation dynamic that we observe in body shops and car insurance companies. Kind of evil symbiosis that develops. So this is a more general phenomenon than just healthcare.

See also: https://www.nakedcapitalism.com/2020/02/what-the-heck-happened-to-surprise-billing-legislation-or-its-never-too-late-for-the-lobbyists-to-win.html

[Feb 15, 2020] Doctor Surprise Billing

Highly recommended!
This is the same spiral of cost inflation that we observe in dealing with repair shops and car insurance companies. They form symbiosis that prosper by mutual inflation of costs.
Notable quotes:
"... The Insurance company must apply 80% of healthcare insurance premiums to actual care. and 20% to Overhead and Profit. Dr. ZDogg states most of the tests were not needed such as a Pan-Viral test when a rapid-strep swab would do. Dr. ZDogg contends this was a virus and the most one should do is the swab the throat or just wait to see what develops . . . this sounds familiar to me as a patient too. ..."
"... The hypothetical? Lets say at the most, what was done should be about $1000 or $800 to actual care and $200 to Overhead and Profit. Multiple this by 26 and see what it amounts to. In Dr. ZDogg's words: "What if we make the pie bigger and 3% of a bigger pie is more money? What if we actually let people overcharge for procedures they don't need? Then all we have to do next year is raise the premiums to cover the actual medical cost, which is now higher, and then we make a higher amount of profit." That was the untoward side effect of the government policy on this, which, by the way, happens with many policies that are top-down. You can't predict what happens and then it happens. " ..."
Feb 15, 2020 | angrybearblog.com

Going to her PCP located in Manhattan, a woman complains of a sore throat. Forget the Manhattan part of this as various versions (surprise billing) of this situation are happening everywhere. The doctor swabbed the throat, sent it off to the lab, ordered some tests, and then gave her a prescription for antibiotics. She took her meds and went on vacation feeling better.

The tests came back negative. She later received a bill for ~$26,000.

The lab was out of network which usually results with insurance only paying a portion of the bill and the patient the balance unless the insurance negotiates a lesser charge (hospital 3rd party employees) which they will pay. This is another version of Surprise Billing, not in a hospital setting, which we have heard so much about, and the patient gets screwed with the balance of the Surprise Billing.

More Information

The lab was out of network but it was a part of the employer the PCP worked for also. Usually doctors use the hospital they are affiliated with to run tests or do lab work which are also in network (today). I suspect more hospitals will relegate lab work to 3rd parties to cut costs and improve profits.

There was a time when I had catastrophic insurance which only paid 50% of costs. I had pneumonia and really could not afford to go to my PCP at $150 (then) as I was out of work. My PCP was not sympathetic and wrote me script to take to the hospital for imaging and another test. I called the U 0f M hospital and talked to a clerk there about cost. He finally told me to go to Quest (outside lab) and they would be half the cost in doing imaging, etc. U of M has some major Overhead to pay for today.

By the way, Blue Cross Blue Shield paid almost all of the bill for this lady with the sore throat.

Even More Information and a Hypothetical

The Insurance company must apply 80% of healthcare insurance premiums to actual care. and 20% to Overhead and Profit. Dr. ZDogg states most of the tests were not needed such as a Pan-Viral test when a rapid-strep swab would do. Dr. ZDogg contends this was a virus and the most one should do is the swab the throat or just wait to see what develops . . . this sounds familiar to me as a patient too.

The hypothetical? Lets say at the most, what was done should be about $1000 or $800 to actual care and $200 to Overhead and Profit. Multiple this by 26 and see what it amounts to. In Dr. ZDogg's words: "What if we make the pie bigger and 3% of a bigger pie is more money? What if we actually let people overcharge for procedures they don't need? Then all we have to do next year is raise the premiums to cover the actual medical cost, which is now higher, and then we make a higher amount of profit." That was the untoward side effect of the government policy on this, which, by the way, happens with many policies that are top-down. You can't predict what happens and then it happens. "

I would like to think doctors, hospitals, and healthcare insurance companies are not prone to this. Yet we have record of numerous surprise billing instances by hospitals, this one is an example of one by a doctor. Medicare Advantage plans are over billing CMS for treatments running totals up to $10 billion per year. And what about Commercial Healthcare Insurance? I have not heard of insurance pushing back on over charges. Usually, they reject a bill or a portion of it and the patient pays the balance.

And what Happens as a Result?

Again Dr. ZDogg: "Guess what's going to happen to her insurance premiums next year? They're going to go up by 10%, 15%, 20 percent. And what will happen at employers around the country who are paying most of the bill? They're going to drop or keep wages flat (happening today). Healthcare becomes a financial albatross with collusion between healthcare providers charging a bunch of money and insurance companies paying it, hospitals overbuilding, overcharging, and doing stuff we don't even need. The results of these money games are a minority of people getting rich and everybody else's wages staying stagnant. 1 in 5 Americans have collection agencies coming after them for medical bills that are inflated and unnecessary.

Dr. ZDogg recommended exposure to sunlight might cure the problem.

The patient; "I made it very clear [to the doctor's office] that I was unhappy about it." And told them I would report the doctor to New York state's Office of Professional Medical Conduct. She also reached out to "Bill of the Month," a joint project of NPR and Kaiser Health News. After a reporter started asking questions about the bill, Blue Cross and Blue Shield of Minnesota stopped payment on the check it issued and is now investigating.

The bottom line to this is, it should have never got this far or even happen.

Recently it was disclosed Michigan No Fault Accident Coverage was paying an ~289% of Medicare rates to hospitals and clinics to care for patient injuries suffered from automobile accidents. No Fault coverage will die in a few years as the new legislation sponsored by Quicken Loans Dan Gilbert and Michigan Repubs have allowed people to opt out or take lesser coverage which will now pay hospitals and clinics 220% of Medicare rates. No Fault would not disclose what it was paying caregivers. Another surprise which should have never happened . . .

This story is from December 2019 and was in NPR For Her Head Cold , Insurer Coughed Up $25,865, NPR, Richard Harris.

Paperwork: Manhattan Specialty Care
$26,000 for a Throat Swab?! , ZDoggMD, MedPage Today, February 6, 2020
The Doctors Who Bill You While You're Unconscious , The Atlantic, Olga Khazan, February 11, 2020


Chris, February 14, 2020 1:19 pm

The solution is to have one network and a single payer. Simple.

run75441 , February 14, 2020 7:49 pm

Chris:

You remind of someone else who insists it is that simple. It is not unless you have 60% of Congress inline. And if you do make the change, look forward to much of the Senate and the House being replaced as the population likes their Employer sponsored commercial healthcare insurance in spite of being screwed over by commercial healthcare, healthcare, and the pols who kiss the industries butt. What you and others are insisting on as being so simple is not so simple to enact.

davebarnes , February 14, 2020 1:39 pm

I have Kaiser Medicare Advantage and am happy.
Colon cancer fix cost me $2500 for surgery + chemo.
Perianal abscess cost me $300. Three surgeries.

EMichael , February 14, 2020 2:49 pm

Chris,

The solution is indeed simple. Getting to the solution is a huge task.

Meanwhile, It would be very simple legislation to stop this criminal treatment by providers. Person has insurance and is treated by someone out of network without giving specific orders to go out of network, is only liable for the in network charges.

Hard to vote against that, but we all know how many will, and who they are.

[Jan 14, 2020] I also think that if I call 911 and need emergency assistance, it should be provided by the city or county, not a private company

Jan 14, 2020 | angrybearblog.com

Angry Bear " Preventing Surprise Medical Bills ,

Mike B. , January 13, 2020 10:15 am

The only surprise medical bills I have received is for claims that were denied by my insurance company. Then the provider does not just demand what they would have received if the claim had been approved, but the full billed amount, which is generally 2 to 10 times the insurance amount. Providers should have to charge everyone the same price for the same thing. Now they have an incentive to order dubious tests or procedures, because if a claim is denied, they can bill for more money. I assume people without insurance are also billed for the full amount, and they can least afford it.

I also think that if I call 911 and need emergency assistance, it should be provided by the city or county, not a private company. That's true if police or fire engines are needed, and likewise it should be for EMTs or ambulances.

[Jan 12, 2020] Preventing Surprise Medical Bills by run75441

Notable quotes:
"... If you are on Medicare, do not stay for observation unless you have a Plan G or Plan F. If you are on Plan N Supplemental to Medicare or lower, the plan will NOT pay 100% for Observation. You have to be admitted. You can go anywhere with Medicare for treatment. ..."
"... Medicare Advantage? You had better be in network or have some type of alternative program within your plan. ..."
Jan 11, 2020 | angrybearblog.com

The idea I have is not to be surprised. I am a careful patient who asks a lot of questions and also advocate for myself. I have refused treatment when they use drugs which may threaten my health further (Heparin). I am also not well liked by the bloodsuckers who come in to draw blood and stab me through the vein for two weeks and destroyed my left arm in the process. Ask them questions and do not be so willing to accept treatment (if cognizant) until they answer your questions and then get their name. Take names and dates. It is ok to be a forceful advocate for yourself. When all is said and done, the bill will come to you alone.

If you are on Medicare, do not stay for observation unless you have a Plan G or Plan F. If you are on Plan N Supplemental to Medicare or lower, the plan will NOT pay 100% for Observation. You have to be admitted. You can go anywhere with Medicare for treatment.

Medicare Advantage? You had better be in network or have some type of alternative program within your plan.

There are good points to this article which is why I C and P-ed it here per their request.

As taken from Preventing Debt from Surprise Medical Bills , Bankrate, Madison Blancaflor. July 19, 2019

The cost of healthcare has become a hot topic in American politics in recent years, and with good reason. A recent survey found that 22 percent of Americans are losing sleep over healthcare or insurance costs, up from 13 percent just one year ago.

One aspect in particular has even gained attention from both Congress and the President within the past two months: surprise medical bills.

Congress has proposed bi-partisan legislation that sets up consumer protections against surprise billing in certain situations. President Trump also issued an executive order in June that calls for hospitals to be more transparent upfront about prices for common tests and procedures, a measure that should go into effect later this year. ( While the House took out the 10 year exclusivities for Biologic drugs, it ended up in the Budget bill giving exclusivity for 12 years on new biologics. As I have pointed out repeatedly, risk adjusted R & D costs are recouped in a median period of 3- 5 years. It is another give-away to pharma. )

Past the leap, causes and prevention of Surprise Billing.

The cause of surprise billing

Unexpected medical bills, often outrageously expensive, can catch patients by surprise if they see a doctor who is not within their insurance network. It's a common issue, with the Wall Street Journal reporting that an estimated 51 percent of ambulance rides, 22 percent of ER visits and 9 percent of elective cases lead to surprise medical costs.

What often happens is that while the hospital or clinic might be considered in-network, a specific doctor might not be in-network (or vise versa). The legislation proposed by the Senate includes cost protections for situations such as these, plus scenarios where patients receive emergency care or follow-up care at an out-of-network facility due to travel restrictions.

While the new legislation and executive action may help patients and their families, surprise billing will persist in situations outside the purview of these new protections. ( The proposed prevention of surprise billing did not make it through the Senate this time for reasons I am not aware of today. More later .)

Preventing surprise healthcare bills

The best way to combat surprise billing is to prevent it whenever possible. This requires staying up-to-date on your insurance policies and looking at your options when scheduling appointments.

Know the details of your insurance policy

The first step is understanding your specific insurance policy. Check with your provider for a list of in-network hospitals, specialists and primary care physicians in your area so you can know ahead of time where you'll have coverage. If you have an upcoming appointment, it's worth calling your provider to double-check whether the facility and doctor you're seeing are in-network and covered.

Your provider may also require prior authorization before an appointment in order to cover some healthcare services or prescriptions, especially when visiting specialists.

Ask about costs upfront

Whether you're visiting a new primary care physician, seeing a specialist or have a planned procedure coming up, call ahead to see what out-of-pocket costs you will be responsible for paying. If you find that the facility or physician is out-of-network, you can request a referral to a facility or physician that is in-network.

For planned visits, you can also ask about the billing codes for the tests or procedures you'll be having so that you can confirm that your insurer will cover them. While many standard preventative procedures like a basic cardiac stress test or mammogram are covered by insurance policies, more advanced screenings such as a 3D mammogram may be billed under a different code that is not covered by your insurance.

Make an emergency plan

While it's impossible to predict when emergencies will happen, you can make a plan to help you prepare. If you know which emergency care providers are covered by your insurance plan, you can have an idea of where to go. While it requires some research on the front-end, you can save some stress and a lot of money in the long-run.

Understand your rights

In addition to new federal protections, many states have additional regulations regarding "balance billing," when patients are billed for out-of-network providers at an in-network facility. Don't be afraid to negotiate with hospital billing managers or doctors who billed you when you are balance billed, and keep your insurance company in the loop on the situation. Knowing your state's specific protections can help you get fees waived or lowered in these cases.

Combating debt from surprise medical bills

Unfortunately, it's impossible to entirely prevent surprise medical bills -- especially in the case of emergency services. In an emergency room, you have little to no control over which physicians you see and what tests are run. You also don't always have time to call ahead to check prices or request transfers to in-network facilities.

While it might not be possible to prevent some surprise healthcare costs, there are still steps you can take to combat debt in these cases.

1. Double check itemized medical bills.

Mistakes happen. Sometimes patients are billed for tests, procedures or medications that they didn't actually receive. Ask for an itemized bill, and ensure that you are only being charged for services received. If you find a mistake in your bill, talk to the hospital's billing department and the service provider.

In the case that a procedure or service on your bill should have been covered by your insurance provider, ask about the specific billing code the hospital used. It's possible that while the insurance provider covers a basic or general service, the billing code used may not fall under the billing code your insurance company lists as covered. Talk with both the hospital billing department and your insurance provider to see what can be done.

2. Avoid using credit cards whenever possible

Credit cards average around a 17 percent interest rate, meaning they are less-than-ideal for covering high medical costs . There are medical credit cards out there that offer short and long term financing plans to cover medical expenses with minimal interest, which is an option for those who can realistically pay off the debt within the specified time period.

When using a credit card is unavoidable, consider a credit card that offers a long intro period to help you save on interest charges, such as well known Platinum Visa Card might offer. If you end up with bills spread across multiple credit cards, a balance transfer credit card can also help you eliminate debt and save money on interest charges.

Just keep in mind that for all of these credit options, it's imperative that you can pay off the debt within the 0% interest offer period. Otherwise, you'll be subject to high interest rates that can cause even more financial stress.

For larger medical bills or debts, consider a personal loan (which offer lower, fixed interest rates) to help cover the cost.

3. Protect your credit score

If for any reason you are unable to pay your medical bills on time, it's important to take steps to protect your credit score. When you go more than 90-180 days without paying a medical debt, it could become an unpaid collection account, which can show up on your credit report and negatively affect your score. Luckily, newer credit score models such as the VantageScore 4.0 and FICO Score 9 often reduce the impact of these types of collection accounts.

If you know you'll be unable to pay medical bills, be open and honest with the hospital or provider. You might be able to set up a plan that better fits your budget. At the very least, you can explain the situation, pay as much as you can at the moment and potentially prevent them from writing off your debt as a loss and selling it to a collection agency.

4. Open a savings account for unplanned medical costs

While you can't predict unplanned medical costs, you can prepare for them by saving money for a rainy day. One option is contributing to a Healthcare Savings Account (HSA), which allows you to add pre-tax/tax-deductible money into a savings account that you can use for approved healthcare costs.

You can also set up a savings account with any bank to be used for healthcare costs. While these accounts may not be tax-exempt, you can often get a better interest rate and avoid regulations on what medical expenses you can and can't cover with the account.

Even if you only contribute $20 a month, it will add up over time and can help offset costs to make medical expenses more affordable.

The Bottom Line

While it's promising that both Congress and the President are making strides towards eliminating surprise medical bills and helping lower overall healthcare costs, sometimes surprise billing is unavoidable. These tips can help you prevent these charges or combat excessive debt that can often result from unplanned medical expenses.


davebarnes , January 11, 2020 9:28 pm

Kaiser Medicare Advantage.
Have NEVER has a strange nor bogus charge.

My colon cancer surgery + chemo was $2500 which I consider reasonable.
My 3 surgeries for a perianal abscess (trust me, you don't want one) was a few hundred bucks.

4.5 miles to the hospital/medical center/pharmacy.

run75441 , January 11, 2020 11:42 pm

That is nice. Your time will come when they will charge more for those operations. You are there forever and can not come back to Medicare. What do you think is happening with commercial healthcare today for a majority of the people who have commercial healthcare?

likbez , January 12, 2020 12:09 am

Great post on a very important in the USA topic. Thank you run75441!

I would add the danger of calling ambulance from home in non-critical cases. Taxi to the hospital is approx. 100 times cheaper and most cases is as effective :-).

In case the case is critical (like a real heart attack) be ready to pay out of network changes ($5K-$15K) for the ride in states that do not provide protection against surprise billing. Less then a half of the USA states some minimal (really minimal) protection against those sharks.

Ambulances in the USA are overtaken by private equity and venture capital firms.criminals. They are real Mafiosi. Or even worse because they profit of human sufferings. Private equity sharks circle around and if they smell blood they will devour the victim without any merci. I sometimes wonder why among around 40K of gun violence victims (39,773 in 2018) in the USA per year this category is so underrepresented 😉 .

The core of the problem is that ambulances and private insurance companies do not agree on a fair price, so the ambulance service doesn't join the insurance network. That leaves patients stuck in the middle with out-of-network charges..

See for example:

https://www.nbcnews.com/health/health-news/taken-ride-ambulances-stick-patients-surprise-bills-n824141

One patient got a $3,660 bill for a 4-mile ride. Another was charged $8,460 for a trip from one hospital that could not handle his case to another that could.

Still another found herself marooned at an out-of-network hospital, where she'd been taken by ambulance without her consent.

These patients all took ambulances in emergencies and got slammed with unexpected bills. Public outrage has erupted over surprise medical bills -- generally out-of-network charges that a patient did not expect or could not control -- prompting 21 states to pass laws protecting consumers in some situations.

But these laws largely ignore ground ambulance rides, which can leave patients stuck with hundreds or even thousands of dollars in bills, with few options for recourse, finds a Kaiser Health News review of 350 consumer complaints in 32 states.

Patients usually choose to go to the doctor, but they are vulnerable when they call 911 -- or get into an ambulance. The dispatcher picks the ambulance crew, which, in turn, often picks the hospital. Moreover, many ambulances are not summoned by patients. Instead, the crew arrives at the scene having heard about an accident on a scanner, or because police or a bystander called 911.

Betsy Imholz, special projects director at the Consumers Union, which has collected over 700 patient stories about surprise medical bills, said at least a quarter concern ambulances.

"It's a huge problem," she said.

[Dec 24, 2019] Congress refuses to ban surprise billing racket: "We've started to realize it's not us versus the hospitals or the doctors, it's us versus the hedge funds," said James Gelfand, senior vice president of health policy at ERIC, a group that represents large employers.

Dec 24, 2019 | www.nakedcapitalism.com

tegnost , December 23, 2019 at 8:49 am

As the days go by I become more convinced that the impeachment drama was used to cover up the passing of the usmca and axing of the venture capital in health care bill and containing surprise medical billing
https://khn.org/news/investors-deep-pocket-push-to-defend-surprise-medical-bills/
FTA
"We've started to realize it's not us versus the hospitals or the doctors, it's us versus the hedge funds," said James Gelfand, senior vice president of health policy at ERIC, a group that represents large employers.

Kayfabe

paddlingwithoutboats , December 23, 2019 at 9:14 am

From the KHN article on surprise billing
"surprise medical bills, which generally arise when an insured individual inadvertently receives care from an out-of-network provider."

How did "inadvertently" get in there when it is a revenue generation model? Asymmetry of information is always how profits are made.

I like to invert the model and estimate the outcomes for a lot of these fictions: if working class people controlled the upward distribution of wealth, how would society be different?

Joe Well , December 23, 2019 at 11:11 am

Yves has posted about how private equity firms specifically make this a business model.

[Dec 22, 2019] This neoliberal maggot Schumer managed to defeat 'suprise blling" legistlation

Notable quotes:
"... Where is AOC in all this? She was th e prime mover on impeachment, specifically impeachment over a phone call rather than concentration camps and genocide. And now with impeachment she gave Pelosi cover to sell the country out again. I was wondering why many libreral centrists were expreasing admiration for her, a socialist. Maybe they recognized something? ..."
Dec 22, 2019 | www.nakedcapitalism.com

flora , December 21, 2019 at 7:41 am

re:impeachment redux

Interesting, to me at least, that the rocket docket timetable of the House impeachment coincided with the deadline to pass a budget to avoid a(nother) govt shutdown. While all msm eyes were transfixed by the hyperventilating spectacle, behind the scenes the budget passed through the Dem House was filled with more tax breaks for the corporations and the .001%, more money than the admin asked for the MIC, and killed a bill that would end medical 'surprise billing' (another gift to medical PE investors and giant hospital corporations), basically a whole neolib wish list.

Interesting the two events coincided, and, that Nancy decided not to sent on the articles to the Senate at this time. What gives? Is she hold on to them for a future time when she'll need to use them as another distraction for the msm to report on? (no, that could not be the reason. ;) )

Spring Texan , December 21, 2019 at 9:44 am

Schumer and a top House Democrat with ties to private equity were instrumental in defeating the surprise medical bill legislation: https://www.commondreams.org/news/2019/12/20/schumer-revealed-key-industry-ally-defeat-effort-curb-surprise-billing
https://www.salon.com/2019/12/18/top-house-democrat-kills-effort-to-end-devastating-surprise-medical-bills/
https://slate.com/business/2019/12/surprise-medical-bills-legislation-congress-democrats.html

Pat , December 21, 2019 at 2:31 pm

Pointed this out a couple of days ago (Slate and Buzzfeed). Happy that it is not just the online press pointing out it was Democrats killing this measure, Democrats in leadership positions. I also like that few, if any, of our media is falling for the kabuki used by Neal to stick the shiv in. Everyone gets that the 'competing plan' was there strictly to derail a law that end the hugely profitable but fraudulent price gauging of healthcare by private equity.

If he keeps this up, walking POS Schumer might make me miss Al D'Amato nah Al and Chuck are just two different colors of tulle, adding illusion to the political process.

Carey , December 21, 2019 at 3:51 pm

..and they could have just passed it for the good PR and then de-fanged it
administratively, but it looks like they wanted to press the point:
"No, Proles, we're not gonna let you breathe, not a bit."

Good to know.

Joe Well , December 21, 2019 at 11:03 am

Where is AOC in all this? She was th e prime mover on impeachment, specifically impeachment over a phone call rather than concentration camps and genocide. And now with impeachment she gave Pelosi cover to sell the country out again. I was wondering why many libreral centrists were expreasing admiration for her, a socialist. Maybe they recognized something?

[Dec 08, 2019] Something to keep in Mind when you enroll in Medicare Advantage Plans

Dec 07, 2019 | angrybearblog.com
It is not a dirty or hidden little secret. Insurance companies offering MA plans do not tell you that once you are in their plan, you are there potentially forever.

Returning to traditional Medicare is ok but, getting a Medigap Plans to supplement the gap may lead to rejection or much higher premiums if you choose to come back and especially if their are pre-existing conditions.

The same as the Commercial MA companies, Medicare.gov websites are not always clear about the process of transferring out of MA to traditional Medicare and obtaining a Medigap plan.

Being unconditionally accepted by a Medigap plan is guaranteed only within the first 12 months after enrolling in Medicare at age 65.

In 2019, one-third (34%) of all Medicare beneficiaries, 22 million seniors were enrolled in Medicare Advantage (MA) plans.

As most know, Medicare consists of Part A, B, C, and D plans.

To cover the gaps in A & B and the gap, you buy supplemental insurance which is about the same as Part B in premium cost. Unless Medicare rules change, the most one can experience is changes in premiums.

In contrast, Part C or Medicare Advantage plans can cover a broad array of health services at a low cost. Unless one gets sick, the price for MA Plans can remain low. If one does gets sick, out-of-pocket costs can increase in later years . Once in an MA plan, getting out can result in less affordability. Medigap plans in all but four states can and do reject people or require higher premiums if you came back to them after Medicare Advantage Plans. Diabetes, heart disease, or even a knee replacement can be criteria for exclusion.

"After Mills underwent a mitral valve repair and suffered a mild stroke with no lasting effects, the San Diego resident's plan now charges him hundreds of dollars in monthly copays for drugs and other medical services. He had to pay $295 a night for his hospital stay.

But there was a much bigger shock. Mills, 71, learned that switching out of his MA plan he would incur exorbitantly higher costs the next time he needs a serious medical intervention. If he moves to traditional Medicare and a prescription plan, he will still need a supplemental Medigap plan to pick up his 20% copays and deductibles."

Again, this is something most people do not know, an should know before they make any move to Medicare Advantage plans. Furthermore, there are many MA plans which have narrow networks to which you must go to. In comparison, traditional Medicare pays where ever you go in the United States.

Comments (4)

davebarnes , December 7, 2019 1:25 pm

" if their are pre-existing conditions" really? perhaps if there are would be better

davebarnes , December 7, 2019 1:29 pm

All you wrote is true. But, I really like my Kaiser Advantage plan. My total cost for colon cancer (including surgery, chemo) was $2500. My total cost for a perianal abscess (3 surgeries) was $300.

run75441 , December 7, 2019 2:19 pm

My total cost for being in the hospital for 3.5 weeks and 4 doses of Rituxan was less than $1000 under Traditional Medicare and Plan N Supplemental. Medicare Advantage is problematic. Premiums can go up in Traditional but out of pocket is stable.

Carol , December 7, 2019 1:45 pm

@davebarnes i agree, but KP isn't available nationwide, and it is problematic getting the same coverage elsewhere

[Nov 26, 2019] Beware of the Medicare Disadvantage Corporate Trap Wake Up AARP by Ralph Nader

Nov 25, 2019 | chrisyeh96.github.io
While the Democratic presidential candidates are debating full Medicare for All, giant insurance companies like UnitedHealthcare are advertising to the elderly in an attempt to lure them from Traditional Medicare (TM) to the so-called Medicare Advantage (MA) – a corporate plan that UnitedHealthcare promotes to turn a profit at the expense of enrollees.

Almost one third of all elderly over 65 are enrolled in these numerous, complex MA policies the government pays so much for monthly. The health insurance industry wants more enrollees as they continue to press Congress for more advantages.

Medical Disadvantage would be a more accurate name for the programs, as insurance companies push to corporatize all of Medicare, yet keep the name for the purposes of marketing, deception, and confusion.

Elderly people enrolled in MA will experience its often merciless denials when they get sick. As hospital expert – attorney, physician, Dr. Fred Hyde put it: "It's not just what you pay, it's what you get."

Start with the cross-subsidy of MA from TM. In 2009, the Congressional Budget Office estimated these overpayments would cost the federal government $157 billion over the coming decade. Obama's Affordable Care Act started to reduce these subsidies to the giant insurers, but they still amount to many billions of dollars per year.

Add that with Medicare Disadvantage you are restricted to networks of vendors. That restricts your choice for competence and skills, and sometimes, requires you to travel longer distances for treatment. This could mean fewer enrollees will utilize their healthcare and more profits for the insurance companies.

Under Medicare Disadvantage you are subject to all kinds of differing plans, maddening trapdoor fine print, and unclear meaning to the insurers arguing no "medical necessity" when you're denied care.

The advertisements for Medicare Disadvantage stress that you can sometimes get perks – gym memberships, hearing aids, and eyeglasses, as enticements, but they avoid telling you they are not so ready to cover serious needs like skilled nursing care for critically ill patients.

Under Medicare Disadvantage, there is no Medigap coverage as there is for TM. Co-pays and deductibles can be large. Under a recent Humana Medicare Advantage Plan in Florida, your co-pay for an ambulance is up to $300, up to $100 co-pay for lab services, and another $100 for outpatient x-rays.

A few years ago, UnitedHealthcare corporations dismissed thousands of physicians from their MA networks, sometimes immediately, sometimes telling their patients before telling their physicians.

Dr. Arthur Vogelman, a gastroenterologist, said he received a termination letter in 2013 from UnitedHealthcare. He appealed, documenting his successful treatment of many patients. The company denied his appeal, with no reason, as it had for thousands of network physicians.

Dr. Vogelman called it "an outrage. I have patients in their 80s and 90s who have been with me 20 years, and I'm having to tell them that their insurer won't pay for them to see me anymore. The worst thing is I can't even tell them why." Except that the company wanted more profits.

After a lengthy protest by national and state medical societies in 2013, UnitedHealthcare began to be less aggressively dismissive.

Studies show the main reason MA enrollees return to TM is how badly the corporate insurers treated them when they became sick.

Medicare itself is getting overly complex. But nothing like the ever changing corporate rules, offerings, and restrictions of Medicare Disadvantage. How strange it is that AARP, with its Medigap insurance business run by UnitedHealthcare, doesn't advise its members to go with the obviously superior Traditional Medicare. AARP reportedly receives a commission of 4.95% for new enrollees on top of the premiums the elderly pay for the Medigap policy from United Healthcare. This money – about seven hundred million dollars a year – a significant portion of AARP's overall budget.

AARP responded to my inquiries into their Medicare Advantage policy saying that it does not recommend one plan over another, leaving it to the less informed consumer. That's one of AARP's biggest cop-outs -- they know the difference.

There is no space here to cover all the bewildering ins and outs of what corporations have done to so-called managed Medicare and managed Medicaid. That task is for full-time reporters. The government does estimate a staggering $60 billion in billing fraud annually just on Medicare – manipulating codes, phantom billing, etc. You need the equivalent of a college-level course just to start figuring out all the supposed offerings and gaps.

Suffice it to say that, in the words of Eleanor Laise, senior editor of Kiplinger's Retirement Report, "the evidence on health care access and quality decidedly favors original Medicare over Medicare Advantage, according to a Kaiser Family Foundation review of 40 studies published between 2000 and 2014."

All this anxiety, dread, and fear, all these arbitrary denials of care – prompted by a pay-or-die commercial profit motive – all these restrictions of what doctors or hospitals you can go to, do not exist in Canada. All Canadians have a Medicare card from birth; they have free choice of health care vendors. There are few American-style horror stories there; patients have better outcomes, and almost never even see a bill. The whole universal system costs half per capita of that in the U.S., where over 80 million people are uninsured or underinsured – still! (See singlepayeraction.org, for civic action to rid Americans of this perverse chaos). Join the debate on Facebook More articles by: Ralph Nader

Ralph Nader is a consumer advocate, lawyer and author of Only the Super-Rich Can Save Us!

[Oct 05, 2019] Medicare Advantage is a hustle designed to allow for-profit corporations to suck up public dollars. For years, Republicans have shoveled money into Medicare Advantage plans and allowed them to offer benefits that traditional Medicare is forbidden from covering

Oct 05, 2019 | economistsview.typepad.com

EMichael , October 04, 2019 at 11:48 AM

They will allow trump to do anything he wants as long as he does things like this.

"
" Back
Trump's Executive Order is Backdoor Privatization of Medicare

run75441 | October 3, 2019 8:52 pm

"Trump's Executive Order is Backdoor Privatization of Medicare," Social Security Works, Nancy Altman, October 3, 2019

I had to search around for someone who is an expert on Medicare Advantage Plans and Original Medicare. Nancy is one of those experts....

"Medicare Advantage is a hustle designed to allow for-profit corporations to suck up public dollars. For years, Republicans have shoveled money into Medicare Advantage plans and allowed them to offer benefits that traditional Medicare is forbidden from covering. This is a ploy to push seniors into Medicare Advantage plans instead of traditional Medicare. Medicare Advantage is stealth privatization intended to undermine traditional Medicare, which is an effective, popular government program and therefore loathed by Republican ideologues.

Under the Trump Administration, the thumb on the scale has turned into an entire arm. They've been flooding seniors' inboxes with advertisements for Medicare Advantage. What these emails don't mention is that Medicare Advantage plans often have narrow networks, restricting which doctors and hospitals patients are allowed to use. Worse, a recent government report found tt Medicare Advantage plans improperly deny care "in an attempt to increase their profits." It's no surprise that older, seniors are more likely to drop Medicare Advantage plans.

Medicare Advantage plans are also a terrible waste of public dollars. They have overcharged Medicare by $30 billion in the past three years alone.

Today's executive order is yet another giveaway to the corporations that run Medicare Advantage plans. Ironically, the Trump Administration is framing the executive order as an attack on Medicare for All. In fact, the massive flaws of Medicare Advantage epitomize the need to get for-profit greed out of health care by improving Medicare and expanding it to cover all Americans.

Medicare, like Social Security, works. Republicans want to privatize both of them. We have to stop them and instead, expand both."

https://angrybearblog.com/2019/10/trumps-executive-order-is-backdoor-privatization-of-medicare.html#more-52393

EMichael -> EMichael... , October 04, 2019 at 11:52 AM
"The President* Is a Blight, But Watch What the Conservative Movement's Up to Behind Him

They're coming for Medicare, folks.

Even while he's floundering and crimin' his way across the landscape, El Caudillo del Mar-a-Lago still needs watching -- not just because of his many offenses against the Constitution and against human decency, but also for all the standard Republican policy goals that he's putting within reach. For example, on Thursday, the president* signed an executive order that supposedly "improved" Medicare. Then he flew to Florida to lie about it in front of an audience of the elderly. Within the executive order is a poison pill the size of a horse's head. Check out Section 3.

Section 3: Providing More Plan Choices to Seniors. (a) Within 1 year of the date of this order, the Secretary shall propose a regulation and implement other administrative actions to enable the Medicare program to provide beneficiaries with more diverse and affordable plan choices. The proposed actions shall:....

That, dear friends, is pretty much the same plan that Paul Ryan, the zombie-eyed granny starver from the state of Wisconsin, spent years trying to slime into law. It is the first big step toward Ryan's lifetime goal of privatizing the Medicare system, which, as someone who has enjoyed its benefits for almost a year, I can tell you is a terrible idea. Look at all the little buzzing land mines in there. "Competition." "Market pricing." This thing even expands Medical Savings Accounts, a terrible idea that emerged in the 1990s and that Bill Frist was going to ride into the White House in 2000.

The president* is a blight and impeachment is the only cure, but the conservative project rolls merrily on. I'm not entirely sure he knew what he was signing, because he doesn't know anything about anything, but the people who find him useful do, which is why he'll be around for a while longer."

https://www.esquire.com/news-politics/politics/a29368460/president-trump-medicare-executive-order/

ilsm -> EMichael... , October 04, 2019 at 01:47 PM
top dems, all corrupt, one unhealthy and one [self identified] false minority.... what does one do about them?
EMichael -> EMichael... , October 05, 2019 at 07:14 AM
And things like this. Imagine the lives they are going to destroy.

"Here's How We Know the Supreme Court Is Preparing to Devastate Abortion Rights

There's no other reason for the justices to take up the Louisiana abortion case.

The Supreme Court agreed on Friday to hear June Medical Services v. Gee, a challenge to Louisiana's stringent abortion restrictions. There is very little doubt that the conservative majority will use this case to overrule 2016's Whole Woman's Health v. Hellerstedt, allowing states to regulate abortion clinics out of existence. In the process, the Republican-appointed justices will set the stage for the formal reversal of Roe v. Wade. The court's decision to hear June Medical Services came with the alarming announcement that it will also consider whether to strip doctors of their ability to contest abortion laws in court. These aggressive moves augur an impending demise of the constitutional right to abortion access. ....

Because the 5th Circuit refused to adhere to binding precedent, Louisiana's abortion providers asked the Supreme Court to step in and block the law. It agreed to do so -- but only by a 5–4 vote, with Chief Justice John Roberts joining the liberals. In dissent, Kavanaugh argued that the court should allow the law to take effect and force the doctors to seek admitting privileges once again. His opinion was a rejection of Whole Woman's Health, dismissing the reality that Louisiana, like Texas before it, was trying to shutter clinics, not help women.

Given Kavanaugh's refusal to abide by precedent, the outcome of June Medical Services likely depends upon Roberts. It is true that the chief justice voted to block the law while the clinics appealed to SCOTUS. But his vote is best understood as a reminder to lower courts that they cannot flout liberal precedent just because Kennedy is off the bench. Roberts did not want the 5th Circuit to overturn Whole Woman's Health on its own -- only the Supreme Court can reverse its own precedent. But Roberts dissented in Whole Woman's Health. And when the case comes squarely before him, he will probably follow his conservative instincts, overturn or hollow out Whole Woman's Health, and allow states to impose draconian regulations on abortion providers that obligate clinics to shut their door.

The clearest indication of Roberts' vote is the fact that the court scheduled June Medical Services for oral arguments. When an appeal presents no new question of law and is clearly resolved by precedent, SCOTUS sometimes issues per curiam summary decisions. That means the justices affirm or reverse a lower court ruling without oral arguments through a brief, unsigned order. They prefer to issue these decisions when six justices sign on, but that's not a rule, and the court has issued 5–4 summary reversals before."

https://slate.com/news-and-politics/2019/10/supreme-court-louisiana-abortion-roe-v-wade.html

[Sep 25, 2019] UK Labour Party plan for reducing drug prices includes public funding for research and having new drugs available as generics

Sep 25, 2019 | economistsview.typepad.com

anne , September 24, 2019 at 06:47 PM

https://twitter.com/DeanBaker13/status/1176657390235803649

Dean Baker @DeanBaker13

UK Labour Party plan for reducing drug prices includes public funding for research and having new drugs available as generics (patents in public domain). Maybe progressive Democratic presidential candidates can learn something

http://labour.org.uk/wp-content/uploads/2019/09/Medicines-For-The-Many.pdf

5:39 PM - 24 Sep 2019

[Sep 22, 2019] Sicko The truth about the US healthcare system The Independent

Sep 22, 2019 | independent.co.uk

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Sicko? The truth about the US healthcare system | The Independent <style amp-boilerplate>body{-webkit-animation:none;-moz-animation:none;-ms-animation:none;animation:none}</style> Sicko? The truth about the US healthcare system Michael Moore's new film is a damning indictment of the way the world's richest country looks after those who fall ill. Andrew Gumbel finds out whether his accusations are justified Cynthia Kline knew exactly what was happening to her when she suffered a heart attack at her home in Cambridge, Massachusetts. She took the time to call an ambulance, popped some nitroglycerin tablets she had been prescribed in anticipation of just such an emergency, and waited for help to arrive.

On paper, everything should have gone fine. Unlike tens of millions of Americans, she had health insurance coverage. The ambulance team arrived promptly. The hospital where she had been receiving treatment for her cardiac problems, a private teaching facility affiliated with the Harvard Medical School, was just a few minutes away.

The problem was, the casualty department at the hospital, Mount Auburn, was full to overflowing. And it turned her away. The ambulance took her to another nearby hospital but the treatment she needed, an emergency catheterisation, was not available there. A flurry of phone calls to other medical facilities in the Boston area came up empty. With a few hours, Cynthia Kline was dead.

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She died in an American city with one of the highest concentration of top-flight medical specialists in the world. And it happened largely because of America's broken health care system - one where 50 million people are entirely without insurance coverage and tens of millions more struggle to have the treatment they need approved. As a result, medical problems go unattended until they reach crisis point. Patients then rush to hospital casualty departments, where by law they cannot be turned away, overwhelming the system entirely. Everyone - doctors and patients, politicians on both the left and the right - agrees this is an insane way to run a health system.

When Elizabeth Hilsabeck gave birth to premature twins in Austin, Texas, she encountered another kind of insanity. Again, she was insured -- through her husband, who had a good job in banking. But the twins were born when she was barely six months pregnant, and the boy, Parker, developed cerebral palsy. The doctors recommended physical therapy to build up muscle strength and give the boy a fighting chance of learning to walk, but her managed health provider refused to cover it.

The crazy bureaucratic logic was that the policy covered only "rehabilitative" therapy - in other words, teaching a patient a physical skill that has been lost. Since Parker had never walked, the therapy was in essence teaching him a new skill and therefore did not qualify. The Hilsabecks railed, protested, won some small reprieves, but ended up selling their home and moving into a trailer to cover their costs. Elizabeth's husband, Steven, considered taking a new, better-paying job, but chose not to after making careful inquiries about the health insurance coverage. "When is he getting over the cerebral palsy?" a prospective new insurance company representative breezily asked the Hilsabecks. When Elizabeth explained he would never get over it, she was told she was on her own.

Everyone in America has a health-care horror story or knows someone who does. Mostly they are stories of grinding bureaucratic frustration, of phone calls and officials letters and problems with their credit rating, or of people ignoring a slowly deteriorating medical condition because they are afraid that an expensive battery of tests will lead to a course of treatment that could quickly become unaffordable.

Even when things don't go horribly wrong, it is a matter of surviving by the skin of one's teeth.

In Montana, Melissa Anderson can't find affordable insurance because she is self-employed - an increasingly common affliction. When her son Kasey came down with epilepsy two years ago, she was saved only by a recently introduced child health insurance programme specifically tailored to people who aren't poor but can't afford to pay monster medical bills. She herself remains uninsured for anything short of major care needs.

Over the past 15 years, the stories have become less about poor people without the economic means to access the system - although that remains a vast, unsolved problem - and more about the kind of people who have every expectation they will be taken care of. Middle-class people, people with jobs that carry health benefits or - as the problem worsens - people with the sorts of jobs that used to carry robust health benefits which are now more rudimentary and risk their being cut off for a variety of reasons.

This is the morass that Michael Moore has chosen to explore in his latest documentary, Sicko, which goes on release later this month. Moore spends much of the film demonstrating that there is nothing inevitable or necessary about a system that enriches insurance companies and drug manufacturers but shortchanges absolutely everyone else. His searching documentary looks at health care in France, Britain, Canada, and even Cuba - still regarded as a model system for the Third World.

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Moore has his share of ghoulishly awful stories. The film kicks off with an uninsured carpenter who has to decide whether to spend $12,000 (£6,000) reattaching his severed ring finger or $60,000 to reattach his severed middle finger. Later on, Moore focuses on a hospital worker whose husband needed a bone marrow transplant to save him from a rare disease. The couple's insurance company refused to cover the transplant because it regarded the treatment as "experimental". The husband died.

Many more stories are collected in a newly published book called Sick: The Untold Story of America's Health Care Crisis, by Jonathan Cohn. A woman in California called Nelene Fox died of breast cancer after she, too, was turned down for a bone marrow transplant by her insurance company. In Georgia, a family whose infant son went into cardiac arrest were forced to take him to a hospital 45 miles away on their insurance carrier's orders. He survived, but suffered permanent disabilities that more prompt treatment might have averted. In New York, an infant called Bryan Jones - whose case was trumpeted all over the local media at the time - died of a heart defect that went undetected because his insurance company kicked him and his mother out of hospital 24 hours after his birth, too soon to carry out the tests that might have spotted the problem.

America's health system offers a tremendous paradox. In medical technology and in the scientific understanding of disease, it is second-to-none. Since doctors are better paid than anywhere else in the world, the country attracts the best of the best. And yet many, if not most, Americans are unable to reap the advantages of this. In fact, as The New York Times columnist Paul Krugman has argued, the very proliferation of research and high-tech equipment is part of the reason for the imbalance in coverage between the privileged few and the increasingly underserved masses. "[The system] compensates for higher spending on insiders, in party, by consigning more people to outsider status --robbing Peter of basic care in order to pay for Paul's state-of-the-art treatment," Krugman wrote recently. "Thus we have the cruel paradox that medical progress is bad for many Americans' health."

Having the system run by for-profit insurance companies turns out to be inefficient and expensive as well as dehumanising. America spends more than twice as much per capita on health care as France, and almost two and a half times as much as Britain. And yet it falls down in almost every key indicator of public health, starting, perhaps, most shockingly, with infant mortality, which is 36 per cent higher than in Britain.

A recent survey by the management consulting company McKinsey estimated the excess bureaucratic costs of managing private insurance policies - scouting for business, processing claims, and hiring "denial management specialists" to tell people why their ailment is not covered by their policy - at about $98bn a year. That, on its own, is significantly more than the $77bn McKinsey calculates it would cost to cover every uninsured American. If the government negotiated bulk purchasing rates for drugs, rather than allowing the pharmaceutical companies to set their own extortionate rates, that would save another $66bn.

Astonishingly, there hasn't been a serious debate about health care in the United States since Bill Clinton, with considerable input from his wife Hillary, tried and failed to overhaul the system in 1994. That, though, may be about to change as the 2008 presidential race heats up. Everyone acknowledges the system is broken. Everyone recognises that 50 million uninsured - including almost 10 million children - is unacceptable in a civilised society.

Even the old, classically American free-market argument - that "socialised" medicine is somehow the first step on a slippery slope towards godless communism - doesn't hold water, because in the absence of a functioning private insurance regime the government ends up picking up about 50 per cent of the overall costs for treatment anyway. The indigent rely on a government programme called Medicaid. The elderly have a government programme called Medicare. And perhaps the most efficient part of the whole system is the Veterans' Administration, a sort of NHS for former servicemen.

Rather like London and Paris in the 19th century, where the authorities belatedly paid attention to outbreaks of cholera once the disease started affecting the rich and middle classes, so the American health crisis may be coming to a head because of the kinds of people who are suffering from its injustices.

Corporate chief executives, for a start, are gagging under the ever-increasing costs of providing coverage to their employees. Starbucks now spends more on health care than it does on coffee beans. Company health costs, as a whole, are at about the same level as corporate profits. In a globalised world where US businesses are competing with low-wage countries such as India and China, that is rapidly becoming unacceptable.

That explains, perhaps, why the chief executive of Wal-Mart, Lee Scott, has made common cause with America's leading service sector union - more commonly a bitter critic of Wal-Mart's labour practices - in calling for a government-run universal health care system by 2012. It's going to be a tough battle. The insurance and pharmaceutical industries bankroll the campaigns of dozens of congressmen and have so far been brutally efficient in protecting their own interests. The Clintons were defeated in 1994 in part because of the power of the industry lobbies. Doing better this time will take singular political courage.

In the meantime, we will hear ever more crazy stories like the one told by Marijon Binder, a former nun in Chicago who ended up being sued by a Catholic hospital for $11,000 because her two-night stay for a heart scare was not considered a worthy charity case. Binder, who works as a live-in companion to a disabled old woman, wrote on all her admission forms that she had no insurance and, in her telling at least, was reassured the hospital would take care of her anyway.

After a year and a monstrous bureaucratic fight that went nowhere, a civil judge promptly absolved her of responsibility for her bill - a lucky outcome, for sure. Binder said: "The whole experience was very demeaning. It made me feel very guilty; it made me feel like a criminal." She is, though, alive and solvent. Not everyone in this system catches the same break.

[Sep 07, 2019] Private Equity and Surprise Medical Billing naked capitalism

Notable quotes:
"... By 2013, physician staffing firms owned by Blackstone Group and Kohlberg, Kravis Roberts & Co. (KKR) – among the largest PE firms in the country – cornered 30 percent of this market. Since then, private equity ownership of these services has continued to grow. ..."
"... The Stanford study found that the likelihood that a patient admitted to an in-network hospital would face a surprise medical bill because at least one out-of-network doctor cared for them increased from 26.3 percent 2010 to 42.0 percent in 2016. A particularly egregious instance occurred when an assistant surgeon sent a bill for $117,000 to a patient who had surgery for herniated discs in his neck. ..."
"... Commenting on EmCare's relations with hospitals, Benedic Ippolito, a research fellow in public finance and health economics at the American Enterprise Institute, noted, "Right now, EmCare surprise bills patients and hospitals effectively turn a blind eye. ..."
"... A team of Yale University health economists examined the billing practices of EmCare, Envision's physician staffing arm. [xx] They found that when EmCare took over the management of emergency departments, it nearly doubled its charges for caring for patients compared to the charges billed by previous physician groups. These egregious practices have resulted in a Congressional investigation headed by Missouri Senator Claire McCaskill, lawsuits from shareholders, and court actions involving Envision and UnitedHealth Group, the largest U.S. insurer. [xxi] ..."
Sep 06, 2019 | www.nakedcapitalism.com

September 6, 2019 by Jerri-Lynn Scofield By Eileen Appelbaum and Rosemary Batt Originally published at The Institute for New Economic Thinking website

Surprise medical billing has become a critical issue facing Americans across the country because of purposeful corporate practices designed to increase profits. As hospitals have outsourced emergency rooms and other specialty care to reduce costs, private investors have bought up specialty physician practices, rolled them into powerful national corporations, and taken over hospital emergency services. The result: large out-of-network surprise bills. The hidden actors: Leading private equity firms looking for 'outsized' returns.
Surprise medical billing made headlines in 2019 as patients with health insurance found themselves liable for hundreds or even thousands of dollars in unforeseen medical bills. When patients with urgent medical problems go to an emergency room (ER) or are treated by specialty doctors at a hospital that is in their insurance network, they expect that the services they receive will be 'in-network' and covered by their insurance. But often a doctor not in their insurance network is under contract with the hospital and actually provides the care. When this happens, patients are stuck with unexpected and sometimes unreasonably high medical bills charged by these 'out-of-network' doctors. This typically occurs when the hospital has outsourced the ER or other specialized services to a professional staffing firm or a specialty doctors' practice. This problem has exploded in recent years because hospitals are increasingly outsourcing these services to cut costs.

And more and more patients are faced with surprise medical bills -- adding substantially to the already impossible medical debt that working people face. Hospital outsourcing of emergency, radiology, anesthesiology, and other departments has provided an opening for physician practices to operate these services as independent organizations. Initially, hospitals outsourced these services to small, local doctors' groups

But over the past decade, private equity firms have become major players -- buying out doctors' practices and rolling them up into large corporate physician staffing firms that provide services to outsourced emergency rooms, anesthesiology and radiology departments, and other specialty units. By 2013, physician staffing firms owned by Blackstone Group and Kohlberg, Kravis Roberts & Co. (KKR) – among the largest PE firms in the country – cornered 30 percent of this market. Since then, private equity ownership of these services has continued to grow.

Private equity firms also own two of the three largest emergency ambulance and air transport services – another major source of surprise medical billing. Private equity ownership matters because the business model of private equity firms is to use a lot of debt in a leveraged buyout of companies they acquire and then extract as much cash as possible out of them in order to pay down the debt and reward their investors with 'outsized returns' that exceed stock market gains. They can be thought of as for-profit corporations on steroids. Buying up specialty practices is financially attractive because there is a large and growing demand for outsourced doctors, and out-of-network doctors can command a substantial premium for their services.

Emergency rooms and certain medical services provided in hospitals are not really part of a competitive 'marketplace' because patients in emergency medical situations rarely have a choice: they need immediate medical care and cannot 'shop around' for an in-network trauma doctor or radiologist.

Thus, surprise bills are difficult to avoid if patients face a medical emergency and must go to the ER or if they are hospitalized and require access to specialty medical services. How Widespread is Surprise Billing and Why Has It Grown?

Surprise medical billing is exacerbating the already serious problem of medical debt in this country, which is a leading cause of bankruptcy for American families. [i] And surprise billing is growing rapidly. Forty percent of Americans surveyed by the Kaufman Family Foundation in April, 2019, reported receiving an unexpected medical bill; and 20 percent of those surveyed said it was due to out-of-network charges – or surprise billing. [ii] A study by health researchers at Stanford University, for example, examined fees charged to patients with private insurance who were treated by the emergency department of a hospital. They reviewed 13.6 million trips to the ER that occurred over the period 2010 to 2016. About a third (32.3 percent) of these trips in 2010 resulted in a surprise medical bill. But by 2016, that figure had increased to 42.8 percent. That is, more than 4 in 10 trips to the ER ended with patients getting a surprise medical bill. [iii]

For in-patient stays, surprise billing rose from 26 percent to 42 percent, and the average costs per patient also jumped from $804 to $2,040. At this rate of increase, the estimated percent of hospital visits resulting in a surprise bill would be 48 percent in 2019 – or almost one half.

The study also found that in 2016, 86% of ER visits and nearly 82% of hospital admissions incurred surprise ambulance service bills. Similarly, another 2019 study found that patients who are admitted to a hospital from the ER are much more likely to receive an out-of-network charge -- as many as 26% of admissions from the emergency room were found to include a surprise bill. The study also found that 38 percent of Americans are 'very worried' and another 29 percent are 'somewhat worried' about being able to afford surprise medical bills.

People particularly vulnerable to these charges are those with coverage from large employers that are self-insured. And vulnerability also varied by region, with Texas, New York, Florida, New Jersey, and Kansas having higher rates of surprise billing; and Minnesota, South Dakota, Nebraska, Maine, and Mississippi having lower rates. [iv] While large surprise medical bills are typically associated with doctors in the ER or in specialties such as radiology, anesthesiology, or critical care units such as neo-natal, burn, or trauma centers, other out-of-network physicians may also issue surprise bills. For example, those who assist a patient's doctor in a procedure or hospitalists who check on patients during hospital stays can also charge separately for their services.

The Stanford study found that the likelihood that a patient admitted to an in-network hospital would face a surprise medical bill because at least one out-of-network doctor cared for them increased from 26.3 percent 2010 to 42.0 percent in 2016. A particularly egregious instance occurred when an assistant surgeon sent a bill for $117,000 to a patient who had surgery for herniated discs in his neck.

The patient's own in-network surgeon sent a bill for $133,000, but accepted a fee of $6,200 negotiated with the insurance company. The out-of-network assistant surgeon is seeking full payment of his charges. This is a particularly egregious example, but surprise bills for a few thousand dollars are not uncommon. [v]

The problem of surprise billing has grown substantially in recent years because hospitals have been under financial pressure to reduce overall costs and have turned to outsourcing expensive and critical services to third-party providers as a cost-reduction strategy. Outsourcing is not new, as hospitals began outsourcing non-medical ancillary services such as facilities management and food services in the 1980s, in response to a round of structural changes in government financing.

By the 1990s, hospitals were experimenting with the use of independent 'hospitalists' to care for patients between rounds by the local admitting doctors who had a hospital affiliation. Hospitalists' numbers increased over the next two decades as hospital staffing firms grew and provided a range of temporary or short-term professionals to fill shortages in nursing, technical, or clinical positions. [vi]

Recent outsourcing, however, has expanded to critical care areas – emergency rooms, radiology, anesthesiology, surgical care, and specialized units for burn, trauma, or neo-natal care. Now hospitals contract with specialty physician practices or professional physician staffing firms to provide these services – even if the patient receives treatment at a hospital or at an outpatient center that is in the patients' insurance network. According to one study, surprise billing is concentrated in those hospitals that have outsourced their emergency rooms. [vii] A recent report found that almost 65 percent of U.S. hospitals now have emergency rooms that are staffed by outside companies. [viii] Hospitals and healthcare systems have accelerated their outsourcing of critical care areas since 2010 in part due to declines in Medicaid and Medicare reimbursements and to incentives under the Affordable Care Act to reduce costs and improve care quality. [ix]

At the same time, on the supply side, hospitalist companies were merging and buying up practices of specialists employed mainly in hospitals. Hospitalist companies evolved into physician staffing firms and expanded to include staffing for emergency rooms (ERs), anesthesiology and radiology departments, and burn and neonatal intensive care units in hospitals across the country. The business case for hospitals to outsource was straightforward. Emergency rooms are a major point of entry for patients who are admitted to hospitals, and thus, a major conduit for the in-patient hospital stays that are critical for hospital revenue generation. But they are costly and difficult to manage as they must be adequately staffed on a 24/7 basis regardless of patient flow, which is unpredictable. Outsourcing the management, staffing, and billing of ER services shifts these management problems and the risk of underpayment for these services to the staffing firm or a specialty doctors' practice. Hospital emergency rooms cannot turn patients away if they lack adequate insurance coverage or any insurance at all; they must treat all patients. Emergency departments make money on ER visits of patients with commercial insurance, but lose money on those with Medicare or Medicaid, and see very high losses when patients have no insurance. [x]

Private Equity's Business Model: Its Role in Outsourcing and Consolidating Specialty Services Private equity firms have played a critical role in consolidating physicians' practices into large national staffing firms with substantial bargaining power vis-à-vis hospitals and insurance companies. They have also bought up other emergency providers, such as ambulance and medical transport services. They grow by buying up many small specialty practices and 'rolling them up' into umbrella organizations that serve healthcare systems across the United States. Mergers of large physician staffing firms to create national powerhouses have also occurred. As these companies grow in scale and scope and become the major providers of outsourced services, they have gained greater market power in their negotiations with both hospitals and insurance companies: hospitals with whom they contract to provide services and insurance companies who are responsible for paying the doctors' bills. Hospitals have consolidated in order to gain market share and negotiate higher insurance payments for procedures.

Healthcare costs have been driven up further by the dynamics associated with payments for out-of-network services. As physicians' practices merge or are bought out and rolled up by private equity firms, their ability to raise prices that patients or their insurance companies pay for these doctors' services increases. The larger the share of the market these physician staffing firms control, the greater their ability to charge high out-of-network fees. The likelihood of surprise medical bills goes up, and this is especially true when Insurance companies find few doctors with these specialties in a given region with whom they can negotiate reasonable charges for their services. The design of the private equity business model is geared to driving up the costs of patient care. Private equity funds rely on the classic leveraged buyout model (LBO) in which they use substantial debt to buyout companies (in this case specialty physician practices as well as ambulance services) because debt multiplies returns if the investment is successful. They target companies that have a steady and high cash flow so they can manage the cash in order to service the debt and make high enough returns to pay their investors 'outsized returns' that exceed the stock market. [xi]

Emergency medical practices are a perfect buyout target because demand is inelastic, that is, it does not decline when prices go up. Moreover, demand for these services is large – almost 50 percent of medical care comes from emergency room visits, according to a 2017 national study by the University of Maryland School of Medicine, and demand has steadily increased. [xii]

PE firms believe they face little or no downside market risk in these buyouts. Private-equity owned companies differ from publicly traded for-profit chains not only in their greater use of debt, but also because the private equity firm, via the general partner of the investment fund it sponsors, makes all investment decisions on behalf of the investor shareholders. Investors commit capital to a PE-sponsored fund, typically for 10 years, and have no say in investment decisions. Thus, the PE general partner's power is concentrated and largely unaccountable, as investors cannot 'exit' or sell their shares if they are dissatisfied – unlike shareholders in publicly traded corporations. [xiii]

In addition, PE firms charge their portfolio companies additional 'advisory fees' and 'transactions fees' that can amount to millions of dollars over time. And because PE owned companies are not publicly traded on the stock exchange, they are not required to file a detailed report to the Securities and Exchange Commission (SEC) the way that publicly traded companies must do. Their activities and their financial transactions are largely hidden from the public eye, despite the fact that they receive substantial taxpayer funding from Medicare and Medicaid for their services, though not for surprise charges. Two private-equity owned physician-staffing firms dominate the market for outsourced doctors' practices -- Envision Healthcare, owned by KKR with 69,300 employees, and TeamHealth owned by Blackstone Group with 20,000 employees. KKR also is a major owner (along with other private equity firms) of AirMedicalGroup Holdings -- one of the nation's three largest ambulance and air transport companies.

We also showcase private equity owned Air Methods medical transport company. These examples help illuminate how and why private equity firms have become national powerhouses in the provision of professional healthcare services and why their activities and those of other private equity firms in this sector are leading to higher healthcare costs for patients and the industry as a whole.

Envision Healthcare
Envision Healthcare today is the result of fifteen years of private equity transactions in buying up and consolidating emergency ambulance and specialty physicians' practices. It was formed in 2005 when private equity firm Onex took over two companies -- American Medical Response (AMR) and EmCare -- and merged them. In and out of private equity ownership since 2005, Envision most recently was acquired by KKR in October, 2018 in a public to private leveraged buyout worth $9.9 billion. Its sprawling organization employs tens of thousands of healthcare professionals; and it supplies doctors in 774 physician practices to hospitals and ambulatory surgical centers throughout the United States. It provides ER doctors, anesthesiologists, radiologists, hospitalists, and other specialists covering intensive care, medical, neo-natal, pediatrics, psychiatric, skilled nursing, rehabilitation, and other inpatient units.

Its outpatient ambulatory surgical arm (AMSURG) provides trauma and acute care general surgery in 260 facilities in 35 states. [xiv]

Between 2005 and 2018, Envision provided two types of emergency medical services: an ambulance and medical transport business through American Medical Response (AMR) and emergency physician staffing through EmCare Holdings.

Today, Envision focuses on physician staffing services as it sold the ambulance and transport business in a $2.4 billion leveraged buyout in 2018 to another private equity consortium that still includes KKR (as we detail below). The prior ownership patterns of AMR and EmCare were similar. American Medical Response was listed as a publicly traded company as of August 1992; and in February, 1997, it was acquired by ambulance company MedTrans, a subsidiary of Laidlaw International. At an undisclosed date between 1997 and 2005, PE firm Peak Capital invested an undisclosed amount in the company. Like AMR, EmCare Holdings was acquired by Laidlaw International in the summer of 1997 and subsequently received an undisclosed amount of investment from PE firm Peak Capital.

Emergency physician practices figured prominently among EmCare's 10 acquisitions and 17 sister physician staffing and management firms. [xv] In December 2005, just months after acquiring and merging AMR and EmCare, Onex brought Envision Healthcare to the public market via an IPO in which it retained a majority of the shares. Subsequent sales of shares left Onex with 31 percent of the company's equity at the time it was again taken private, this time by Clayton Dubilier & Rice with participation of PE firm Ardian through a $3.2 billion LBO in May 2011. An IPO in 2013 returned Envision Healthcare to the public market. The PE owners retained about two-thirds of the shares of the now-publicly traded company. The PE companies subsequently sold some of the stock. And in September 2017, two hedge funds – Starboard Value and Comex Management – took minority stakes in Envision Healthcare.

Between July 2006 and October 2018, Envision Healthcare acquired 39 companies. [xvi] Envision Healthcare bought out AMSURG in December 2016 after AMSURG failed in an attempt to acquire TeamHealth (described below). The deal brought together two seemingly complementary healthcare companies to form a single organization with pro forma market capitalization of $10 billion and an enterprise value including debt of approximately $15 billion. A little over $8 billion of this was new debt.

However, KKR contributed $5.57 billion to the deal, using $4.43 billion to retire Envision's prior liabilities and the remainder mainly as equity in the LBO.

Adding AMSURG's large chain of ambulatory surgical centers was supposed to make Envision Healthcare a dominant player across the outsourced medical services landscape – emergency room doctors, hospitalists, outpatient surgery, and ground and air ambulance. But integrating the two health care companies – with a combined 69,300 employees as of December 2017 – proved difficult for publicly traded Envision Healthcare. [xvii] Envision Healthcare appears to be extremely profitable, but its financials are murky, with no publicly available accounting of its transactions with each round of private equity buyouts. And under private equity ownership, when companies are taken private or pass from one private equity fund to another, there is no transparency.

Each private equity buyout, however, is typically accompanied by levering substantial debt on the target company, which must be serviced by managing for cash. Emergency medical services are attractive to private equity firms and are very lucrative because they throw off a lot of cash, and as noted earlier, demand is inelastic and the fees are not subject to competitive market pricing. The contracts negotiated between these physician staffing companies and hospitals also are not publicly available. Depending on how they are crafted, they may provide incentives to outsource even more ER departments, and in turn increase out-of-network billing. One Wall Street investor analysis, for example, highlights Envision's 'joint venture' model that raises serious questions.

A 2013 analysis by Deutsche Bank Securities described a 2012 joint venture between EmCare and the HCA Healthcare chain – with a history of private equity ownership between 2006 and 2011 and substantial PE ownership of shares following its 2011 IPO. HCA apparently agreed to give up directly charging for physicians' services and outsourced these services to EmCare in exchange for a 50-50 profit split once EmCare achieved a 13% margin threshold, according to the Deutsche Bank calculation. This allowed EmCare to " penetrate HCA's 160+ hospital portfolio more deeply with its physician offerings." As of 2014, EmCare valued its HCA joint venture at a net revenue of $124 million, with assets of $155 million and liabilities of $31 million, according to the company's SEC filing. The filing identified similar joint ventures with hospitals involving Evolution Health (also owned by Envision). [xviii]

Commenting on EmCare's relations with hospitals, Benedic Ippolito, a research fellow in public finance and health economics at the American Enterprise Institute, noted, "Right now, EmCare surprise bills patients and hospitals effectively turn a blind eye." [xix] Envision has come under heavy scrutiny for the huge out-of-network surprise medical bills it sends to ER patients.

A team of Yale University health economists examined the billing practices of EmCare, Envision's physician staffing arm. [xx] They found that when EmCare took over the management of emergency departments, it nearly doubled its charges for caring for patients compared to the charges billed by previous physician groups. These egregious practices have resulted in a Congressional investigation headed by Missouri Senator Claire McCaskill, lawsuits from shareholders, and court actions involving Envision and UnitedHealth Group, the largest U.S. insurer. [xxi]

TeamHealth

TeamHealth has also grown into a powerful national healthcare professional staffing company with 20,000 employees. It contracts with hospitals to provide doctors and other healthcare professionals as ER staff, anesthesiologists, hospitalists, and hospital specialists (OB/GYN, orthopedics, general surgery, pediatric services); and in post-acute care, ambulatory care, and behavioral health. [xxii] The company experienced successive rounds of private equity leveraged buyouts punctuated by IPOs that returned it to the public markets – only to be taken private again through another LBO. In 1999, private equity firms Cornerstone Equity Investors and Madison Dearborn Partners, with minority participation of Becken Petry O'Keefe and Company, acquired TeamHealth as a platform for a physician staffing company. According to PitchBook (an industry research and data firm), TeamHealth acquired an anesthesiology practice, a hospitalist company, and a health management business in its first two years. It made no further acquisitions until after it was acquired by the Blackstone Group in 2005 in a leveraged secondary buyout (in which one PE fund sells a company to another PE fund). TeamHealth made two more acquisitions between 2005 and 2009 – an emergency physician's group and a hospitalist company.

In 2009, Blackstone Group returned TeamHealth to the public market via an IPO, but retained possession of a majority of shares in the newly public company. Passage of the Affordable Care Act in 2010, with its promise of cost containment via capitated and bundled payments, spurred TeamHealth to go on a buying spree. Between 2010 and 2016, TeamHealth acquired 51 companies, mainly practices of emergency doctors and anesthesiologists and a few hospital management companies. One very large exception to this pattern was TeamHealth's 2015 acquisition of IPC Healthcare. [xxiii]

IPC Healthcare was a major hospitalist company. In its early years, it attracted four rounds of venture capital investments between 1998, when it was launched as IPC The Health Company, and 2002. In June 2002, IPC had an IPO and began its life as a publicly traded company. Between 2002 and 2009, IPC acquired 20 physician practices. Between 2010 and 2015, following passage of the ACA, it acquired 78 more. The companies acquired by IPC were overwhelmingly hospitalist companies with a smattering of doctor's practices in specialties such as geriatrics. [xxiv]

TeamHealth's acquisition of IPC in 2015 raised questions. There was no evident fit between TeamHealth's specialty physician practices and IPC's hospitalist companies. IPC was also in trouble with the Department of Justice, which in June 2014, had filed a civil lawsuit against the company for "knowingly engaging in systematic overbilling" for services billed to Medicare and Medicaid and other government health programs. Ultimately, TeamHealth paid $60 million plus interest to resolve these allegations. [xxv] This fueled speculation that TeamHealth, which had rebuffed AMSURG's attempt to acquire it, wanted this very large acquisition in order to protect itself from being taken over. TeamHealth's explanation was that it wanted IPC's expertise in participating in Medicare and Medicaid bundled payments programs. [xxvi]

In February 2017, Blackstone Group once again took TeamHealth private in a $6.1 billion leveraged buyout. Similar to Envision Healthcare, the financials of TeamHealth are murky. After many LBOs, its revenues, debt load, and financial stability remain unknown, as do the contracts it negotiates with the phyisician groups it has acquired and the hospitals it contracts with for services.

And like Envision, its billing practices are being scrutinized. The Yale researchers who investigated EmCare and found excessive use of surprise medical billing also examined TeamHealth's billing practices. They found that Blackstone owned TeamHealth has taken a somewhat different tack. It uses the threat of sending high out-of-network surprise bills for ER doctors' services to an insurance company's covered patients to gain high fees from the company as in-network doctors. In most cases, the researchers noted, TeamHealth emergency physicians would go out-of-network for a few months, then rejoin the network after bargaining for in-network payment rates that were 68 percent higher than in-network rates received by the previous ER doctors. [xxvii] While this avoids the situation of a patient getting a large, surprise medical bill for the services of ER doctors, it raises healthcare costs and premiums for everyone.

Emergency Ambulance and Air Transport Services

Emergency ambulance and air transport is also a lucrative target for private equity investment, which has fueled consolidation in this industry segment. Demand is inelastic – there is no competitive market pricing. And demand for air transport has grown considerably because many rural hospitals have closed or consolidated, leading to far longer distances for access to emergency care. Two of the three air transport companies that together control two-thirds of this US market are private equity owned – AirMedicalGroup Holdings and Air Methods. The third, PHI Air Medical, is privately owned. [xxviii]

Returning to the Envision story, recall that American Medical Response (AMR) was the ambulance service division that Envision spun off in 2018. Before the divestiture, however, AMR grew to a national powerhouse in the decade from 2007 to2017 through 12 acquisitions of ambulance and medical transport businesses and one air ambulance company7. In addition to these acquisitions, AMR has seven sister companies – mainly ambulance companies, including several air ambulance businesses. It was acquired in 2017 by air ambulance company, AirMedicalGroup Holdings (AMGH) -- owned by PE firms Ardian, Koch Equity Development, and KKR -- in a $2.4 billion leveraged buyout. With this acquisition, AirMedicalGroup now holds a leading position in emergency and medical transport across a range of transport modalities. [xxix] The acquisition merged the largest provider of ground ambulance services in the U.S. with a leading operator of medical helicopters, with over 320 locations in 38 states. [xxx] The combined entity creates the opportunity for KKR to substitute its more expensive medical helicopters for short trips previously done by AMR's ambulances. [xxxi]

Air Methods became private equity owned in 2017, when it was acquired by American Securities and Alpinvest Partners through a $2.5 billion public-to-private LBO. The company's air medical transport services operate out of over 300 bases in 48 states. [xxxii] The buyout came in response to pressure from activist hedge fund investor, J. Daniel Plants, founder of Voce Capital Management. Concerned about the bad publicity surrounding predatory charges by air ambulance companies, Plants wanted Air Methods to agree to be taken private by a PE firm in order to keep information about its billing practices out of public view. According to the hedge fund, Air Methods big price hikes created economic and political risks for the company. Going private would shield its financial documents from patients and insurers. The hedge fund was right to be concerned about Air Methods predatory billing practices. The average bill for being transported in one of its medical helicopters was $17,262 in 2009 and had risen to $40,766 in 2014. Air Methods calculates that it accounts for nearly 30 percent of total air ambulance revenue in the U.S. Its profit increased sevenfold from 2004 to 2014. [xxxiii]

In general, charges for out-of-network ambulance services are likely to be high. In the case of air ambulances, they are exceedingly high – not only due to the high costs of air travel, but especially because an estimated 69 percent of charges are out-of-network -- according to a 2017 US General Accountability Office (GAO) study of private insurance records for 2012-2017. That is, insured patients in these cases ended up being billed for most of the charge. The GAO study also found that the median price for helicopter service doubled between 2010 and 2014 – from roughly $15,000 to $30,000 per tri;p it also found that the average cost of an air ambulance trip is over $36,000. . [xxxiv] Another study by researchers at Johns Hopkins University found charges were likely to be – as they put it – sky high. The study found that air ambulance charges had risen substantially from 2012 to 2016, and in 2016 these charges ranged from 4 to 9 times higher than what Medicare paid for this service. Some of the largest providers had among the highest charges. Between 2012 and 2016, the median charge ratios (the charge divided by the Medicare rate) for the services increased by 46-61 percent. [xxxv]

Legislative Solutions

Some hospitals have attempted to solve the problem of surprise billing on their own by simply requiring all attending physicians in their hospitals to remain in-network – receiving payment from the insurance companies with whom the hospital has contracted. This has been the traditional approach used by hospitals in managed care networks. According to John Cascell, Senior Vice President of Managed Care at MemorialCare Health System in Fountain Valley, California, "Such stipulations were commonplace decades ago, but some experts say the practice slipped out of favor around 2000 as major physician staffing companies -- which tend to make more money when they're out of network -- gained market power." [xxxvi] MemorialCare, however, has retained this long-standing policy, which Cascell supports. The downside of this approach, however, is that it may shift bargaining power to insurance companies who will seek to set lower in-network payments for specialty services. In these cases, according to Cascell, MemorialCare takes a strong role in negotiating with insurance companies to maintain reasonable payments. [xxxvii]

More generally, the public, healthcare providers, insurers, and state and federal legislators recognize that individual solutions are only stop-gap measures and that no individual hospital can solve the pervasive problem of surprise medical billing on its own. Twenty-five states have passed legislation that aims to protect patients from surprise billing, but these laws do not fully cover all types of situations. Over seventy-five percent of Americans believe that the federal government should step in and protect them from surprise bills, according to a Kaufman Family Foundation April, 2019 national survey. The same survey found that 90 percent of Democrats, three-quarters of Independents, and 60 percent of Republicans favored federal legislation to protect patients. [xxxviii] Americans differ, however, in who they think should bear the costs of care. According to the Kaufman survey, about half say insurance companies alone should cover the costs of care (43 percent) while about half favor joint responsibility between providers and insurance companies (47 percent). [xxxix]

Two approaches to 'fixing' surprise medical bills have been put forward. One would benchmark the fees paid to out-of-network doctors to the negotiated fees received by in-network doctors in that region for the procedure performed or the service provided. This would have the effect of holding down health care costs by setting limits to what out-of-network physicians can charge. In the second approach, out-of-network doctors would immediately be paid a given amount by the patient's insurance company – possibly 125 percent of the Medicare payment or, alternatively, the median payment for that procedure or service in the geographic region – and could then take the insurance company to arbitration in an effort to collect the balance of the patient's bill.

The second approach has the potential to raise health care costs if arbitration panels award out-of-network doctors all or a major part of the fees they charge. This approach, which is favored by investor-owned physician staffing firms and by large physician practice groups, would further raise health care costs for consumers. Even if many of these physician practices became in-network doctors, as Envision now claims to be doing [xl] , the threat of going out-of-network remains. As the TeamHealth example illustrates, this allows physician staffing firms to negotiate high in-network rates that drive up premium costs for consumers.

In sum, there is growing concern over the pricing practices of companies like Envision, TeamHealth, AirMedicalGroup, and Air Methods -- leading emergency healthcare companies owned and operated by private equity firms. There is little oversight of the prices they charge, and evidence suggests that these companies are among those responsible for driving up health costs by taking advantage of the possibilities for surprise medical billing. But they are not alone, as private equity firms buy out medical services in specialties other than trauma and radiology and as large physician practices take a page from the PE playbook when setting fees. Reining in these charges is critical to efforts to slow the growth or even reduce health care costs.

[i] Mireya Villarreal. 2019. "Insurance Gap Leaves Patients on the Hook for Unexpected Hospital Bills." CBS News TMarch 18, 6:45 PM https://www.cbsnews.com/news/insurance-gap-leaves-patients-on-the-hook-for-unexpected-hospital-bills/ (last accessed August 17, 2019)

[ii] Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. 2019. "KFF Health Tracking Poll – April 2019: Surprise Medical Bills and Public's View of the Supreme Court and Continuing Protections for People with Pre-Existing Conditions." Figure 13. Kaufman Family Foundation. April 24. https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-april-2019/ (last accessed August 20, 2019)

[iii] Eric C. Sun, Michelle M. Mello, Jasmin Moshfegh, et al. 2019. "An Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals," American Medical Association JAMA Internal Medicine, August 12. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2740802?guestaccesskey=9fba6e0c-f029-401a-9675-737db3e67b5d&utm_source=for_the_media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=081219&alert=article (last accessed August 18, 2019)

[iv] Karen Pollitz , Matthew Rae , Gary Claxton , Cynthia Cox and Larry Levitt . 2019. "An Examination of Surprise Medical Bills and Proposals to Protect Consumers from Them." Kaiser Family Foundation . June 20. https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them/# (last accessed August 16, 2019)

[v] Elisabeth Rosenthal. 2014. "After Surgery, Surprise $117,000 Medical Bill from Doctor He Didn't Know," New York Times , September 20. https://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html ; (last accessed August 12, 2019); Sun, Mello, Moshfegh, et al. 2019.

[vi] Mark A. Marinella. 2002. "Hospitalists – Where They Came From, Who They Are, and What They Do," Hospital Physician , May.

https://pdfs.semanticscholar.org/c1a1/4f8e3e2f70489380db025235661b80d84349.pdf (last accessed July 23, 2019) ,

[vii] Zack Cooper, Fiona Scott Morton and Nathan Shekita. 2018. "Surprise! Out-of-Network Billing for Emergency Room Services in the U.S.," Yale University Working Paper , March. https://isps.yale.edu/sites/default/files/publication/2018/03/20180305_oon_paper2_tables_appendices.pdf (last accessed August 1, 2019)

[viii] Mireya Villarreal. 2019.

[ix] Beckers Hospital Review. 2013. "Outsourcing is Exploding in Healthcare -- Will the Trend Last?" October 4. https://www.beckershospitalreview.com/human-capital-and-risk/outsourcing-is-exploding-in-healthcare-will-the-trend-last.html (last accessed August 25, 2019)

[x] Zack Cooper, Fiona Scott Morton and Nathan Shekita. 2018.

[xi] For a detailed explanation of the PE business model, see Chapter 2, Eileen Appelbaum and Rosemary Batt. 2014. Private Equity at Work: When Wall Street Manages Main Street , NY: Russell Sage Foundation Press.

[xii] Jeff Lagasse. 2017. "Nearly Half of Medical Care Comes from Emergency Rooms, Study Shows."

https://www.healthcarefinancenews.com/news/nearly-half-medical-care-comes-emergency-rooms-study-shows (last accessed July 13, 2019).

[xiii] Rosemary Batt and Eileen Appelbaum. 2019. "The Agency Costs of Private Equity: Why do Limited Partners Funds Still Invest?" Academy of Management Perspectives. Forthcoming.

[xiv] Envision Physician Services. https://www.envisionphysicianservices.com/; https://www.amsurg.com/ (last accessed August 22, 2019)

[xv] PitchBook_EmCare_2019_08_10_14_18_43, EmCare Company Profile dated July 27, 2019.

[xvi] PitchBook_Envision_Healthcare_2019_08_10_16_06_31, Envision Healthcare Profile dated July 27, 2019; Brooke Sutherland. 2018. "It's the Great Health Care Buyout Shuffle," Think Advisor , June 11. https://www.thinkadvisor.com/2018/06/11/its-the-great-health-care-buyout-shuffle/?slreturn=20190710143530 (last accessed August 13, 2019)

[xvii] PitchBook. 2019. Envision Healthcare Profile dated July 27, 2019.

[xviii] Susannah Luthi. 2019. "In Battle Over Surprise Bills, Senate Ponders Requiring In-Network Rates." June 12. https://www.modernhealthcare.com/physicians/battle-over-surprise-bills-senate-ponders-requiring-network-rates (last accessed August 10, 2019).

[xix] Susannah Luthi. 2019.

[xx] Zack Cooper, Fiona Scott Morton and Nathan Shekita. 2018.

[xxi] Michael J. de la Merced. 2018. "K.K.R. Said to Be Near Deal to Acquire Envision Healthcare," New York Times , June 10. https://www.nytimes.com/2018/06/10/business/dealbook/kkr-envision-healthcare-deal.html?dlbk=&emc=edit_dk_20180611&nl=dealbook&nlid=70726928_dk_20180611&te=1 ; Shelby Livingston. 2018. "UnitedHealth Hits Back at Envision over ER Billing Practices," Modern Healthcare , March 20. http://www.modernhealthcare.com/article/20180320/NEWS/180329992 ; Senator Claire McCaskill's letter to Envision can be found here https://www.hsgac.senate.gov/imo/media/doc/2017-09-20%20CMC%20Ltr%20to%20EmCare%20re%20Pricing.pdf (last accessed August 2, 2019)

[xxii] TeamHealth. 2019. Our Company. https://www.teamhealth.com/our-company/ (last accessed August 22, 2019).

[xxiii] PitchBook. 2019. Team_Health_Holdings_2019_08_09_17_21_39, TeamHealth Holdings Company Profile dated July 27, 2019.

[xxiv] PitchBook. 2019. IPC_Healthcare_2019_08_09_17_57_38, IPC Healthcare Company Profile dated July 27, 2019.

[xxv] U.S. Attorney's Office, Northern District of Illinois. 2014. "U.S. Files Lawsuit against IPC The Hospitalist Company, Alleges Overbilling of Federal Health Insurers for Physician Services," Department of Justice , June 17. https://www.justice.gov/usao-ndil/pr/us-files-lawsuit-against-ipc-hospitalist-company-alleges-overbilling-federal-health ; M.L. McLaren. 2017. "$11M Whistleblower Award on TeamHealth $60M Overbilling Medicare & Medicaid at IPC Healthcare," Whistleblower News Review , February 27. https://www.whistleblowergov.org/healthcare-and-pharma.php?article=TeamHealth-pays-60M-on-IPC-Healthcare-Upcoding-Fraud-Whistleblower-Allegations_107 (last accessed August 19, 2019)

[xxvi] Jason Carris. 2015. "TeamHealth Announces $1.6 Billion Acquisition of IPC Healthcare," The Hospitalist , August 4. http://www.the-hospitalist.org/article/teamhealth-announces-1-6-billion-acquisition-of-ipc-healthcare/ ; Steven Ross Johnson. 2015. "Why TeamHealth Plans to Pay $1.6 billion for IPC Healthcare," Modern Healthcare , August 4. http://www.modernhealthcare.com/article/20150804/NEWS/150809978 (last accessed August 16, 2019)

[xxvii] Zack Cooper, Fiona Scott Morton, and Nathan Shekita. 2018.

[xxviii] United States Government Accountability Office. 2019. "Air Ambulance: Available Data Show Privately-Insured Patients Are at Financial Risk," GAO, March. https://www.gao.gov/assets/700 (last accessed August 25, 2019)

[xxix] PitchBook. 2019. American_Medical_Response_2019_8_10_13_21_18, American Medical Response Company Profile dated July 27, 2019.

[xxx] AirMedCare Network. 2019. https://www.airmedcarenetwork.com/coverage/ (last accessed August 22, 2019)

[xxxi] Carl O'Donnell. 2017. "Exclusive: Buyout Firm KKR in Lead to Acquire Envision's Ambulance Unit – Sources," Reuters , July 14. http://www.reuters.com/article/us-envision-healthcare-m-a-kkr-idUSKBN19X309 (last accessed July 19, 2019)

[xxxii] PitchBook. 2019. Air Methods Company Profile dated August 25, 2019.

[xxxiii] Bob Herman. 2017. "Air Methods Bought Out for $2.5 Billion," Axios , March 14. https://www.axios.com/air-methods-bought-out-for-25-billion-1513300942-29d45472-f787-4c79-9eea-7f38ae92a371.html ; Peter Eavis. 2015. "Air Ambulances Offer a Lifeline and Then a Sky-High Bill," New York Times , May5. https://www.nytimes.com/2015/05/06/business/rescued-by-an-air-ambulance-but-stunned-at-the-sky-high-bill.html?_r=0 (last accessed July 28, 2019)

[xxxiv] United States Government Accountability Office. 2019.

[xxxv] Ga Bai, Arjun Chanmugam, Valerie Y. Suslow, and Gerard F. Anderson. 2019. "Air Ambulances with Sky-High Charges," Health Affairs , July: 38(7):1195-1200. https://www.ncbi.nlm.nih.gov/pubmed/31260345 (last accessed August 19, 2019)

[xxxvi] Tara Bannow. 2019. "Hospitals' Solution to Surprise Out-Of-Network Bills: Make Physicians Go In-Network." Modern Healthcare. January 12. https://www.modernhealthcare.com/article/20190112/TRANSFORMATION04/190119990/hospitals-solution-to-surprise-out-of-network-bills-make-physicians-go-in-network (last accessed August 13, 2019)

[xxxvii] Tara Bannow. 2019.

[xxxviii] Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. 2019. Figures 10-11.

[xxxix] Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. 2019. Figures 12.

[xl] Envision's website states that it is committed to negotiating contracts for 'in-network status whenever possible.' https://www.evhc.net/endsurprisecoverage (last accessed August 20, 2019)

[Sep 04, 2019] The NY Times has an article today detailing hospitals suing patients, garnishing wages, and placing liens on property for people with "access" by way of health insurance.

Notable quotes:
"... There is shortage of doctors and nurses(?) but a surfeit of administrators and executives and managers, as it was said in The Godfather, "dipping their beaks." ..."
Sep 04, 2019 | www.nakedcapitalism.com

Jason Boxman , September 3, 2019 at 3:00 pm

Also, on "access", the NY Times has an article today detailing hospitals suing patients, garnishing wages, and placing liens on property for people with "access" by way of health insurance.

What we really need in this country is clearly _more_ access, yes?

What we should be doing is nationalizing all providers. Period. Then we can vastly reduce the number of useless healthcare executives that feed upon American citizens.

Synoia , September 3, 2019 at 3:56 pm

Need a couple of well funded lawsuits, with discovery, to illustrate the lack of disclosures amd mythical charges in Hospital billing.

John , September 3, 2019 at 4:10 pm

There is shortage of doctors and nurses(?) but a surfeit of administrators and executives and managers, as it was said in The Godfather, "dipping their beaks."

Lambert Strether Post author , September 3, 2019 at 4:44 pm

Access to Debt Collectors™ -- a winning program for liberal Democrats!

pretzelattack , September 3, 2019 at 7:33 pm

for some starving seniors, access to food would be nice. hey, maybe there's a market for food insurance, cause adding a layer of predators helps efficiency.

[Aug 30, 2019] Angry Bear Purdue Offers Up $10 12 Billion to Settle All Lawsuits MedPage Update by run75441

Aug 27, 2019 | angrybearblog.com

Just revealed:

The opioid/OxyContin maker Purdue and members of the billionaire Sackler family owning the company have offered to settle thousands of lawsuits against the company for $10 to $12 billion. according to people briefed on the offer. More than 2,000 states, cities, and counties across America are pursuing the OxyContin maker over the large bills for cleaning up the opioid crisis -- and are deciding whether to accept the offer by Friday. The Financial Times is reporting on this offer from the Sacklers and Purdue.

On August 26, Purdue paid $270 million to Oklahoma and Teva Pharmaceuticals paid $75 million also to Oklahoma.

From the Financial Times: "Purdue said it believes a 'constructive global resolution is the best way forward' and is working with state attorneys-general and other plaintiffs to achieve it. While Purdue Pharma is prepared to defend itself vigorously in the opioid litigation, the company has made clear that it sees little good coming from years of wasteful litigation and appeals".

For all the harm done to this nation due to purposeful deceit and lies on the use of opioids claiming it was not addictive, someone needs to go to prison from the Sackler family.

Purdue Exposed

Medpage Today, Kristina Fiore, August 28,2019

I suspect with the new information being available, Purdue finally threw in the towel and offered a settlement. I also suspect this will impact other companies decisions to appeal as J & J is doing.

STAT News Wins Legal Fight Over Purdue Documents

A trove of documents detailing Purdue Pharma's role in the opioid epidemic will be made public, STAT News reported, as the Kentucky Supreme Court denied the company's request to review lower courts' decisions to release them.

STAT waged a 3.5-year legal battle to make those records public. While some remain under seal, the outlet posted a sought-after video deposition of Richard Sackler. It had obtained a transcript of that deposition in February, which gained further attention when comedian John Oliver hired famous actors including Bryan Cranston and Michael Keaton to re-enact it.

The documents promise new information on how Purdue promoted its oxycodone product OxyContin and what, exactly, its executives knew about its risk of addiction. Among those documents are depositions of other Purdue executives; physician testimony; emails and memos about marketing strategies; internal reports on clinical trials; and communications about earlier legal cases.

All of the documents were part of Kentucky's lawsuit against Purdue over its alleged illegal marketing of OxyContin. That suit was settled in 2015, with Purdue shelling out $24 million.

Purdue may soon be paying a far higher bill, with media including NBC News reporting that the company has pitched a $10 to $12-billion settlement in the consolidated cases set to go to trial before a federal judge in Ohio in October.

This does not bode well for Purdue, its settlement, or threat of years of litigation. The smoking gun was always there and pieces of it can be found in previous posts of mine. Relating the US Senate Joint Committee numbers to when Oxycontin was introduced after 1995 and the incremental increase in deaths from opioids, the use of a part of the Porter and Jink letter to the NEJM which said opioids were not addictive " minus the part where it said when used in a hospital setting ," the abuse of the Porter and Jink letter in the number of citations , the millions spent in lobbying state legislatures to block new laws, etc.

John Oliver uses Keaton and Cranston to portray Richard Sackler in this 20 minute Clip. It is worth watching. " the launch (Oxycontin) would be followed by a blizzard of prescriptions that will bury the competition. The blizzard will be so deep, dense, and white,."

  1. wooley , August 28, 2019 10:19 am

    Run .I am a 30 year veteran of being a sales person and at times, a sales executive in the networking industry. What these stories reveal is a sustained effort by this company and others to sell as many pills as possible without any controls or brakes on what any responsible sales executive would notice the second his point of sale report came in showing massive amounts of sales to certain individuals or areas. There is no way I can accept that this was not under the control of both sales and marketing at this company. They made bundles of money for years on sales of these highly addictive drugs. They ignored sales to abusers of prescriptions that likely formed the basis for the addiction of millions in order to make quotas and gain bonus money. This stinks to high heaven. Some blame doctors rightly so but do not let them off the hook. A point of sale report shows exactly where all these pills are being sold and Perdue sales management decided not to give a damn.

  1. mike shupp , August 28, 2019 3:03 pm

    These people at Purdue Pharma and Teva are never going to go to prison or even face individual financial penalties -- after all, they are upper class capitalists!

    My suggestion: (1) Reflect that courts have decided that "Corporations are individuals!" And decide to punish the guilty individuals -- seize the corporations. The governments of the UK and USA ought to act to take over all assets of Purdue and Teva -- including all pharmacological products they own or have rights in. Nationalize them. Pay not one cent in compensation to stock holders. Stop paying all employees, and terminate any payments to pension funds. Cease all outgoing payments to suppliers and terminate all leases and real estate transactions.

    Then either operate the seized firms as a government operation, transfer all assets to the National Institute of Health for research purposes, or sell the real property on the open market to the highest bidder, with the purchase money being diverted to compensation of individuals unwittingly addicted to opioids. No one else should benefit from the continued existence of the guilty firms.

    (2) Alternately, state governments should feel encouraged to press for as much compensation as possible from the firms AND THEIR EXECUTIVES until all forced into complete bankruptcy.

    (3) Whichever alternative occurs, economic "experts" should recount this case and its resolution in the first chapter of any ECON 101 textbook they write, or describe the details in the first week or so of freshman/sophomore economic courses. Beginning economics students need to be made really clear about what "the Free Market" actually entails in the modern world. instead of swallowing Ayn Rand-ish fantasies.

    Sigh! To think I used to call myself a libertarian.

[Aug 29, 2019] Opiod epidemic is a a neoliberal Epidemics

Notable quotes:
"... My judgement includes findings of fact and conclusions of law that the state met its burden that the defendants Janssen and Johnson & Johnson's misleading marketing and promotion of opioids created a nuisance as defined by 50 O.S. Sec. 1 , including a finding that those actions compromised the health and safety of thousands of Oklahomans. ..."
"... Specifically, defendants caused an opioid crisis that is evidenced by increased rates of addiction, overdose deaths and neonatal abstinence syndrome in Oklahoma ..."
"... "As I just stated, the opioid crisis has ravaged the state of Oklahoma. It must be abated immediately. For this reason, I am entering an abatement plan that consists of costs totaling $572,102,028 to immediately remediate the nuisance," Balkman said. "This is the amount of costs that I am constrained to order Janssen and Johnson & Johnson to pay based on the particulars of a nuisance claim and the evidence that was presented at trial. ..."
"... Gorsky also assured Johnson & Johnson's business partners the stimulants it plans to produce will be every bit as addictive as opioids and accompanied by an equally widespread misinformation campaign. ..."
Aug 29, 2019 | www.nakedcapitalism.com

Everything went according to neoliberal dogma: Greed is good

As nondoc.com reported:

"I've opted not to read the entire 42-page judgment," Balkman told a packed courtroom in Norman shortly before announcing the numbers in his verdict. "The opioid crisis is an eminent and menace to Oklahomans.

My judgement includes findings of fact and conclusions of law that the state met its burden that the defendants Janssen and Johnson & Johnson's misleading marketing and promotion of opioids created a nuisance as defined by 50 O.S. Sec. 1 , including a finding that those actions compromised the health and safety of thousands of Oklahomans.

Specifically, defendants caused an opioid crisis that is evidenced by increased rates of addiction, overdose deaths and neonatal abstinence syndrome in Oklahoma."

Balkman said the opioid crisis is a "temporary public nuisance that can be abated."

"As I just stated, the opioid crisis has ravaged the state of Oklahoma. It must be abated immediately. For this reason, I am entering an abatement plan that consists of costs totaling $572,102,028 to immediately remediate the nuisance," Balkman said. "This is the amount of costs that I am constrained to order Janssen and Johnson & Johnson to pay based on the particulars of a nuisance claim and the evidence that was presented at trial.

"Whether additional programs and fundings are needed over an extended period of time, those are determinations to be made by our legislators and policy makers. In this moment and based on this record, this is what the court can and will do to abate the nuisance."

Balkman noted that he still has jurisdiction over the case , and that he almost certainly will be asked to make additional rulings.

"So it impossible for me to make any further statements about the trial or my ruling other than what I have said today," Balkman said.

Note that a judge, not a jury set the amount of damages to be awarded. A jury would almost certainly have awarded a higher payout by J & J (although that hypothetical amount may then have been reduced after appeal).

The amount J & J must now pay the state of Oklahoma is significantly greater than the $270 million Purdue Pharma, the manufacturer of OxyContin owned by the Sackler family, and the $85 million Teva Pharmaceuticals, separately agreed previously to settle each's respective Oklahoma claims. \

Additionally, Purdue and Teva also avoided incurring the costs of contesting a trial.


John Zelnicker , August 28, 2019 at 12:25 pm

Jerri-Lynn – Thank you for keeping us updated on the progress of these lawsuits. The pharmaceutical drug dealers need to be held accountable for the damage they have caused. The claim that OxyContin was not addictive, or less so than other opioids, was laughable to anyone who had some experience with them.

There have been three prosecutions locally of doctors who were giving out opioids like candy, even letting nurses write the scrips so the "patients" could be moved through the process more quickly.

I was a patient of one of those doctors (back problems, including surgery) for a while a couple of years before he was prosecuted, lost his license, and had to do some time in prison (IIRC). He seemed to follow most of the rules (and wrote all scrips himself), but was easily persuaded to increase a patient's dosage. Fortunately, I stopped taking opioids before things got hot.

Adam1 , August 28, 2019 at 12:39 pm

Unless it comes with several decades of jail time and confiscation of all private property obtained with ill begot gains (that's what we'd hand a major heroin dealer) then it's not a reasonable settlement.

J&J the company didn't do anything. It's just a legal, non-person thing. The criminals are the people running it and they need to be the ones held liable.

Don't get me wrong. J&J as a company needs to help fix this mess, but we can't let the real criminals slither into the night and drift off on their yachts drinking champagne bought with money taken from ruined families and communities.

PKMKII , August 28, 2019 at 12:43 pm

For context, J&J's net income for 2018 was $15.29 billion. So this particular verdict represents 3.74% of J&J's annual net income.

Annieb , August 28, 2019 at 1:37 pm

To get the full extent of Purdue's criminality, read "American Overdose." The author is Chris McGreal While reading it, I thought that this opioid epidemic began and developed in a similar fashion to the subprime mortgage fiasco with the same type of warnings, collusions and criminal fraud. Huge profits for the corporate criminals. And , tragically, the resulting human consequences, financial ruin in the one case and death in the other.

notabanktoadie , August 28, 2019 at 4:16 pm

In a healthy society, i.e. one with economic justice*, the demand for drugs would be small since there would be little need to escape reality per:

Give strong drink to him who is perishing,
And wine to him whose life is bitter.
Let him drink and forget his poverty
And remember his trouble no more.

Open your mouth for the mute,
For the rights of all the unfortunate.
Open your mouth, judge righteously,
And defend the rights of the afflicted and needy.
Proverbs 31:6-9 [bold added]

*Which certainly would not include government privileges for private credit creation, i.e. for the banks and the rich, the most so-called credit worthy of what is then, in essence, the PUBLIC'S credit but for private profit.

DonCoyote , August 28, 2019 at 4:35 pm

Johnson & Johnson Pledges To Push Uppers For Couple Decades To Even Things Out (The Onion)

Gorsky also assured Johnson & Johnson's business partners the stimulants it plans to produce will be every bit as addictive as opioids and accompanied by an equally widespread misinformation campaign.

I think they forgot to mention that that's where $544 million of the $572 million settlement will go–back to J&J to produce, market, and distribute the uppers.

[Aug 25, 2019] Pruning the tree when spring starts

Aug 25, 2019 | angrybearblog.com

run75441 | August 25, 2019 8:00 pm

Healthcare Hot Topics End of month July and Pfizer is spinning off Upjohn to generic drug/device company Mylan NV. Pfizer bought 57% of the unnamed (mid – 2020) new company. This move comes under Pfizer CEO Albert Bourla who took over the reins from Ian Read in January, 2019. Bourla has been with Pfizer for 25 years. Before becoming the CEO, Bourla was the Chief Operating Officer (COO) overseeing the company's commercial strategy, manufacturing, and global product development functions.

CEO Bourla has been making strategic moves following what he has called a "pruning the tree when spring starts and Pfizer is in the spring of high growth" strategy. What caught my eye is this one comment in the Wall Street Journal about remaking Pfizer into a company focused on patent-protected prescription medicines with the potential for significant sales growth from a more diversified but slower-growing player. To me, this translate into a; "hey the Mylan EpiPen strategy worked, lets do the same with other products" strategy.

To date, he has overseen a restructuring at the company and made smaller deals to boost Pfizer's pipeline of cancer and other drugs under development. Still not the biggest deal which would make Pfizer a giant. He has been guiding the combining of a division selling Advil, vitamins, bathroom found meds with GlaxoSmithKline PLC's own consumer-health business to be spun off in a joint venture. Nothing earth-shattering there.

CEO Bourla focus for Pfizer on higher profit, exclusive, prescription drugs while moving the rest of its lower profit operations into other ventures. Off-patent drugs such as Lipitor and Viagra having lower profit margins would be targeted for joint ventures and Pfizer would still retain sizeable amounts of cash flow from these drugs to fund R&D. Pfizer is shifting the declining brands to Upjohn. The intent is to consolidate this business with Upjohn and merge Upjohn with the EpiPen company Mylan and rename the two.

The new Pittsburgh – based unnamed company is expected to be among the world's largest sellers of generic and off-patent medicines with more than $19 billion in yearly sales. Pfizer Shareholders will own 57% of the new company and Mylan shareholders would the rest. Pfizer would be paid $12 billion raised from new debt acquired from the joint venture. Upjohn would return to the US from its corporate base in Shanghai, a reversal of its earlier inversion.

To me, this is a strategic move along the lines of Pfizer selling off the marketing of EpiPen to Mylan and keeping the manufacturing of it. Pfizer owned Meridian Medical Technologies manufactured EpiPen for Mylan and it will now be a part of the sale to Mylan. EpiPen was a huge success story for Mylan. A quadrant strategy of milking of a cash cow to fund new ventures.

Including EpiPen, " Mylan's operating profit for its Specialty segment grew from about 35% in 2012 to roughly 60% in the second quarter of 2016." Most of this can be traced back to the change in design of the EpiPen (cap) , exclusivity of it due to design changes which was covered by patents, and the rejection of Teva's generic by the FDA due to a difference in application.

Add to this strategy story, Eli Lilly's Alex Azar's success profiteering off of the decades old diabetes drug Humalog and one can begin is imagine what the new "unnamed" company's role will be under CEO Albert Bourla's direction . . . more of the same.

In its analysis, World Health Organization determined the expenditure of one dollar in R&D being covered by $14.50 profit for cancer pharmaceuticals or more than enough to recoup expenditures for R&D and provide a healthy return for investors. The generics Upjohn will acquire have more than paid back the costs of R&D and are more than likely to be in a decline in producing profits. The question then becomes how to enhance the return on these generics.

Mylan changed Pfizer's EpiPen design to achieve patented exclusivity. Teva could not duplicate it as a generic because patients could not use the Mylan instructions in applying the Teva generic. According to FDA'a rules, the Teva product could not be cast as a generic for the Mylan EpiPen in the marketplace as it could "not" be used in the same manner..

EIi Lilly's Humalog, same formulation as what was made decades ago. The list price for one vial of Humalog has nearly tripled over the last decade. No new and improved or patent changes. Lilly appears to be taking increased profits from the price changes and passing on a larger slice to Pharmaceutical Benefit Managers to gain preference by healthcare insurance plans represented by the PBMs.

The same at the other diabetes med manufacturers Sanofi and Novo. Sanofi , a diabetes drug manufacturer and competitor to Eli Lilly gave insurers and pharmacy benefit managers rebates totaling more than half of its gross sales in the U.S. last year, resulting in net price declines across its portfolio despite list price hikes taken on dozens of its prescription products.

What is occurring is "shadow pricing" increases where one company raises pricing and the others follow.

A lawsuit filed in 2017 alleged three companies ( Eli Lilly , Novo Nordisk, and Sanofi) intentionally raised the list prices on their drugs to gain favorable treatment from pharmacy benefit managers, who work with health insurers and drug makers and help decide how a drug will be covered on a list of approved drugs. Insurance companies do not pay manufacturer list pricing. The PBMs negotiate a rebate to the insurance companies from which they take a portion of it for themselves. The insured gets the net price after Rebates are paid to insurance company minus the PBM bonus for negotiated price.

It is in this circus of net profits after rebates and bonuses, I believe the Upjohn/Mylan "nameless" new company battle will be fought to increase Pfizer's profit. This is not like the EpiPen medical device where a change in design of the pen can be made and a new patent secured. Some drugs may be changed which would result in a new patent. I suspect much of Upjohn/Mylan product profit improvement will be fought by getting preference from Pharmacy Benefit Managers.

CEO Albert Bourla will be watching the new company to see how successful they are in creating preference with PBMs and the resulting profit.

https://www.youtube.com/embed/aeG2lWxYO_Y Why are our drugs so Costly? Watch the YouTube Presentation to Understand why Drugs are so Expensive to You.

[Aug 08, 2019] Free Market Drugs Are a Really Big Deal

Aug 08, 2019 | economistsview.typepad.com

anne , August 03, 2019 at 07:39 AM

http://www.socialisteconomist.com/2019/08/why-arent-democrats-talking-about.html

August 2, 2019

Big Pharma Current Affairs Dean Baker United States
Why Aren't the Democrats Talking About Ending Patent-Financed Drug Research?
By DEAN BAKER

Direct Public Funding: The Alternative to Patent Monopolies.
________________________________
It would be nice to see Democrats propose plans that would stop the government from making drugs expensive in the first place.
________________________________

Many of the leading Democratic candidates, especially Bernie Sanders and Elizabeth Warren, have been putting forward bold progressive plans in a wide variety of areas. Sanders and Warren have both supported a quick transition to a universal Medicare program, with no premiums, co-pays, or deductibles. Several candidates have supported a Green New Deal, which in some versions would guarantee every worker in the country a decent paying job.

Such policies are really big deals. They would both have a huge impact on people's lives and also pose serious problems of implementation. The willingness of Democrats to think big in other areas makes their determination to think small on prescription drugs surprising. Replacing government-granted patent monopoly financing of research is both a huge deal and one that can be implemented gradually without threatening massive disruptions in a transition process.

Free Market Drugs Are a Really Big Deal

First, it is necessary to realize that having drugs available at free market prices, without patent monopolies or other forms of exclusivity, would have an enormous impact on the economy and the health care system. On the first point, we will spend more than $460 billion on prescription drugs in 2019. Without patent protection, these drugs would almost certainly sell for less than $80 billion, implying a savings of more than $380 billion. (I go through this calculation here .)

To put this $380 billion figure in context, it is more than five times the annual food stamp budget. It is more than twice the size of the Trump tax cut. If we project out the savings over the course of a decade, they would come to more than $5 trillion. That is more than three times the amount that is projected to be needed to cover the cost of full forgiveness for outstanding student loan debt. This is more than $30,000 per household. In short, there is huge money at stake by any measure.

On the first point, we will spend more than $460 billion on prescription drugs in 2019. Without patent protection, these drugs would almost certainly sell for less than $80 billion, implying a savings of more than $380 billion.

Of course this goes well beyond a dollar and cents calculation. Millions of people facing debilitating conditions or potentially fatal diseases struggle to come up with the money needed to pay for their drugs. This often requires patients and/or their families to battle with insurance companies. The need to raise money for drugs is also now a major use of GoFundMe pages.

If the research was paid in advance, so drugs could be sold as generics, it would not be a struggle to pay for even the newest and most innovative drugs. The price of generics is often less than 1.0 percent of the cost of high-priced drugs in the United States. For example, when the Hepatitis C drug Sovaldi was selling for $50,000 in the United States, a high-quality generic version was available in India for just over $300 for a 12-week course of treatment.

There would be comparable stories for breakthrough drugs and treatments in other areas, many of which now sell for more than $100,000 a year in the United States. The most expensive now cost more than $1 million. Without government-granted patent monopolies, the prices would almost certainly be less than 1.0 percent as high, and possibly closer to 0.1 percent of the current U.S. price.

The basic story is drugs are cheap. It is rare that the manufacturing and distribution process involves major costs. Prices are a problem because of government-granted monopolies.

The patent problem goes beyond prescription drugs. It applies to medical equipment and medical tests as well. An MRI or other scan would just be a couple of hundred dollars if it was a question of covering the wear and tear on the equipment and the pay for a skilled technician to conduct the scan and a doctor to read and assess the findings. It is patent monopolies that make these scans expensive. The savings from ending reliance on patent monopolies in these other areas would probably add $100 to $150 billion annually to the total, another 1.5-2.0 multiples of the annual food stamp budget.

National Public Radio recently did a piece about a woman who had a surprise bill of $94,000 for neuromonitoring services during a surgery on her spine. The reason this process could be billed for $94,000, as opposed to perhaps one-twentieth of this amount, is that the process is patented. If the neuromonitoring system had been developed with public funds, there would be no huge bill with which to surprise patients.

In short, the main reason that so many aspects of medical care are tremendously expensive is that we give companies patent monopolies. Since they are selling items that are essential for people's health or their life, these monopolies allow them to charge outlandish prices. This is the same story as if firefighters set prices based on what it is worth to have family members rescued from burning houses. Needless to say, we would all be willing to pay lots of money in such situations, especially if we could get a third party (e.g., our insurance company or the government) to foot the bill.

Direct Public Funding: The Alternative to Patent Monopolies

The pharmaceutical industry and its supporters in Congress try to pretend that we couldn't possibly develop new drugs without the incentive of patent monopolies. For some reason we are supposed to believe that, even though in all sorts of jobs people work for money, they can only develop drugs with the prospect of getting a patent. I suppose you have to be on the pharmaceutical industry's payroll to understand this logic.

The industry's argument gets even more bizarre when we consider that it is the biggest advocate of increased funding for the National Institutes of Health (NIH). NIH and other agencies get more than $40 billion a year to do biomedical research. This money is primarily spent on basic research.

Somehow we are supposed to believe that this money is well spent, but if the government were to spend more to replace the industry's patent-supported research and clinical testing, it would be the same thing as throwing the money in the toilet. The industry's argument is especially bizarre since many important drugs have actually been developed with government funding. In addition, the NIH has supported thousands of clinical trials.

One interesting comparison is the $2.6 billion that the industry claims it costs it to develop a single drug through patent monopoly financing, with the dozens of drugs and treatments that have been developed by the Drugs for Neglected Diseases Initiative with a cumulative 15-year budget that is less than half of this amount. While there are differences that make the two efforts not strictly comparable, the comparison shows why it is difficult to take seriously the pharmaceutical industry's claims that we have the best possible system for financing research.

There is a good argument for not having all research done directly by the government, but there is no reason that it could not be contracted out to private companies who would operate under long-term contracts. The condition of getting a contract would be that all findings are posted on the internet as soon as practical and that all patentable inventions would be placed in the public domain. (As a practical matter, it would probably be desirable to "copyleft" the patents. This is discussed in somewhat more detail in chapter 5 of Rigged.)

The incentives for a company operating on a long-term contract would be to try to make a case for having a contract renewed and expanded. This would mean doing as much as possible to improve public health in the areas for which they have contracted research. This includes not just developing useful drugs, but also scientific breakthroughs that could lead others to develop useful drugs or other treatments.

Under this public funding system, they would have incentive to publicize their findings as widely as possible..

In this way, the incentives are directly at odds with the patent system. Under the patent system, companies have incentive to keep their findings secret (apart from having to disclose information to get the patent) in order to be best positioned to be able to profit from them. Under this public funding system, they would have incentive to publicize their findings as widely as possible so that they could get credit if they eventually lead to the development of a product or process with important public health benefits.

Another huge advantage of this system is that it would take away the corruption that is endemic to the system of patent-supported drug research. Patent monopolies give drug companies an enormous incentive to push their drugs as widely as possible, even when they may not be the most effective drug or have harmful side effects. Purdue Pharma would not have been pushing OxyContin so vigorously if it were selling at generic prices. While the opioid epidemic is an extreme case, drug companies exaggerate the benefits of their drugs and conceal negative side effects all the time.

Going from Patent Monopolies to Free Market Drugs

There is one other important aspect to the switch away from patent monopoly-supported research to direct public funding; it can be done piecemeal. There is no reason to deny companies the opportunity to go ahead and do research with the expectation that they will recover the costs with their patent monopolies. They just would have to worry that they will be competing with a new drug that is every bit as good, or possibly even better, selling at generic prices.

We don't even have to try to displace patent-supported research all at once. There is no reason the government can't add $4 or $5 billion to its annual spending on NIH to support the development and testing of drugs in specific areas, such as cancer or heart disease. This can allow us both to see how the effectiveness of direct funding compares to patent-supported research and also to uncover whatever problems exist with this mechanism.

Given this simple story, it is difficult to see why none of the more progressive Democratic presidential candidates have taken up the cause of ending patent-monopoly financing of prescription drug research. This failure is especially peculiar, since both Sanders and Warren (along with Senators Booker, Gillibrand, and Klobuchar) were sponsors of a bill that would provide some public funding for research that would lead to new drugs being introduced as generics.

It's great to see the candidates proposing plans that would bring down the cost of prescription drugs. It would be even better to see them propose plans that would stop the government from making them expensive in the first place.

ilsm -> anne... , August 03, 2019 at 08:40 AM
why, democrats are not talking about ending the perpetual wars.... their base in not us.

[Aug 06, 2019] Marianne Williamson suggests that the antidepressants are hugely and recklessly overused.

Notable quotes:
"... My problem is not with antidepressants per se, which clearly have and do help many people. My problem is only with their overprescription, and the practices of pharmaceutical companies when drugs are marketed in predatory ways." ..."
"... I have met hundreds of people going through hell trying to get off antidepressants that should never have been prescribed to them. I've worked with people going through normal human crises since 1983. And I have seen what has been, in many cases, the devastating effects of overprescription. ..."
Aug 06, 2019 | www.nytimes.com

In books, interviews and posts on social media, Ms. Williamson has criticized the widespread use of antidepressants ; suggested they were to blame for some celebrities' suicides ; characterized treatment guidelines for postpartum depression as a way for pharmaceutical companies to make more money ; and called the distinction between ordinary sadness and clinical depression "artificial."

How widely antidepressants should be prescribed, and under what circumstances, is a real debate among psychiatrists. But Ms. Williamson has tended to make broad arguments, suggesting that the drugs are hugely and recklessly overused. Mental health experts say comments like these can increase stigma and make people less likely to seek treatment, even if that is not the intention.

... ... ...

"I have no judgment -- nor do I believe I have ever expressed any -- of anyone taking antidepressants," she added in a text message after the interview. "I'm happy for anyone who is finding the help they need for any ailment whatsoever. My problem is not with antidepressants per se, which clearly have and do help many people. My problem is only with their overprescription, and the practices of pharmaceutical companies when drugs are marketed in predatory ways."

... ... ...

She also says she has twice received diagnoses of clinical depression, and writes:

However deep my suffering, I didn't want to be anesthetized as I went through it. Like an expectant mother who wants to give birth naturally, rejecting drugs during labor because she wants to experience "natural childbirth," I wanted to be fully available to the depths of my pain. Why? Because I knew it had something to teach me. I knew that somehow, in some way, my suffering would lead to a blazing new dawn in my life -- but only if I was willing to endure the deep, dark night preceding it.

... ... ...

I have met hundreds of people going through hell trying to get off antidepressants that should never have been prescribed to them. I've worked with people going through normal human crises since 1983. And I have seen what has been, in many cases, the devastating effects of overprescription.

That's not to say that some people do not have serious -- and by the way, I have certainly had experiences where I have said, "I think you should go see a psychiatrist." I can tell you the difference.

One is, "I'm crying because my boyfriend left," and one is someone who can't even look up. I understand the difference, and when someone is showing certain symptoms, I'm the first to say, "I think you should go see a psychiatrist."

[Aug 01, 2019] Private Equity: The Perps Behind Destructive Hospital Surprise Billing

Aug 01, 2019 | www.nakedcapitalism.com

Posted on August 1, 2019 by Yves Smith I have to confess to having missed how private equity is a central bad actor in the "surprise billing" scam that is being targeted by Federal and state legislation. This abuse takes place when hospital patients, even when using a hospital that is in their insurer's network, are hit with charges for "out of network" services that are billed at inflated rack rates. Even patients who have done everything they can to avoid being snared, like insisting their hospital use only in-network doctors for a surgery and even getting their identities in advance to assure compliance, get caught. The hospital is in charge of scheduling and can and will swap in out-of-network practitioners at the last minute.

Private equity maven and co-director of the Center for Economic and Policy Research Eileen Appelbaum explained in an editorial in The Hill in May how private equity firms have bought specialist physicians' practices to exploit the opportunity to hit vulnerable patients with egregious charges:

Physicians' groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians' practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms .

Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not operate like an ordinary marketplace. Physicians' practices in these specialties do not need to worry that they will lose patients because their prices are too high.

Patients can go to a hospital in their network, but if they have an emergency, have a baby in the neonatal intensive care unit or have surgery scheduled with an in-network surgeon, they are stuck with the out-of-network doctors the hospital has outsourced these services to .

It's not only patients that are victimized by unscrupulous physicians' groups. These doctors' groups are able to coerce health insurance companies into agreeing to pay them very high fees in order to have them in their networks.

They do this by threatening to charge high out-of-network bills to the insurers' covered patients if they don't go along with these demands. High payments to these unethical doctors raise hospitals' costs and everyone's insurance premiums.

As an example, Appelbaum cites the work of Yale economists who examined what happened when hospitals outsourced their emergency room staffing to the two biggest players, EmCare, which has been traded among several private equity firms and is now owned by KKR and TeamHealth, held by Blackstone:

.after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded.

The study also described how TeamHealth extorted insurers by threatening them with high out-of-network charges for "must have" services:

in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates.

We'd wondered why California legislation to combat surprise billing got yanked so quickly, with the opponents not even bothering to offer excuses . The official story was that hospitals objected, but the speed of the climbdown looks to have much more to do with the political clout of private equity donors.

The Financial Times yesterday made explicit how proposed Federal legislation would hit KKR's EmCare and other private equity health care predators :

A push on Capitol Hill to stop US patients from being caught unaware by medical bills is weighing on the debt of KKR-backed Envision Healthcare, the target of one of the biggest leveraged buyouts last year

Investors are concerned that a new so-called "surprise billing" law could crimp revenues at companies such as Envision, which employs emergency-room doctors and anaesthetists through its subsidiary EmCare .

"It is like a ransom negotiation: 'I'll hit your enrollees with giant bills unless you pay me enough money not to do that'," said Loren Adler, associate director at USC-Brookings Schaeffer Initiative for Health Policy.

The debt that has gone wobbly. Recall that so-called credit funds, also managed by private equity firms, are big buyers of the leveraged loans that private equity firms use to finance their acquisitions. And public pension funds like CalPERS invest in these credit funds:

Envision's $5.4bn loan due in 2025, sold in September when investor demand for leveraged loans was very strong, slid from almost 97 cents on the dollar at the start of May to just 87.8 cents on the dollar on Thursday, as more detail surrounding possible legislation has been released.

Leveraged loans for Blackstone's TeamHealth and private-equity-owned air ambulance companies Air Methods and Air Medical have also taken hits.

The normally cool-headed, pro-business Financial Times readers were almost without exception appalled: "..highway robbers .smacks of fraud sheer criminality .ambushing patients .criminals." Welcome to health care, USA style.

Sadly, the article says that while both parties are eager to be seen to be Doing Something about health care costs, neither wants to give the other side a win, making new Federal legislation unlikely in the current session. But exposing private equity as the hidden hand behind this extortion may lead to more inquisitiveness about the degree to which private equity finding and exploiting economic choke-points has contributed to the suffering.


Tom Stone , August 1, 2019 at 6:50 am

The Hospital that both my Primary Care Physician and my Cardiologist are affiliated with has outsourced their Emergency Room.
If you show up needing care RIGHT NOW, your choice is to scrawl an assent on their little I Pad or die.
I landed there twice this year, and the bills are just starting to show up from the first trip.
Fuck'em.
If I live long enough to bother I'll fight them on the basis that I signed under duress and if that doesn't fly there's Bankruptcy.

Christopher Herbert , August 1, 2019 at 7:26 am

One of the peculiarities of our wildly inefficient medical care industry is that there are so many 'pens' in the ink bottle that overhead costs eat up money that should be used to improve services.

I describe our medical care system as a '100 silos' system. The jumble is enormously expensive. We generously fund this industry, but we do not get anywhere near the benefit.

Mark , August 1, 2019 at 7:53 am

"Consent is for in-network services only and excludes out-of-network services"

Elisabeth Rosenthal in "An American Sickness" suggested that one add this statement to the consent forms one is required to sign as a strategy to inoculate oneself against this practice. I've not had an opportunity to try it and was wondering if anyone has done it and if there was a reaction or objection from the provider.

Also Mark , August 1, 2019 at 11:06 am

For years, I have written words to the effect of "All charges not covered by insurance will be paid at a rate to be negotiated" on health care providers' financial responsibility forms, and initialed the addition. I've never had a doctor's office or hospital challenge it. I think most don't even notice that I've done it.

I've also never had to invoke it, so I don't know how effective it is, but thinking I am at least somewhat protected from surprise bills gives me some comfort in the face of our crazy health care system.

By the way, I routinely cite "An American Sickness" when making the point to people that it's not just the pharmaceutical companies and the insurance companies. It's pretty much every part of the health care industry.

Elspeth , August 1, 2019 at 11:45 am

I do it, every time, you just need to smile when you do so they know you still love them.

Jim A. , August 1, 2019 at 8:31 am

Which brings up what I was thinking about during last night's debate: Insurance companies are only SOME of the profit seeking pigs chowing down at the healthcare trough. Even if we eliminate them in a "medicare for all" plan the rest of of them will gladly eat their share. It would take something more like a VA for all plan with hospitals run by the government to deal with some of the others.

jfleni , August 1, 2019 at 8:41 am

What a surprise the medical OFFAL will #### you to the max when you need help;
YAHOO, up ###, Medicare for ALL,RIGHT NOW!!! SCREAM it to your congress-critter!

Mark , August 1, 2019 at 8:41 am

Who 'yanked' the California legislation?

Their names would help voters to hold them accountable.

TBone , August 1, 2019 at 9:19 am

If this does not change in 2020 I'm moving to a civilized nation like Canada even if I have to walk there. Grrrrrr this is SO WRONG. How do retirees apply to move to Canada? Are they letting us in anymore???

TBone , August 1, 2019 at 9:23 am

Oh new plan necessay, I can't pay that much for 5 years.
https://www.sapling.com/8474864/can-retire-canada-citizen

TBone , August 1, 2019 at 9:26 am

I'm just gonna avoid the medical system forever and die at home of natural causes or go to New Jersey for assisted suicide if necessary. Thanks USA medical crapification you filthy greedy (family blog)

ambrit , August 1, 2019 at 10:14 am

Don't just crawl off to an obscure corner and expire passively. Take some Medical Industry execs with you when you go. /s?

hemeantwell , August 1, 2019 at 10:49 am

/s? = ?

ambrit , August 1, 2019 at 11:03 am

/s = ending sarcasm tag. So that s/ = beginning sarcasm tag.
/s? = ending sarcasm tag indicates real sarcasm?

Chris , August 1, 2019 at 10:03 am

Class action lawsuit against south western Ohio hospital's and surgeon for balance billing:

https://www.google.com/amp/s/www.daytondailynews.com/news/crime–law/lawsuit-filed-against-premier-health-surgeon/DSEkWli4T4RR7VKoE8VJfP/amp.html

softie , August 1, 2019 at 10:09 am

In 2012, a neighbor's kid stayed three days in the hospital when his motorcycle got him into an accident. The bill is almost half million dollars.

flora , August 1, 2019 at 10:27 am

Thanks very much for this post. This is a PE medical extortion racket, imo.

Off The Street , August 1, 2019 at 10:40 am

My plumber showed me a type of client rights form that he is required to present during various repairs. That form is essentially a mitigant against being extorted, given the potential for such behaviors during exigent circumstances. Drip, drip, drip turns into flooding, or no hot water turns into challenges with dishes and washing clothes. Now envision your elderly relative in that situation.

An unscrupulous repairman could make some extra money by exploiting such circumstances, turning a seemingly innocent service call into triple golden time toward that new Mercedes. Disclosure: phrase inspiration from an old Frasier episode.

ambrit , August 1, 2019 at 11:11 am

I once worked for such a dishonest plumbing service company, for a very short time. I was fired after I refused to do unnecessary work at a customers house so as to jack up the bill. That outfit, and another I briefly worked for later were both cases where investor syndicates had 'bought' the companies, with predictable implementation of maladaptive behaviours.
"For the love of money is the root of all evil." 1 Timothy 6:10

Susan the other` , August 1, 2019 at 11:37 am

Thank you. This is astonishing info. Because medicine is changing quicker than lumbering, conniving private equity can kludge together new extortion rackets. It almost feels like PE is running in place. And everybody is on to them thanks to info like this. Just FYI, our new hospital that claims it is a non-profit health care corporation has just built a new wing for "specialty clinics" housed on site. And of course it has been their billing practice from day one to inform you that you might receive additional bills from any of these physicians. So far this seems to be under control. We've had 4 same-day surgeries there and no big surprises. But there is obviously a reason to establish this loophole. The takeover of emergency rooms by KKR/EM Care and Blackstone Team Health is pure extortion. Extortion lurking in the wings. I hope PE rots in hell sooner than later.

Anon , August 1, 2019 at 12:14 pm

The intro to the post could have been an instant replay of my hospital experience. Reading the many comments about medical billing shenanigans is somewhat "comforting" in that my experience wasn't singular. However, it is important that more people recognize the hospital billing scam and that some doctors have never memorized the Hippocratic Oath. If today's modern medicine saves you, the medical billing will likely "kill" you.

sleepy , August 1, 2019 at 12:19 pm

Speak of the devil. Right now, I'm sitting in a clinic waiting room while my wife has minor surgery for a basal cell carcinoma. She went to a medicare advantage plan awhile back due to the high premiums of her medicare supplemental plan. She was assured everything was in her network. We'll see, I guess.

[Jun 30, 2019] Systems like the Liverpool Care Pathway may be evil enough to begin with and then they are administered by bureaucratic incompetents that insist they are doing as they are instructed while watching the patients become worse.

Jun 30, 2019 | www.zerohedge.com

OCnStiggs , 2 hours ago link

Couldn't be the British National Healthcare System now could it? You know, the one where elderly patients are wheeled on gurneys to wait out the weekend in darkened corridors with minimal attention. If they survive the weekend, they get a new room and more care. Most die a lonely death because the system has deemed them past their productive age. Only the best from Big Gubmint.

Just sayin'.

silent one , 1 hour ago link

One ploy, experienced by my mother 75, blood pressure too high so on meds to lower it, then set date of op 6 weeks in advance, take blood for testing 4 weeks before the op, turn up on day of op wait 2 hours for nurse to come and tell her the results of the blood test 4 weeks earlier indicate her sodium is to low and cancel the op, told to up the sodium and referred back to doctor, told by doctor nurse on holiday for two weeks creating a delay, 3 weeks later for blood test to decide how many salt pills to prescribe, delay for subsequent blood test, week before blood test hospital phone to say it has taken to long for the blood tests so have taken her off the waiting list and referred her back to the doctor to start the process all over again. My mother a little old lady is in a lot of pain, now talking about ending it all. THE ******* CUNTS

Mariposa de Oro , 1 hour ago link

So sorry to hear of this. I hope things get better for her. Also, is there a naturopathic doctor in the area you can take her too?

Umh , 59 minutes ago link

Incompetence has limits that can be exceeded by bureaucratic incompetence. Systems like the Liverpool Care Pathway may be evil enough to begin with and then they are administered by bureaucratic incompetents that insist they are doing as they are instructed while watching the patients become worse.

[Jun 22, 2019] 1 In 6 Insured Hospital Patients Get A Surprise Bill For Out-Of-Network Care

Notable quotes:
"... By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News . ..."
"... On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.) ..."
"... The research also found that when a patient is admitted to the hospital from the emergency room, there's a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill. ..."
"... Each time ..."
"... "but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher) deductibles and co-pays." ..."
"... inpatient stays ..."
Jun 22, 2019 | www.nakedcapitalism.com

1 In 6 Insured Hospital Patients Get A Surprise Bill For Out-Of-Network Care naked capitalism

Posted on June 22, 2019 by Lambert Strether Lambert here: But it doesn't matter. People love their health insurance companies! (And do note the role, entirely accidental I am sure, played by body shops outside staffing firms.)

By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News .

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published Thursday.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.)

The research also found that when a patient is admitted to the hospital from the emergency room, there's a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill.

"Millions of emergency visits and hospital stays left people with large employer coverage at risk of a surprise bill in 2017," the authors wrote.

The researchers got their data by analyzing large-employer claims from IBM's MarketScan Research Databases, which include claims for almost 19 million individuals.

Surprise medical bills are top of mind for American patients, with 38% reporting they were "very worried" about unexpected medical bills.

Surprise bills don't just come from the emergency room. Often, patients will pick an in-network facility and see a provider who works there but isn't employed by the hospital. These doctors, from outside staffing firms, can charge out-of-network prices.

"It's kind of a built-in problem," said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don't know whether they are being treated by an out-of-network doctor while in a hospital.

"By definition, there are these circumstances where they cannot choose their provider, whether it's an emergency or it's [a doctor] who gets brought in and they don't even meet them face-to-face."

The issue is ripe for a federal solution. Some states have surprise-bill protections in place, but those laws don't apply to most large-employer plans because the federal government regulates them.

"New York and California have very high rates of surprise bills even though they have some of the strongest state statutes," Pollitz said. "These data show why federal legislation would matter."

Consumers in Texas, New York, Florida, New Jersey and Kansas were the most likely to see a surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and Mississippi saw fewer, according to the study.

Legislative solutions are being discussed in the White House and Congress. The leaders of the Senate Health, Education, Labor and Pensions Committee introduced a package Wednesday that included a provision to address it. The legislation from HELP sets a benchmark for what out-of-network physicians will be paid, which would be an amount comparable to what the plan is paying other doctors for that service.

That bill is set for a committee markup next week.

Other remedies are also being offered by different groups of lawmakers.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

https://acdn.adnxs.com/ib/static/usersync/v3/async_usersync.html

https://c.deployads.com/sync?f=html&s=2343&u=https%3A%2F%2Fwww.nakedcapitalism.com%2F2019%2F06%2F1-in-6-insured-hospital-patients-get-a-surprise-bill-for-out-of-network-care.html

https://eus.rubiconproject.com/usync.html <img src="http://b.scorecardresearch.com/p?c1=2&c2=16807273&cv=2.0&cj=1" />


Arizona Slim , June 22, 2019 at 7:26 am

Seriously, who are these people who love their health insurance?

Pat , June 22, 2019 at 8:58 am

At this point, I am pretty sure with few exceptions the people who love their insurance are top management and or the companies that negotiate these profiteering contracts with those same insurance companies. Only the bubble beltway hasn't gotten the message. Witness all those people at the Fox Town Hall with Sanders that shocked the moderators when they asked the gotcha question about their employer health insurance.

Amfortas the hippie , June 22, 2019 at 7:55 am

""It's kind of a built-in problem," said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don't know whether they are being treated by an out-of-network doctor while in a hospital."

again no menu, no price tags, no team shirts .
it ain't a "market".

(""rational actors with perfect information" lol)

we've got around 10k in debt for the first month or so of our long emergency with cancer the period before medicaid kicked in.
some of it will get paid.
most of it will likely not(something about blood and turnips )

interestingly and apparently largely unknown is that one can get a "debt consolidation loan" for credit card, mortgage, and other "consumer" debt .but not for medical debt.
you must, instead, deal with fifty bill collectors representing many medical outfits you may have never heard of -- -imaging, labs, that guy in a white coat who walked by and looked in the door --
one of the articles of faith with the neoliberal order, is that since transactions are inherently Good, it makes sense to maximise them.
so instead of the floor doctor being employed by the hospital, itself she is employed by an LLC with an anodyne, hard to remember, name.

"It's kind of a built-in problem,"

a global economy of pickpockets.
yay.

Monty , June 22, 2019 at 10:08 am

Sounds awful. The last thing you need is extra stress at a time like that. Deepest sympathies. Here's hoping it works out for you all.

NY Geezer , June 22, 2019 at 8:20 am

The problem here is not the health insurer. It is corruption in the provision of medical services by the in network hospital that permits out of network doctor staffing agencies and doctors to perform expected medical services on its premises.

I live in the Capital district area of NY. I discovered recently that almost all the hospitals here have entered into contracts with emergency care staffing corporations for the provision of medical care. In addition, Urgent care facilities staffed by only Physician's Assistants are proliferating here. This area is apparently regarded as a good target for medical profiteers.

Pat , June 22, 2019 at 8:52 am

In a rational society, you know one where the recognizes the captive or powerless entity and provides them the protection they are denied, the hospital/medical group etc would be responsible to make sure all parities working there are in network. And by law all additional out of network charges would be theirs.

Of course in a truly enlightened and rational society we would have single payer and the government would use all its power making sure that society at all levels were healthy and well cared for when they weren't. And massive profits would be on things that were truly discretionary like private jets and yachts not on emergency care.

Bobby Gladd , June 22, 2019 at 9:29 am

In 2015 I came down with sepsis after a prostate biopsy (which turned out positive for cancer). Was admitted to John Muir hospital in Walnut Creek via the ER (I was a Muir system patient at the time). Subsequently got a bill advising that the Emergency Dept at Muir was "out of your Network" (an "independent contractor"). Eye roll.

'Nuther thing I already knew, but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher ) deductibles and co-pays.

ambrit , June 22, 2019 at 9:46 am

Ah. Now that's news I can use. As I mentioned below, I spoke to a claims adjuster yesterday concerning my bus accident. One of the questions she asked was about my eligibility for Medicare. So, the question wasn't just informational in nature. Real money is involved.
Thanks for the enlightenment.

Bobby Gladd , June 22, 2019 at 10:32 am

My late daughter was a Kaiser-Permanente member. She was admitted to a KP hospital several times during her recent Stage IV pancreatic cancer ordeal (she died 15 months ago). Each time , she had to go through the ER for admission. Even Kaiser , who owns their own hospitals, subs out their ERs to "independent contractors," which, of course, raised Danielle's co-pays and "co-insurance." The only route to admission was an 8-12 hr "triage" stint in the ER.

There's hardly any such thing as a through-the-front-door "elective admission" any more.

ambrit , June 22, 2019 at 11:02 am

That's the definition of fraud, right there.
When I was on a jury hearing a "pill mill" case from Biloxi Mississippi, we were told that one definition of a "pill mill" was when the 'patient' was required to go through, and pay for, a full doctors appointment for what was essentially a renewal of a pre-existing prescription. The mandatory "triage" endurance each time a "regular" patient was admitted for an already diagnosed condition fits this definition. Perhaps a resort to the RICO provision would be salutary.
Sorry about your daughter. I hope she 'passed' peacefully.

Bobby Gladd , June 22, 2019 at 4:26 pm

Thanks. Danielle died peacefully (6 weeks into home hospice care), but her illness was anything but.

Talk about "surprise bills," the night at the ER she decided to go into hospice care rather than do another futile admit, they insisted she come home via ambulance (subbed out to the city fire & rescue dept) -- all 1.9 miles to our house. After she died, I kept getting bills for her, one of which was about $2,500 for the ambulance ride ( "Seriously?" ). Needless to say, that did not get paid. Wish in one hand, [bleep] in the other, see which one fills up faster. She died way beyond broke, there was no "estate" to be probated or attached. Not that a host of claimants didn't repeatedly try. They all came to know Bad Bobby, who, while not a lawyer, was way ready for all of them (It wasn't my first rodeo, and I didn't want anyone BS'ing my grandson into assuming any bogus liabilities).

Cal2 , June 22, 2019 at 12:54 pm

Good to know, many of my friends are getting Medicare Part B insurance solicitations from Kaiser. Will inform them to look elsewhere. My condolences to you Sir.

Everyone needs to use things like Yelp and other rating services to make such things known to the curious public.

jake , June 22, 2019 at 4:14 pm

"but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher) deductibles and co-pays."

I don't get it. You want ER services to fall under Part B ("out patient"), because it has a relatively small deductible. And once it's satisfied, you're clear for the year.

Part A, for hospital admissions, has a much larger deductible, and it's applied per admission, not per year.

Bobby Gladd , June 22, 2019 at 5:48 pm

Well, legally, because you're not yet admitted "to the floor," it's necessarily an outpatient encounter. People just don't know that generally. You're right about the "deductible." The co-insurance is quite another matter ( apropos of both A and B). Which is why one needs a "Medi-Gap" supp. Humana Medi-gap lost their butts on me last year. In June after Danielle died I had hernia surgery, followed by open heart aortic valve replacement ("SAVR px") in late August. My OoP for the year was nil. Thank you Humana.

In a bit of irony, I'm now Kaiser, "Medicare Advantage." My OoP caps for the year at $6,700. Though, I don't expect anything major, got all my heavy lifting done in 2015 and last year.

Oh , June 22, 2019 at 9:35 am

They prey on the weak and helpless, especially the ones that go for emergency care. This is another example of hospitals not really caring for the well being of the sick. Once they capture a victim, their aim is to suck him dry.

The insurance companies are to blame too because they allow the out of network charges to occur. The insured doesn't know what service or provider is "in network". He makes a good faith attempt to go to "in network" hospitals but then the gougers take over.

ambrit , June 22, 2019 at 9:41 am

The 'attending physician' I saw during my ER sojourn after last month's bus accident was a "Body Shop Droid." The bill I received, which was the one I described earlier, the semi-threatening one, was from an "Emergency Room Physicians Management Company LLC." I have nothing to compare it to, but it came to just over $700 dollars US, for two or three 'look see's' at my battered carcass.
The ambulance "service," a properly neo-liberalized separate commercial entity, (anyone remember when ambulances were a part of the hospital apparat?,) billed me just over $1000 dollars US. I finally reached a claims adjuster for the bus companies insurance company yesterday. One of the questions she asked me, after I had established that I had been 'ambulanced' to the hospital was, how many people were transported in that one ambulance? When I quipped about 'double dipping' on the part of the ambulance "services," she laughed and said, "If you only knew."
I have still not heard from the hospital itself.

Mark , June 22, 2019 at 10:15 am

In Elisabeth Rosenthal's excellent book "An
American Sickness" she recommends adding the following statement to any consent form you sign in the hospital "Consent is limited to in-network services only and excludes out-of-network services". My wife and I carry copies of this in our wallets just in case. Haven't had occasion to try this yet and see their reaction.

Bobby Gladd , June 22, 2019 at 10:21 am

" An American Sickness ," yes, an important read.

Oh , June 22, 2019 at 12:16 pm

Yes, a well written expose.

Cal2 , June 22, 2019 at 1:07 pm

"I read 1,182 emergency room bills this year. Here's what I learned."

https://www.vox.com/health-care/2018/12/18/18134825/emergency-room-bills-health-care-costs-america

The corollary of "Someone has to pay!" is "Someone gets it for free."

What happens locally at San Franciscan General Hospital:

Undocumented person or homeless guy;
1.Get ride to hospital in ambulance.
2. Get free translator, if needed
3. Claim no I.D.
4. Get treatment.
5. Pick up free meds at pharmacy.
6. "No hope of recovery"= "Free"

American citizen with insurance
1. Walk in hospital.
2. Spend half an hour proving I have insurance.
3. Get treatment.
4. Get bill for hundreds of thousands because they "are out of network ."

https://www.vox.com/policy-and-politics/2019/1/7/18137967/er-bills-zuckerberg-san-francisco-general-hospital

A state bill is in the works to ban this. However, taxpayers will still provide free care for indigents and now, per a new state law, not only illegals in emergency rooms, but all illegals, until age 26, get full medical inpatient insurance coverage, paid by taxpayers.

https://www.nationalreview.com/news/california-to-provide-full-health-benefits-to-illegal-immigrants-under-age-26/

Joe Well , June 22, 2019 at 3:47 pm

If you have to link to the National Review to support your opinion, maybe you should rethink your opinion.

Cal2 , June 22, 2019 at 4:28 pm

E pur si muove!
https://www.sacbee.com/news/politics-government/capitol-alert/article231310348.html
Facts
https://thehill.com/homenews/state-watch/446075-california-lawmakers-vote-to-offer-health-insurance-to-undocumented
Are
https://www.sfchronicle.com/politics/article/California-will-give-health-coverage-to-13964206.php
Facts

Synoia , June 22, 2019 at 2:00 pm

I'm with Kaiser in CA.

I just send their member services this, based on the wording by Mark above.

"Kaiser Emergency Room Consent is limited to in-network services only and excludes out-of-network services."

I will post responses from Kaiser.

samhill , June 22, 2019 at 3:22 pm

Being first gen Italian I applied for Italian citizenship back before Eurolandia was consummated just in case the rules were changed. Main reason was worries over my on and off health insurance, so just to be safe. Sure enough found myself in my fifties w/o insurance, which is a seriously unwise situation, and hesitently moved to Italy. It's been rough to say the least, the country is deep in the dumps, but the health system is WONDERFUL. Yeh, everyone moans and complains about a long list of valid problems with health care here, but they have no idea the alternative. I tell everyone here to mark my words and protect what they got from the devious, erosive neo-liberal threat.

Preaching to the choir on NC but just in case anyone has doubts the positives; no financial stress to compound health stress, no corporate bureaucracy, state system is quite well streamlined, no copays if you're unemployed or poor, outweighs ALL the negatives.

dk , June 22, 2019 at 4:55 pm

I think the title is a little inaccurate, it's not 1-in-6 patients, it's 1-in-6 visits (or stays). Two visits in a year bring an individual's odds to 1-in-3, etc.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge.

Also, note "at least," aggregation removes detail.

From the study:

Even when patients were admitted to in-network facilities, though, 16% of these stays resulted in at least one out-of-network charge for a professional service.

And out-of-network charges can occur for simple services like a blood test, this recently happened to a friend. She visited a service office listed by her insurer, but the office had contracted with an out-of-network analysis lab, resulting in a non-covered $1100+ charge. Which is a bit amazing in itself, during a recent checkup (my first in 12 years) which was covered by a Medicaid plan, I inquired about the costs for my various tests, to understand affordability; how much would this or that cost if I walked in without any coverage plan? My comprehensive blood test would have cost $183, my echo-cardiogram $118. What about the hormone-level test my friend got? Under $500. All these prices are for cash up front of course, avoiding the 25%+ in interest and finance fees that a payment plan would incur.

GroundZeroAndLovinIt , June 22, 2019 at 5:05 pm

Tangentially, I just saw an anti-Medicare for All ad on TV in my market yesterday (the DC metro area), the first such I have seen. The focus of the ad was that M4A would result in long wait times for procedures; 4 weeks for a cancer consultation, 8 weeks for a kidney replacement consultation, and so on. The ad was so patently misleading it was kind of astonishing: people already wait many many weeks for medical consultations under our gloriously inefficient "excellent" healthcare system–a fact I'm sure most Americans are familiar with. I know of people with cancer diagnoses who have had to wait months to get an appointment with a specialist. So, I'm surprised that's the tack that the lobbyists would take in their "M4A will ruin everything" scary ad. That was the whole focus of the ad: wait times. Seemed like a weak tea argument to me.

flora , June 22, 2019 at 5:16 pm

In the DC metro area?
The healthcare industry spends four times as much on lobbying as the MIC.
That ad is part of the lobbying blitz, imo.

[Jun 05, 2019] Lawmakers Push To Stop Surprise ER Billing

Jun 05, 2019 | www.nakedcapitalism.com

May 30, 2019 by Yves Smith Yves here. This article is a bit fuzzier than I'd like on the details of how the proposed California legislation to bar balanced billing would work, and past failures to halt this practice says that details matter.

However, as I read this piece, the intent is make health insurance work like old-fashioned indemnity plans, at least as far as emergency room coverage is concerned. Indemnity plans were once the norm, and the insured could go to any doctor. No network, no GP gatekeeping.

The sticky part here is the patient is supposed to be on the hook for only what he'd have to pay if he went to an emergency room that was in network. That would seem to give the upper hand to the insurance companies, since the hospital has no recourse to the patient beyond his obligation for an in-network visit. The insurer sends the same reimbursement to the out-of-network hospital as it would to an in-network hospital, and washes its hands of the matter.

One downside for the insurer is that they will now be on the hook for ER bills from any hospital. So they will wind up increasing premiums as a result. But routine care, managing chronic conditions like diabetes, and scheduled surgeries still constitute the substantial majority of what those premiums are intended to cover.

By Ana B. Ibarra, Reporter for California Healthline, based in Sacramento. Previously, she covered health in California's Central Valley for the Merced Sun-Star. She is a 2015 Center for Health Journalism fellow and a Cal Poly Pomona graduate. Originally published at Kaiser Health News

California has some of the nation's strongest protections against surprise medical bills. But many Californians still get slammed with huge out-of-network charges.

State lawmakers are now trying to close gaps in the law with a bill that would limit how much hospitals outside of a patient's insurance network can charge for emergency care.

"We thought the practice of balance billing had been addressed," said state Assemblyman David Chiu (D-San Francisco), author of the bill . "Turns out there are major holes in the law potentially impacting millions of Californians with different types of insurance."

"Balance billing," better known as surprise billing, occurs when a patient receives care from a doctor or hospital -- or another provider -- outside of her insurance plan's network, and then the doctor or hospital bills the patient for the amount insurance didn't cover. These bills can soar into the tens of thousands of dollars .

Chiu's proposal would prohibit out-of-network hospitals from sending surprise bills to privately insured emergency patients. Instead, hospitals would have to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles. Hospitals are fighting the proposal, calling it a form of rate-setting.

"If we are able to move this forward in California, it could be a model and standard for what happens around the country," Chiu said of his measure, which the state Assembly is expected to consider this week.

Surprise billing is a scourge for patients around the country.

Last year , a Kaiser Family Foundation poll found that two-thirds of Americans are "very worried" or "somewhat worried" about being able to afford a surprise bill for themselves or a family member. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Health policy experts say the problem demands federal action rather than an inconsistent patchwork of state laws. And President Donald Trump has called on Congress to pass legislation this year to put a stop to surprise medical bills.

"In one swipe, the federal government can offer a universal approach in protecting consumers," said Kevin Lucia, a research professor with Georgetown University's Health Policy Institute.

Lawmakers in both the U.S. Senate and House have introduced bills to end surprise billing. But passing federal legislation promises to be an uphill battle because two influential lobbying groups -- health insurers and health providers -- have been unable to agree on a solution.

Frustrated by waiting for federal lawmakers to act, states have been trying to solve this issue. As of December 2018, 25 states offered some protection against surprise billing, and the protections in nine of those states were considered "comprehensive," according to the Commonwealth Fund . California, New York, Florida, Illinois and Connecticut are among the nine.

New state laws also have been adopted since, including in Nevada , which will limit how much out-of-network providers, including hospitals, can charge patients for emergency care, starting next year.

In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive non-emergency care.

But millions remain vulnerable, largely because California's protections don't cover all insurance plans. The California Supreme Court ruling applies to people with plans regulated by the state Department of Managed Health Care. That leaves out the roughly 1 million Californians with plans regulated by the state Department of Insurance and the nearly 6 million people with federally regulated plans, most of whom have employer-sponsored insurance.

The state law governing non-emergency care also doesn't apply to the millions of residents with health plans regulated by the federal government.

Chiu's bill attempts to close those loopholes by targeting hospitals and their billing practices. With this strategy, a patient's health plan -- and the agency that regulates it -- would not matter, explained Anthony Wright, executive director of Health Access California, a Sacramento-based advocacy group that is sponsoring the legislation.

The proposal "extends protections to a broader set of Californians," Wright said.

The California Hospital Association opposes the measure, which would limit the amount hospitals could charge insurance plans to a certain rate for each service, varying by region .

The association believes that would equate to the state setting prices, which could discourage health plans from entering contracts with hospitals, said Jan Emerson-Shea, a spokeswoman for the association.

"We fully support the provision of the bill that protects patients. It is the rate-setting piece that is our concern," she said.

Chiu said his bill was prompted by the peculiar billing practices at Zuckerberg San Francisco General Hospital spotlighted by Vox in January.

Unlike most large hospitals, San Francisco General does not contract with private insurers. Vox found that the hospital considered patients with private insurance out-of-network, and was slapping many of them with whopping bills.

Stefania Kappes-Rocha was one of them.

On April 30, 2018, Kappes-Rocha, 23, landed in San Francisco General's emergency room with a fever and intense pain in her lower right back caused by a kidney infection. A student at Hult International Business School at the time, she had a private plan through the college.

"I didn't know it at the time, but that was the problem -- that I did have insurance," Kappes-Rocha said.

She was sent home a day later with ibuprofen. About two months later, she was billed $27,767.70.

"I couldn't move because of the pain," she said. The last thing on her mind was that she'd be on the hook for the entire cost of her hospital visit.

Her insurance eventually agreed to pay about $24,000 of her bill.

"I fought back, I pressured them every week," she said. "But some people don't know they should do that."

Skewered by media reports, the hospital announced in April that it would no longer balance-bill privately insured patients.


Joe Well , May 30, 2019 at 10:21 am

I think it is "balance billing" as in "your insurer pays part and you pay the remaining outstanding balance."

Thank you so much for this article on yet another crime against the 99%!

https://en.m.wikipedia.org/wiki/Balance_billing

Cal2 , May 30, 2019 at 11:40 am

There's a reason that this state bill originated in the civic disaster that is San Francisco.

San Francisco General, now named for the billionaire, used to be an excellent public teaching hospital affiliated with the University of California. It has one of the better trauma units in California, thanks to the proximity of nearby gang turf wars and housing projects that keep it replenished with fresh gunshot wounds.

Someone has to pick up the tab for San Francisco being a magnet for the uninsured homeless and undocumented from all over the western hemisphere. All this is very expensive.

The city has a dedicated health plan for the "undocumented."
https://healthysanfrancisco.org/en/

Billions have been spent on free health care for "homeless" people.
https://www.sfchronicle.com/bayarea/heatherknight/article/Businesses-must-contribute-more-to-city-s-13178743.php

More spending coming:
https://dailycaller.com/2018/11/01/san-francisco-homeless-spending-proposition-c/

The word among some locals, third generation Americans, who grew up in the city, even those who have insurance , if they go to the emergency room, is to claim to not be insured, give a false name and social security number for emergency treatment. That idea came from refugees flushing their passport down the toilet on the plane.

Joe Well , May 30, 2019 at 12:50 pm

OK, I actually followed the link to the SF Chronicle you posted to support the claim that in SF, one city, "billions have been spent on free health care for 'homeless' (scare quotes?? why??) people."

In fact, that article does not even use the word "healthcare" and implies the exact opposite of what you claim, stating that 2.2% of a $250 million annual budget dedicating to homelessness issues was spent on "health services" for the homeless. The vast bulk of the budget went to fight evictions and keep housed people from becoming homeless. It does not discuss emergency departments at all.

You're making stuff up, not just little things, but enormous things.

Might I add, IMHO, this kind of thing is typical of conservatives, and dovetails nicely with today's post about conservative ideology dying out.

Cal2 , May 30, 2019 at 1:21 pm

You corrected my pre-coffee error. Thank you.
People that make things up don't post a contradictory URL.

"Billions have been spent on the homeless in San Francisco", is what I meant to say. Healthcare is part of that, which includes ambulance rides, fire department calls. BTW, there's lots of debate about numbers. "Billions includes housing, subsidies etc.

Why "homeless" quotes? There are actual Homeless people who have been kicked out of public housing or who simply cannot afford rents. The majority of the "homeless" in San Francisco are recently arrived who have never had a home here, move from place to place and are mostly just junkies and drug users, who would continue to be, even if given "a home."

I'm a Bernie, Medicare for All, Peace in The Middle East, free transit, tax the wealthy "conservative", glad they are coming around.

Joe Well , May 30, 2019 at 10:10 pm

You should actually read that article you linked to.

Where is your figure for the billions that were supposedly spent on the homeless in San Francisco coming from? As that article makes clear, most of the money is being spent on people who live in apartments in San Francisco, to keep them from becoming homeless. Another huge chunk is spent on people who are homeless and in precarious temporary arrangements rather than on the street. Very little is being spent on the "visible homeless" as the article calls them.

Your general impression that SF is a net economic contributor in any way to American society is absurd. It is sucking wealth out with scam companies like Uber while it is casting out lower income people to every other corner of the state and country.

If SF did take in some homeless people and provide them a few thousand dollars a year of services, that would be a drop in the bucket compared to the damage its citizens have done. But you have not provided one word of evidence that the homeless in SF have primarily come from out of town, much less out of state. Given the Bay Area's efforts to gentrify over the decades, it seems quite likely that they were formerly housed inhabitants of the city.

Cal2 , May 31, 2019 at 8:53 pm

"Your general impression that SF is a net economic contributor in any way to American society is absurd."
You must be confusing me with someone else?
I think San Francisco is a giant black hole of exorbitant social services for "homeless", illegals, and profit sucking billionaires that often pay zero local taxes. i.e. Twitter, in it's special Mid Market Resurrection Zone. All those stock options think of the savings.
Add up the money spent over the last 25 years or so on homeless and preventing homelessness and it's in the billions.
$40,000 per "homeless" person per year. With the passage of Proposition C, to go to $70,000 per year.

Here's article with per year expenditures on homeless:
https://www.sfchronicle.com/bayarea/heatherknight/article/Businesses-must-contribute-more-to-city-s-13178743.php

I grew up in San Francisco and have been involved in local politics for half a century. So where are you from? Where are you getting your numbers? Please share. We can all learn from each other.

KevinD , May 30, 2019 at 11:54 am

As long as the people making the rules are monetarily above worrying about health care costs, the rest of us will continue to get squeezed out of existence. Put some people in charge who cannot afford today's medical costs and you will see them go down. Pretty simple actually ( at least in my head)

Anon , May 30, 2019 at 1:54 pm

I have direct experience with this sort of 'balance billing'. It's not just the hospitals that do it. Doctors are a big part of the problem, too.

My doctor recommended major surgery and so we scheduled a specific time and date with the hospital. My medical insurance required the use of in network doctors. So I explained to the chief nurse (in a long discussion prior to admittance) at the in-network hospital I needed to vet ALL doctors for their network status. Actually put it in writing. (I gave them a list of the known in-network doctors affiliated with the hospital.)

Survived the surgery (as you can tell). But to my surprise a 'balance bill' appeared in the mail. Then another. What?! I don't recognize any of these people (doctors). In California the Legislature has given the State Medical Board authority over hospital operating room procedure. The medical board 'requires' three doctors to be 'present' in the operating room for certain major surgeries; they are selected by the primary surgeon. These other two doctors, whom I was never introduced to (before or after surgery) had sent me the unexpected billing (with no discussion of the medical work they performed– or not) in the mail. Of course, they were not in-network and my insurance initially refused to pay them.

Long story shortened, I was able to convince my insurance provider to pay them in-network fees. The doctors refused it, we went to court, they got nothing (zero, nada, zilch). Written record carried the day.

Hospital care in America is a wild ride. You literally need a personal advocate every minute you are in one.

Joe Well , May 30, 2019 at 10:13 pm

Congratulations on your victory and for fighting the good fight.

I have tried hard to get as much of my healthcare as possible outside the US.

I am confident that many American specialist doctors are decent people, but too many of them are clearly greedy.

wilroncanada , May 31, 2019 at 4:53 pm

Canadian specialist doctors who are REALLY greedy may stay around and join those trying to privatize our system, or they may move to the US where greed is king. We made the mistake back in the 1970s of engaging an obstetrician at a maternity hospital in Vancouver for the birth of our first two children. For our oldest he showed up seconds before the birth, leaving a me and a resident who had not done a birth before. Of course, the nurses knew exactly what to do. His fee from medicare was, I guess, being there to catch. With our second two years later, he knew exactly what might happen–my wife would race through the transition phase of labour and almost immediately into delivery. That did not matter to him, he still arrived within seconds of delivery completion.
Our third was with a GP in a different city. He was a REAL doctor, present and supportive. It didn't matter, though, because the obstetrician had moved to Texas where he could schedule caesareans around his golf game.

baldski , May 30, 2019 at 10:29 pm

I have a Medicare PPO from Humana. The hospital selected by them for emergencies is Northern Nevada. I happened to fall off my porch and hurt my arm. I went to the emergency room and was told I had a fractured elbow. Some time later Humana denied the payment for the attending doctor because he was in the group of emergency physicians that man the emergency room and were not in Humana's network. Catch-22 – The emergency room bill is in network but the doctors are not.

Calling all lawyers: Please answer.

Is this not Agency of Estoppel on Humana's part?

The Emergency Room of Northern Nevada Hospital is writ large by a large neon sign. The doctors there are contracted with Northern Nevada and practice in their facility. I contend that the doctors are agents of the hospital and Humana is denying that agency by not paying the bill. Agency of Estoppel is illegal, I was taught in my limited business law course.

Any lawyer out there please respond.

run75441 , May 31, 2019 at 10:31 pm

baldski:

What you have just described is pretty common in Texas. These doctors do not have a contract with the hospital and are usually 3rd party. Is your PPO supplemental or are you in an Advantage (BS) Plan? If you are truly in Medicare and using a Supplemental for the 20% of Part B not covered, you are safe.

If you are in an Advantage Plan I would go back to Humana and ask them to negotiate a price. Not an attorney; but, doctors are agents of the hospital whether 3rd party and contracted or employed.

Paul P , June 1, 2019 at 2:23 am

The hospital is in network, they ask for your insurance,
and then supply out of network doctors, who don't contact you to enter into a contract to provide out of network services. i don't see how a contract has been
made with these out of network doctors.

You probably signed an ABN ("I'm responsible for what
insurance does not pay."} So, that is an "I gotcha" in favor of their right to bill you. I've been crossing out their ABNs and writing I will only be responsible for what insurance pays.

run75441 , June 1, 2019 at 9:58 pm

Paul:

When you go to the ER, you get whoever comes through the door which baldski got. Again what I will say, this is happening with greater frequency and especially in Texas where a hospital contracts the ER doctors out to a 3rd party and does not negotiate the ER rates. It is like having a vendor in your hospital who is contracted to the hospital and charges whatever price. There is a term for this and it is little more than entrapment.

Janie , May 30, 2019 at 2:25 pm

Every one of us should be concerned about this. We are vulnerable, even in our homes. Ambulances take you to the nearest hospital where there is space in Emergency, not necessarily to one in your network. You may be unconscious or incoherent.

Next issue:. Ongoing care. A friend had a pancreatitis attack while on vacation. After ER, he was admitted and told he needed immediate surgery. His insurance company refused to pay for the surgery, saying he could have returned home safely. As you can imagine, the bill was a big one. Insurance never came through, and he settled with the hospital for a large amount.

Joe Well , May 30, 2019 at 10:17 pm

I think the issue with balance billing is not whether the ER is in your network. Here in Massachusetts, for instance, health plans cover every ER visit to every ER on earth. The issue is that some of the doctors provide services which are for whatever reason not considered "emergency" for the purposes of your health plan and if that doctor is out of network, you get charged for the "balance" beyond whatever small amount the plan will pay. Oftentimes the doctors are greedy sharks and pile on the charges which understandably the insurer is unwilling to pay.

The ER admission itself is only a manageable amount, about $500 when I went. It was the fees and medications that added up.

run75441 , May 31, 2019 at 10:33 pm

Joe:

As you "may" know, they are 3rd party and contracted.

Bob Hertz , May 31, 2019 at 12:54 pm

In Yves's fine piece, a spokesman for hospitals complained that the new legislation was a form of 'rate setting."

Well heck yes. When consumers are helpless and a legitimate contract is impossible, it is accepted that courts and legislatures can regulate the fees.

For that matter, Maryland has had regulated hospital charges for several decades, and I know of no crisis that has occurred nor of a hospital that went broke.

The very idea that every hospital bill for emergencies should involve attorneys and the media is grotesque. Seeiing the hospital as a greedy, grabbing institution that sets fees at $100,000 and accepts $10,000 would be considered idiotic in most nations. In Germany, a bargaining unit for all hospitals meets annually with a bargaining unit for all insurers and they set all the fees. In America, hospitals
"bargain" esssentially by financial terrorism.

run75441 , May 31, 2019 at 10:53 pm

Bob:

That is Maryland which does regulate pricing.

The other 49 states do not regulate pricing and set market rates. Places like University of Michigan hospital charge more than other generic hospitals, As hospitals consolidate, there is less competition as the most recent Commonwealth Fund funded Health Affairs study determined in their findings. Indeed from 2007 to 2014, hospital-prices for inpatient care grew 42% compared to 18 percent for physician-prices for inpatient hospital care. For hospital-based outpatient care, hospital-prices rose 25 percent compared to 6 percent for physician-prices.

If you go to a hospital with 3rd party doctors, they can balance bill you. We are not in Germany and it varies state by state what can be done.

You being an insurance guy like ME should already know this as you expound about it over at Charles Gaba's site.

[May 30, 2019] Trump: Today I'm announcing principles that should guide Congress in developing bipartisan legislation to end surprise medical billing

Notable quotes:
"... May 9 - surprise medical bills will be outlawed ..."
May 30, 2019 | www.moonofalabama.org

powerandpeople , May 29, 2019 6:45:22 PM | 8

Regarding a candidate addressing a really important domestic issue in USA, Pres. Trump has drawn the teeth (to an extent) on that one, and put the Democratic party in the position of either supporting the Republican initiative, or throwing sand in the wheels of a measure which will be very popular with the American public:

May 9 - surprise medical bills will be outlawed

"...Today I'm announcing principles that should guide Congress in developing bipartisan legislation to end surprise medical billing...we have bipartisan support, which is rather shocking..."

powerandpeople , May 29, 2019 6:49:29 PM | 9

website URL for press release info on ending surprise medical billing and provision for cheap generics

https://www.whitehouse.gov/briefings-statements/remarks-president-trump-ending-surprise-medical-billing

[May 21, 2019] CounterPunch

May 21, 2019 | www.counterpunch.org

May 20, 2019 Private Equity is a Driving Force Behind Devious Surprise Billings by Eileen Appelbaum Surprise medical bills are in the news almost daily. Last Thursday, the White House called for legislation to protect patients from getting surprise doctor bills when they are rushed to the emergency room and receive care from doctors not covered by insurance at an in-network hospital.

The financial burden on patients can be substantial -- these doctor charges can amount to hundreds or even thousands of dollars.

What's behind this explosion of outrageous charges and surprise medical bills? Physicians' groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians' practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms.

As health reporter Bob Herman observed , acquisition of these health services "exemplifies private equity firms' appetite for buying health care providers that wield a lot of market power."

Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not operate like an ordinary marketplace. Physicians' practices in these specialties do not need to worry that they will lose patients because their prices are too high.

Patients can go to a hospital in their network, but if they have an emergency, have a baby in the neonatal intensive care unit or have surgery scheduled with an in-network surgeon, they are stuck with the out-of-network doctors the hospital has outsourced these services to.

This stands in stark contrast to other health-care providers, such as primary-care physicians, who will lose patients if they are not in insurers' networks.

It's not only patients that are victimized by unscrupulous physicians' groups. These doctors' groups are able to coerce health insurance companies into agreeing to pay them very high fees in order to have them in their networks.

They do this by threatening to charge high out-of-network bills to the insurers' covered patients if they don't go along with these demands. High payments to these unethical doctors raise hospitals' costs and everyone's insurance premiums.

That's what happened when private equity-owned physician staffing firms took over hospital emergency rooms.

A 2018 study by Yale health economists looked at what happened when the two largest emergency room outsourcing companies -- EmCare and TeamHealth -- took over hospital ERs. They found:

" that after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded."

TeamHealth used the threat of sending high out-of-network bills to the insurance company's covered patients to gain high fees as in-network doctors. The researchers found:

" in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates."

What the Yale study failed to note, however, is that EmCare has been in and out of PE hands since 2005 and is currently owned by KKR. Blackstone is the once and current owner of TeamHealth, having held it from 2005 to 2009 before buying it again in 2016.

Private equity has shaped how these companies do business. In the health-care settings where they operate, market forces do not constrain the raw pursuit of profit. People desperate for care are in no position to reject over-priced medical services or shop for in-network doctors.

Private equity firms are attracted by this opportunity to reap above-market returns for themselves and their investors.

Patients hate surprise medical bills, but they are very profitable for the private equity owners of companies like EmCare (now called Envision) and TeamHealth. Fixing this problem may be more difficult than the White House imagines.

This column first appeared on The Hill .

[Feb 05, 2019] Trump and His Golfing Buddies Continue Neoliberalism s Assault on the Veteran s Administration by Lambert Strether

Notable quotes:
"... By Lambert Strether of Corrente . ..."
"... It's almost like there's a neo-liberal playbook, isn't there? No underpants gnomes , they! (1) Defund or sabotage, (2) Claim crisis, (3) Call for privatization (4) Profit! [ka-ching]. Congress underfunds the VA, then overloads it with Section 8 patients, a crisis occurs, and Obama's first response is send patients to the private system . ..."
"... Assuming that wait time is a function of resources, you can easily see how the playbook would work: (1) Reduce resources, (2) whinge about wait time, and (3) drain patients from the VA system, for profit! (Note that while Democrats are ostensibly jumping on board the #MedicareForAll train, they are, in the main, silent -- Warren and Sanders being the only notable exceptions -- about the destruction of an existing ..."
"... "This is nothing short of a steady march toward the privatization [1] of the VA," Sanders said. "It's going to happen piece by piece by piece until over a period of time there's not much in the VA to provide the quality care that our veterans deserve." ..."
"... Now, just because privatizing the Veterans Administration is a project of the political class as a whole doesn't mean that the Trump Administration hasn't brought its own special mix of corruption and buffoonery to the table. Indeed it has! Who, we might ask, were the actual factions in the Republican administration pushing for VA Mission? Three of Trump's squillionaire golfing buddies at Mar-a-Lago[2], as it all-too-believably turns out. From Pro Publica, " The Shadow Rulers of the VA ": ..."
"... The wretched excess of Trump's policy-by-golfing buddies aside, I don't see why privatiizing the Veterans Administration shouldn't become a major campaign issue, especially given Sanders' presence on the relevant committee. We send our children off to die in wars for regime change where the only winners are military contractors. ..."
Feb 03, 2019 | www.nakedcapitalism.com

February 3, 2019 By Lambert Strether of Corrente .

With the release of new proposed eligibility rules under the VA Mission Act, we see that privatization at the Veterans Administration (VA) continues to unfold, as outlined in the neoliberal playbook , to which we have alluded before:

The stories intertwine because they look like they're part of the neoliberal privatization playbook , here described in a post about America's universities:

It's almost like there's a neo-liberal playbook, isn't there? No underpants gnomes , they! (1) Defund or sabotage, (2) Claim crisis, (3) Call for privatization (4) Profit! [ka-ching]. Congress underfunds the VA, then overloads it with Section 8 patients, a crisis occurs, and Obama's first response is send patients to the private system .

Congress imposes huge unheard-of, pension requirements on the Post Office, such that it operates at a loss, and it's gradually cannibalized by private entities, whether for services or property. And charters are justified by a similar process.

(I've helpfully numbered the steps, and added 'sabotage' alongside defunding, although defunding is neoliberalism's main play, based on the ideology of austerity.)

We can see this process play out not only in public universities, public schools, the Post Office, and the TSA , but in Britain's NHS, a national treasure that the Tories are systematically and brutally dismantling .)

The political class has been trying to privatize the VA across several administrations -- " Veterans groups are angry after President Obama told them Monday that he is still considering a proposal to have treatment for service-connected injuries charged to veterans' private insurance plan" -- although it is true that the Trump administration has brought its own special brand of crassness to the project, as we shall see. As we might expect , the project has nothing to do with the wishes of veterans :

Nearly two-thirds of veterans oppose "privatizing VA hospitals and services," according to a poll released Tuesday by the Vet Voice Foundation. And some 80 percent of the veterans surveyed believe veterans "deserve their health care to be fully paid for, not vouchers which may not cover all the costs."

A plurality of veterans, or 42 percent of those surveyed, agreed with the statement that the VA "needs more doctors," according to the poll, indicating they believe the VA's problems are at least partly due to a personnel shortage [Step (1)].

Although Vet Voice is a progressive organization, the poll of 800 veterans was jointly conducted by a Democratic polling firm and a Republican one.

And the Veterans are right, because VA hospitals provide better care. Besides many anecdotes , we have this in Stars and Stripes, " Dartmouth study finds VA hospitals outperform others in same regions ":

A new study by Dartmouth College that compares Department of Veterans Affairs hospitals with other hospitals in the same regions found VA facilities often outperform others when it comes to mortality rates and patient safety.

Researchers compared performance data at VA hospitals against non-VA facilities in 121 regions. In 14 out of 15 measures, the VA performed "significantly better" than other hospitals, according to results from the study.

"We found a surprisingly high, to me, number of cases where the VA was the best hospital in the region," said Dr. William Weeks, who led the study. "Pretty rarely was it the worst hospital." "One has to wonder whether outsourcing care is the right choice if we care about veterans' outcomes," Weeks said. "The VA is, for the most part, doing at least as well as the private sector in a local setting, and pretty often are the best performers in that setting."

"One has to wonder" indeed! Be that it may, the new VA eligibility rules accelerate privatization. USA Today :

Nearly four times as many veterans could be eligible for private health care paid for by the Department of Veterans Affairs under sweeping rules the agency proposed Wednesday.

VA officials estimated the plan could increase the number of veterans eligible for private care to as many as 2.1 million – up from roughly 560,000 .

And here are the rules (apparently modeled after TriCare Prime , the military's insurance plan):

Assuming that wait time is a function of resources, you can easily see how the playbook would work: (1) Reduce resources, (2) whinge about wait time, and (3) drain patients from the VA system, for profit! (Note that while Democrats are ostensibly jumping on board the #MedicareForAll train, they are, in the main, silent -- Warren and Sanders being the only notable exceptions -- about the destruction of an existing , and highly functional, single payer system. So how do we get to this point? A previous iteration of the neoliberal playbook, of course!

* * *

Our story begins with the " hastily enacted " Veterans Choice Program of 2014 :

The program, which began in 2014, was supposed to give veterans a way around long waits in the VA. But veterans using the Choice Program still had to wait longer than allowed by law. And according to ProPublica and PolitiFact's analysis of VA data, the two companies hired to run the program [TriWest and Health Net] took almost $2 billion in fees, or about 24 percent of the companies' total program expenses .

More on those fees from Pacific Standard :

According to the agency's inspector general, the VA was paying the contractors at least $295 every time it authorized private care for a veteran. The fee was so high because the VA hurriedly launched the Choice Program as a short-term response to a crisis. Four years later, the fee never subsided -- it went up to as much as $318 per referral .. In many cases, the contractors' $295-plus processing fee for every referral was bigger than the doctor's bill for services rendered, the analysis of agency data showed.

Ka-ching! So, step (3) -- profit! -- worked out very well for TriWest and Health Net, piling up $2 billion in loot. ( Step (2) was a scandal of "35 veterans who had died while waiting for care in the Phoenix VHA system," step (1) being the usual denial of resources/sabotage). The VA Mission Act was the legislative response to Veterans Choice debacle. Naturally, it moved the privatization ball down the field. The American Prospect :

Only two of the 42 members on the House and Senate Veterans Affairs Committee opposed Mission last year , when it came up for a vote.

In other words, privatizing the Veterans Administration has strong bipartisan support. But:

One of those lawmakers, Bernie Sanders, the Vermont Democrat, reiterated his opposition to Mission in December.

"This is nothing short of a steady march toward the privatization [1] of the VA," Sanders said. "It's going to happen piece by piece by piece until over a period of time there's not much in the VA to provide the quality care that our veterans deserve."

Now, just because privatizing the Veterans Administration is a project of the political class as a whole doesn't mean that the Trump Administration hasn't brought its own special mix of corruption and buffoonery to the table. Indeed it has! Who, we might ask, were the actual factions in the Republican administration pushing for VA Mission? Three of Trump's squillionaire golfing buddies at Mar-a-Lago[2], as it all-too-believably turns out. From Pro Publica, " The Shadow Rulers of the VA ":

[Bruce Moskowitz, is a Palm Beach doctor who helps wealthy people obtain high-service "concierge" medical care] is one-third of an informal council that is exerting sweeping influence on the VA from Mar-a-Lago, President Donald Trump's private club in Palm Beach, Florida. The troika is led by Ike Perlmutter, the reclusive chairman of Marvel Entertainment, who is a longtime acquaintance of President Trump's. The third member is a lawyer named Marc Sherman. None of them has ever served in the U.S. military or government .

The arrangement is without parallel in modern presidential history.

Everything is like CalPERS.

The Federal Advisory Committee Act of 1972 provides a mechanism for agencies to consult panels of outside advisers, but such committees are subject to cost controls, public disclosure and government oversight. Other presidents have relied on unofficial "kitchen cabinets," but never before have outside advisers been so specifically assigned to one agency. During the transition, Trump handed out advisory roles to several rich associates, but they've all since faded away. The Mar-a-Lago Crowd, however, has deepened its involvement in the VA.

In September 2017, the Mar-a-Lago Crowd weighed in on the side of expanding the use of the private sector. "We think that some of the VA hospitals are delivering some specialty healthcare when they shouldn't and when referrals to private facilities or other VA centers would be a better option," Perlmutter wrote in an email to Shulkin and other officials. "Our solution is to make use of academic medical centers and medical trade groups, both of whom have offered to send review teams to the VA hospitals to help this effort."

In other words, they proposed inviting private health care executives to tell the VA which services they should outsource to private providers like themselves. It was precisely the kind of fox-in-the-henhouse scenario that the VA's defenders had warned against for years.

While it is true that the ideological ground for privatization was laid by the Koch Brothers , among others, the actual vector of tranmission, as it were, seems to have been the Mar-a-Lago crowd. There has been pushback against them, in the form of a Congressional request for a GAO investigation , and a lawsuit by veterans , but as we have seen, the neoliberal play continues to run.

* * *

The wretched excess of Trump's policy-by-golfing buddies aside, I don't see why privatiizing the Veterans Administration shouldn't become a major campaign issue, especially given Sanders' presence on the relevant committee. We send our children off to die in wars for regime change where the only winners are military contractors.

Then, when our children come home, we're going to send them into a health care system that's been as crapified as everybody else's (and that's before we get to PTSD, homelessness, and suicide). Surely a pitch along those lines would play in the heartland? If Sanders doesn't pick up the ball and run with it, Gabbard should.

NOTES

[1] More from Sanders. Common Dreams :

[SANDERS:] No one disagrees that veterans should be able to seek private care in cases where the VA cannot provide the specialized care they require, or when wait times for appointments are too long or when veterans might have to travel long distances for that care. The way to reduce wait times is to make sure that the VA is able to fill the more than 30,000 vacancies it currently has. This bill provides $5 billion for the Choice program. It provides nothing to fill the vacancies at the VA. That is wrong . My fear is that this bill will open the door to the draining, year after year, of much needed resources from the VA.

In other words, the way to solve the problem is not to take Step 1: Give the VA the resources that it needs.

[2] I continue to believe that golf play, or knowledge of golf play, should be a disqualification for high office.

[Jan 21, 2019] The Social Contract According to Elizabeth Warren

Notable quotes:
"... Uber passengers were paying only 41% of the actual cost of their trips; Uber was using these massive subsidies to undercut the fares and provide more capacity than the competitors who had to cover 100% of their costs out of passenger fares. ..."
"... Warren Supports Medicare for All Only Nominally ..."
"... Never mind that Warren can say, virtually in the same breath, that insurance companies "still make plenty of money" and "we have plenty of work to do to bring down health care spending." RomneyCare was the beta version of ObamaCare. We tried it, as a nation, starting in 2009, and here we are.[5] Is that's what Warren wants, fine, but why not simply advocate for it? ..."
"... Except, perhaps, one distinctly slanted toward insiders. " Work hard and play by the rules " is a Clintonite trope ..."
"... but only through the institutional framework of unions ..."
"... Warren's emphasis on the economic market for health "care?" (insurance companies making plenty of money ..."
"... I've long ago disabused myself of the notion that E. Warren is more than "lipstick" on the usual "pig", but it was good to have written support for that thesis and I will save it for my reference. ..."
"... Non-profit health insurance Company – https://www.democratandchronicle.com/story/money/business/2014/04/25/former-excellus-ceo-package-total-m/8155853/ The final retirement package for former Excellus BlueCross BlueShield CEO David Klein likely will exceed -- by millions -- the $12.9 million the company reported to the state in March. $29.8 Million in retirement. Non-profit for who? It's a complete misnomer and a huge problem in the discourse of healthcare. Hospitals are usually non-profits too. They non-profitly charge you $80,000 for a few stitches and some aspirin. ..."
"... The transcript could easily have been a speech by Hillary (and even delivered to Goldman Sachs if Hillary had had the foresight to realize that every speech would become known to everybody in the Internet age -- before Russiagate was leveraged into Social media banning of anti-establishment speech). ..."
"... The Eric Schmidt who took Google down the primrose part of spying on everybody. Warren is centrist. ..."
"... Warren 2020 campaign is DOA. If you want Trump for another four years go with Warren 2020. Bernie would have won. ..."
"... " Elizabeth Warren is Hillary Clinton reborn, and they're both unlikable, because they're both inauthentic scolds who suffer from hall monitor syndrome. They spent their entire lives breaking every rule they could find while awkwardly fantasizing about running every tiny detail of everyone else's lives . ..."
Jan 21, 2019 | www.nakedcapitalism.com

Posted on January 20, 2019 by Lambert Strether New America (board chair emeritus Eric Schmidt , President the aptronymic Anne-Marie Slaughter ), a nominally center-left Beltway think tank ( funding ) " took up the mission of designing a new social contract in 2007 and was the first organization [anywhere?] to frame its vision in these terms." On May 19, 2016, New America sponsored an annual conference (there was no 2017 iteration) entitled "The Next Social Contract." Elizabeth Warren, presidential contender, was invited to give the opening keynote ( transcript , whicn includes video). Warren shared a number of interesting ideas. I will quote portions of her speech, followed by brief commentary, much of it already familiar to NC readers, in an effort to situate her more firmly in the political landscape. But first, let me quote Warren's opening paragraph:

It is so good to be here with all of you. And yes I will be calling on people. Mostly those of you standing in the back. I always know why people are standing in the back. That's what teachers do.

Professional-class dominance games aside, it's evident that Warren is comfortable here. These are her people. And I would urge that, no matter what policy position she might take on the trail, these policies and this program are her "center of gravity," as it were. Push her left (or, to be fair, right) and, like a bobo doll , she will return to this upright position . So, to the text (all quotes from Warren from the transcript ). I'll start with two blunders, and then move on to more subtle material.

Warren Does Not Understand Uber's Business Model

Or, in strong form, Warren fell for Uber's propaganda.[1] Warren says:

Thank you to the New America Foundation for inviting me here today to talk about the gig economy You know, across the country, new companies are using the Internet to transform the way that Americans work, shop, socialize, vacation, look for love, talk to the doctor, get around, and track down ten foot feather boas, which is actually my latest search on Amazon .

These innovations have helped improve our lives in countless ways, reducing inefficiencies and leveraging network effects to help grow our economy. And this is real growth . The most famous example of this is probably the ride-sharing platforms in our cities. The taxi cab industry was riddled with monopolies, rents, inefficiencies. Cities limited the number of taxi licenses

Uber and Lyft, two ride-sharing platforms came onto the scene about five years ago, radically altered this model, enabling anyone with a smartphone and a car to deliver rides . The result was more rides, cheaper rides, and shorter wait times.

The ride-sharing story illustrates the promise of these new businesses. And the dangers. Uber and Lyft fought against local taxi cab rules that kept prices high and limited access to services .

And while their businesses provide workers with greater flexibility, companies like Lyft and Uber have often resisted efforts of those very same workers to try to access a greater share of the wealth that is generated from the work that they do. Their business model is, in part , dependent on extremely low wages for their drivers.

"In part" is doing rather a lot of work, there, even more than "the wealth that is generated," because NC readers know, Uber's business model is critically dependent on massive subsidies from investors, without which is would not exist as a firm. Hubert Horan (November 30, 2016):

Published financial data shows that Uber is losing more money than any startup in history and that its ability to capture customers and drivers from incumbent operators is entirely due to $2 billion in annual investor subsidies. The vast majority of media coverage presumes Uber is following the path of prominent digitally-based startups whose large initial losses transformed into strong profits within a few years.

This presumption is contradicted by Uber's actual financial results, which show no meaningful margin improvement through 2015 while the limited margin improvements achieved in 2016 can be entirely explained by Uber-imposed cutbacks to driver compensation. It is also contradicted by the fact that Uber lacks the major scale and network economies that allowed digitally-based startups to achieve rapid margin improvement.

As a private company, Uber is not required to publish financial statements, and financial statements disseminated privately are not required to be audited in accordance with generally accepted accounting principles (GAAP) or satisfy the SEC's reporting standards for public companies.

The financial tables below are based on private financial statements that Uber shared with investors that were published in the financial press on three separate occasions. The first set included data for 2012, 2013 and the first half of 2014 The second set included tables of GAAP profit data for full year 2014 and the first half of 2015 ; the third set included summary EBITAR contribution data for the first half of 2016. .

[F]or the year ending September 2015, Uber had GAAP losses of $2 billion on revenue of $1.4 billion, a negative 143% profit margin. Thus Uber's current operations depend on $2 billion in subsidies, funded out of the $13 billion in cash its investors have provided.

Uber passengers were paying only 41% of the actual cost of their trips; Uber was using these massive subsidies to undercut the fares and provide more capacity than the competitors who had to cover 100% of their costs out of passenger fares.

Many other tech startups lost money as they pursued growth and market share, but losses of this magnitude are unprecedented; in its worst-ever four quarters, in 2000, Amazon had a negative 50% margin, losing $1.4 billion on $2.8 billion in revenue, and the company responded by firing more than 15 percent of its workforce. 2015 was Uber's fifth year of operations; at that point in its history Facebook was achieving 25% profit margins.

Now, in Warren's defense, it is true that she, on May 19, 2016, could not have had the benefit of Horan's post at Naked Capitalism, which was published only on November 30, 2016. However, I quoted Horan's post at length to show the dates: The data was out there; it wasn't a secret; it only needed a staffer with a some critical thinking skills and a mandate to do the research to come to the same conclusions Horan did, and Uber's lack of profitabilty, easily accessible, is a ginormous red flag for anybody who takes the idea that Uber "generates wealth" seriously. How is it that the wonkish Warren is recommending policy based on what can only be superfical research in the trade and technical press? Should not the professor have done the reading?[2]

Warren Does Not Understand How Federal Taxation Works

The second blunder. Warren says:

First, make sure that every worker pays into Social Security, as the law has always intended. Right now, it is a challenge for someone who doesn't have an employer that automatically deducts payroll taxes to pay into Social Security. This can affect both a worker's ability to qualify for disability insurance after a major [injury], and it can result in much lower retirement benefits. If Social Security is to be fully funded for generations to come, and if all workers are to have adequate benefits, then electronic, automatic, mandatory withholding of payroll taxes must apply to everyone , gig workers, 1099 workers, and hourly employees.

It is laudable that Warren wants to bring all workers in the retirement system. But as NC readers know, Federal taxes do not "pay for" Federal spending, and hence Warren's thinking that Social Security will be "fully funded" through "payroll taxes" is a nonsense (and also reinforces incredibly destructive neoliberal austerity policies). I will not tediously rehearse MMT's approach to taxation, but will simply quote a recent tweet from Warren Mosler:

me title=

And if Mosler isn't good enough, here's John Stuart Mill on currency issuers:

me title=

Again, is it too much to ask that a professor do the reading? After all, MMT gotten plenty of traction, even in 2016. The Sanders staff, for example, could have been helpful to her .

Warren Supports Medicare for All Only Nominally

Warren is indeed a co-sponsor of Sanders' ( inadequate ) S1804. But read the following passages, and you will see #MedicareForAll not where her passion lies:

As greater wealth is generated by new technology, how can we ensure that the workers who support the economy can actually share in the wealth?

(The idea that workers "support" "the" [whose?] "economy," instead of driving or being the economy, is interesting, but let that pass.)

Warren then proceeds to lay out a number of policies to answer that question. She says:

Well, I believe we start with one simple principle. All workers, no matter where they work, no matter how they work, no matter when they work, no matter who they work for, whether they pick tomatoes or build rocket ships, all workers should have some basic protections and be able to build some economic security for themselves and their families. No worker should fall through the cracks. And here are some ideas about how to rethink and strengthen the worker's bargain.

So, she's not just laying out policy for the gig economy (the occasion of the speech); she's laying out a social contract (the topic of the speech). Picking through the next sections, here is the material on health care:

We can start by strengthening our safety net so that it catches anyone who has fallen on hard times, whether they have a formal employer or not. And there are three much-needed changes right off the bat on this.

I hate the very concept of a "safety net." Why should life be like a tightrope walk? Who wants that, except crazypants neoliberal professors, mostly tenured? She then makes recommendations for three policies, and sums up:

These three, Social Security, catastrophic insurance, and earned leave, create a safety net for income.

Hello? Medical bankruptcy ?[3] She then moves on from the "safety net" for income to benefits, which is the aegis under which she places health care:

Now, the second area of change to make is on employee benefits, both for healthcare and retirement. To make them fully portable. They belong to the worker, no matter what company or platform generates the income, they should follow that worker wherever that worker goes. And the corollary to this is that workers without formal employers should have access to the same kinds of benefits that some employees already have.

I want to be clear here. The Affordable Care Act is a big step toward addressing this problem for healthcare. Providing access for workers who don't have employer-sponsored coverage and providing a long term structure for portability. We should improve on that structure, enhancing its portability, and reducing the managerial involvement of employers.

Remember, this is a Democratic audience, and what do we get? "Portability," "access", and reduced "managerial involvement." That's about as weak as tea can possibly get, and this is a liberal Democrat audience. ("The same kinds of benefits that some employees already have." Eeesh.) But wait, you say! This speech iis in 2016, and in 2018, Warren supports #MedicareForAll! For example, " Health care: Supports the "Medicare for All" bill led by Bernie Sanders " (PBS, January 17, 2019). But notice how equivocal that support is. Quoting PBS again, Warren "called that approach 'a goal worth fighting for.'" Rather equivocal! And folliowing the link to that quote, we find it's from a speech Warren gave to Families USA's Health Action 2018 Conference :

I endorsed Bernie Sanders' Medicare for All bill because it lays out a way to give every single person in this country a guarantee of high-quality health care. Everybody is covered. Nobody goes broke because of a medical bill. No more fighting with insurance companies. This is a goal worth fighting for, and I'm in this fight all the way.

There are other approaches as well I'm glad to see us put different ideas on the table.

So, we have a gesture toward #MedicareForAll. But then, Warren, instead of going into detail about how #MedicareForAll would work, immediately backtracks and emits a welter of detail about minor fixes improvements, on the order of "portability," "access," and reduced "managerial involvement." (Different details, but still details). Then she moves on to Massachusetts. Read this, and it's clear where Warren's heart is:

Massachusetts has the highest rate of health insurance coverage in the nation. We are the healthiest state in the nation[4].

That didn't just happen because we woke up one morning and discovered that insurance companies had just started offering great coverage at a price everyone could afford.

We demanded that insurance companies live up to their side of the bargain. Every insurer participating in our exchange is required to offer plans with standard, easy-to-compare benefits and low up-front costs for families. Last year, we had the second-lowest premiums in the ACA market of any state in the country. Massachusetts insurers pay out 92% of the dollars they bring in through premiums to cover costs for beneficiaries – not to line their own pockets.

The rules are tough in Massachusetts, but the insurance companies have shown up and done the hard work of covering families in a responsible way. We have more than double the number of insurers participating on our exchanges, compared to the average across the country. They show up, they serve the people of Massachusetts, and they still make plenty of money.

Look, we still have plenty of work to do, particularly when it comes to bring down health spending, but we're proud of the system we have built in Massachusetts, and I think it shows that good policies can have a real impact on the health and well-being of hard working people across the country.

Never mind that Warren can say, virtually in the same breath, that insurance companies "still make plenty of money" and "we have plenty of work to do to bring down health care spending." RomneyCare was the beta version of ObamaCare. We tried it, as a nation, starting in 2009, and here we are.[5] Is that's what Warren wants, fine, but why not simply advocate for it?

Warren Has No Coherent Theory of Change

Except, perhaps, one distinctly slanted toward insiders. " Work hard and play by the rules " is a Clintonite trope, but let's search on "rules" and see what we come up with. More from the transcript:

But it is policy, rules and regulations, that will determine whether workers have a meaningful opportunity to share in the wealth that is generated.

Here, workers are passive , acted upon by rules, and those who create them. But Warren contradicts herself: "Lyft and Uber have often resisted efforts of those very same workers." Here, workers are active. But if workers are active in the second context, they are also active in the first! Where does Warren think change comes from? The generosity of Uber and its investors? More:

Antitrust laws and newly-created public utilities addressed the new technological revolution's tendency toward concentration and monopoly, and kept our markets competitive. Rules to prevent cheating and fraud were added to make sure that bad actors in the marketplace couldn't get a leg up over folks who played by the rules.

Note the lack of agency in "were added." Warren erases the entire Populist Movement ! She also can't seem to get her head round the idea that workers didn't necessarily play by the existing ruies in order to create new ones. And:

Workers have a right to expect our government to work for them. To set the basic rules of the game. If this country is to have a strong middle class, then we need the policies that will make that possible. That's how shared prosperity has been built in the past, and that is our way forward now. Change won't be easy. But we don't get what we don't fight for. And I believe that America's workers are worth fighting for.

Now, on the one hand, this is great. I, too, believe that "America's workers are worth fighting for." What Warren seems to lack, at the visceral level, is the idea that workers should be (self-)empowered to do the fighting (as opposed to having the professional classes pick their fights for them). Here is Warren on unions:

Every worker should have the right to organize, period. Full-time, part-time, temp workers, gig workers, contract workers, you bet.

Very good. More:

Those who provide the labor should have the right to bargain as a group with whoever controls the terms of their work .

The idea that workers themselves should control the terms of their work seems to elude Warren. This erases, for example, co-ops. More:

Government is not the only advocate on behalf of workers.

"Not the only?" Like, there are lots of others? This seems a tendentious, not to say naive, view of the role of government. More:

It was workers [here we go], bargaining through their unions [and the qualification], who helped [helped?] introduce retirement benefits, sick pay, overtime, the weekend, and a long list of other benefits, for their members and for all workers across this country. Unions helped build America's middle class, and unions will help rebuild America's middle class.

Here, at least, Warren grants workers (partial) agency, but only through the institutional framework of unions . That distorts the history. Granted, "helped introduce" is doing a lot of work, and who they were "helping" isn't entirely clear, but the history is enormously complicated. (Here again, Warren needs to do the reading.) For example, the history of the weekend long predates unions . And "bargaining through their unions" isn't the half of it. Take, for example, the Haymarket Affair . From the Illinois Labor History Society:

To understand what happened at Haymarket, it is necessary to go back to the summer of 1884 when the Federation of Organized Trades and Labor Unions, the predecessor of the American Federation of Labor, called for May 1, 1886 to be the beginning of a nationwide movement for the eight-hour day. This wasn't a particularly radical idea since both Illinois workers and federal employees were supposed to have been covered by an eight-hour day law since 1867. The problem was that the federal government failed to enforce its own law, and in Illinois, employers forced workers to sign waivers of the law as condition of employment.

Fine, "rules." Which weren't being obeyed! More from the Illinois Labor History Society:

Monday, May 3, the peaceful scene turned violent when the Chicago police attacked and killed picketing workers at the McCormick Reaper Plant at Western and Blue Island Avenues. This attack by police provoked a protest meeting which was planned for Haymarket Square on the evening of Tuesday, May 4. Very few textbooks provide a thorough explanation of the events that led to Haymarket, nor do they mention that the pro-labor mayor of Chicago, Carter Harrison, gave permission for the meeting . Most speakers failed to appear . Instead of the expected 20,000 people, fewer than 2,500 attended . The Haymarket meeting was almost over and only about two hundred people remained when they were attacked by 176 policemen carrying Winchester repeater rifles. Fielden was speaking; even Lucy and Albert Parsons had left because it was beginning to rain. Then someone, unknown to this day, threw the first dynamite bomb ever used in peacetime history of the United States. The next day martial law was declared, not just in Chicago but throughout the nation. Anti-labor governments around the world used the Chicago incident to crush local union movements.

This is how workers "helped introduce" the eight-hour day.

Yes, America's workers are "worth fighting for." But they also fight for themselves , and are fought against! Warren's theory of change -- which seems to involve people of good will "at the table" -- cannot give an account of events like Haymarket or why, in the present day, it's Uber's drivers who are also the drivers of change, and not benevolent rulemakers. Warren's views on the social contract are in great contrast to Sanders' "Not me, us."

NOTES

[1] Warren is far stronger in areas where she has developed academic expertise than in areas where she has not.

[2] Google is Google, i.e., crapified, but if Warren has retracted or changed her views on Uber, I can't find it. She was receiving good press for this speech as late as August 2017 .

[3] Oddly, bankruptcy is where Warren made her academic bones. I'm frankly baffled at her lack of full-throated advocacy on this, especially before a friendly audience.

[4] Warren, by juxtaposition, suggests that Massachusetts' health insurance coverage causes it to be "the healthiest state in the nation." This post hoc fallacy ignores, for example, demographics and the social determinants of health .

[5] Warren focuses on health insurance, not health care. I'm nothing like an expert in the Massachusetts health insurance system. However, looking at this chart , I'm seeing all the usual techniques to deny access to care: Deductibles, co-pays, out-of-network costs, and (naturally) high-deductible plans. Health care should be free at the point of delivery. Why is that so hard to understand?


Burritonomics , January 20, 2019 at 5:16 pm

I quickly went over the (188 page!) report referenced in Warren's claim that "Massachusetts has the highest rate of health insurance coverage in the nation. We are the healthiest state in the nation". It should be noted I went in with the expressed purpose of finding something to be snarky about, and I found it.

One of the metrics under "core measures" of clinical care was Preventable Hospitalizations. As it states in the report itself: "Preventable hospitalizations reflect the efficiency of a population's use of primary care and the quality of the primary health care received Preventable hospitalizations are more common among people without health insurance and often occur because of failure to treat conditions early in an outpatient setting". Wow! With such bang up health insurance in MA, one would figure they would do great on this metric. Nope! MA ranks 37th in the country. Many more such examples can be found, I'm sure.

I have a real dislike of these "who's best" lists, regardless of topic. Rarely do they (the aggregated ratings) contain insight beyond that captured by the individual metrics.

lambert strether , January 20, 2019 at 5:24 pm

Massachusetts is #1 on mortality (though they have issues with opioids). They have median US age, so it's not the enormous Boston student population. So they're doing something right, I'm just not sold it's health insurance or, more to the point, health insurers. They do have more physicians (and psychiatrists) per capita.

Joe Well , January 20, 2019 at 8:52 pm

What is "mortality" in this case? I'm curious about this because people often casually say that US health outcomes are worse than in other countries by looking at life expectancy (which I guess is not the same as mortality), and that comparison is rarely done on a state by state basis in the US.

Massachusetts is roughly tied with the other top ten states in life expectancy, which are almost all "blue" states . Worldwide, life expectancy among highly developed countries is roughly similar, within a few years of each other . The US comes out towards the bottom (no. 31), but only by about 1-3 years.

Also amazed just now to see that Asian American and Latino life expectancy are so much higher than for white and black Americans. Does anyone know anything about that? I'm really stunned.

Usually, lower life expectancy for blacks is given as evidence of inequality, but the white-black gap (about 1-2 years) is tiny compared with the black-Latino and black-Asian gap, or for that matter, the white-Latino or white-Asian gap, which are more like 5-10 years. I'm really floored by that.

In general, looking at the numbers just now has shaken my assumptions about poor US life expectancy and also racial disparities and I'm wondering if I'm misinterpreting them.

Joe Well , January 20, 2019 at 9:10 pm

Wow, you learn something new every day.

Apparently there is something called the "Hispanic Health Paradox" that has been studied intensively for over 30 years . The biggest reason seems to be much lower rates of smoking. There also seems to be a filtering effect whereby healthier people migrate to the US. Anecdotally, I'd suggest much lower rates of alcohol and drug abuse, but the article doesn't mention that.

So, why Mass. has a relatively high life expectancy could in part be due to it having one of the earliest and most aggressive anti-smoking movements. I'm guessing historically high smoking rates (up to 50% of adults in the 1950s with huge second-hand exposure) could also account for poorer health outcomes today.

BoyDownTheLane , January 21, 2019 at 12:49 am

One of my favorite pictures (the one I have not yet taken) would have been an elevated shot of the intersection at Longwood and Brookline Avenues (379–385 Brookline Ave) at noon on a clear, sunny spring day to see the murmuration of medical staff running between appointments, lunch, rounds, etc.

The intersection is surrounded by arguably some of the finest medical institutions in the Western world (Beth Israel Deaconess, Dana-Farber, Brigham & Women's (where Atul Gawande, author of the book "Better" and the whole entire concept of positive deviance, once held court), Harvard Medical School itself with its etched-in-granite entrace to the Countway Library that reads "Ars Longa, Vita Brevis", and the Harvard School of Public Health.

The murmuration of white coats may be at that moment the greatest single concentrated density of medical excellence at one time. It is easy to scoff. I've been the recipient of bad medicine myself, but also far more high-quality, life-saving medicine. But the public health movement in Massachusetts has been around for a very long time and is supported by and engrained within governmental regulations, oversight and policy. Insurance plans covering most of the state ranked, typically and for years, #'s 1, 2, 3 and more. The Healthcare Effectiveness Data and Information Systems report out results that are painstakingly gathered, audited to improve performance. It is fair to say that a major part of the intersection between computing and medicine was born and is overseen across the river in Cambridge. Organizations that collect or audit data for health plans and providers are screened, trained and certified by NCQA ( https://www.ncqa.org/about-ncqa/ ).

In addition, there are national, regional and state associations devoted to quality improvement and toi improvement of access. The National Association of Community Health Centers (those clinics funded Federally to serve the under-served for free or on a sliding scale) "works in conjunction with state and regional primary care associations, health center controlled networks and other public and private sector organizations to expand health care access to all in need." There are CHC's dotted everywhere around the country (albeit not enough of them), and there is a state association in almost every state. No one can ever be turned away from a CHC, especially for lack of ability to pay; the Federal government underwrites their care.

nothing but the truth , January 20, 2019 at 5:29 pm

govts can call force us to call toilet paper a pound, but i doubt they can make it worth a pound of sterling silver – if they pretend that they can produce any amount.

Brooklin Bridge , January 20, 2019 at 5:58 pm

Warren's emphasis on the economic market for health "care?" (insurance companies making plenty of money ) and particularly her whole rant on the superlatives of Massachusetts insurance care (that means, care for insurance companies) , increasingly neglects health and people care as the primary concern of medicine and the people who practice it.

As an average Joe, meaning not part of the medical world, I have come across a surprising number of doctors in both social circumstances as well as health issues of my own and of my extended family, where doctors have complained about the ever worsening constraints imposed on them by insurance companies. I know at least three doctors who retired early because of it and one of them talks about it being a significant problem in keeping highly qualified doctors in general practice. From ever more ridiculously short visits, to constant refusal to cover such and such a drug, to all manner of schemes to improve patients health by overseeing and controlling what the doctor does to finding ways to monitor what the patient does; what he or she takes as medicine and exactly when and how often – cutting the doctor out of the loop completely. Improve the patient experience my *ss. It's horrible and it all comes down to ever new ways to reduce coverage – to make more money.

Perhaps I'm being a little unjust, but Warren seems fine with this "system" where the gate keepers make, "plenty of money," as long as people are going in and out of doctors' offices in countable droves as if on run-away conveyer belts. I should at least allow that many of her superlative claims are accurate (or somewhat accurate) and that there is fairly wide coverage in this state but nevertheless stress that our excellent medical facilities in Boston proper are due to historical reasons and NOT to RomneyCare.

deplorado , January 20, 2019 at 5:59 pm

Thank you Lambert, for your cogent and discerning analysis as always. I've long ago disabused myself of the notion that E. Warren is more than "lipstick" on the usual "pig", but it was good to have written support for that thesis and I will save it for my reference.

What worries me more though is Sanders's bill and why he wouldn't go all the way? Would you do an analysis of that please – will really appreciate it.

Thanks!

Joe Well , January 20, 2019 at 6:10 pm

The vast majority of Massachusetts health plan providers are nonprofit HMOs so I'm baffled by the idea that they are making tons of money since legally they are not supposed to.

The most obvious difference between Mass and the rest of the country is precisely the preponderance of nonprofit health plans (it's not commonly called health insurance here) and nonprofit hospitals. The idea of for-profit health plans and hospitals freaks me out.

It's worth noting that Mass health coverage seems to have gotten worse in recent years, though I don't know how much of that is due to Obamacare. High deductibles, coinsurance, confusing in-network requirements combined with poor documentation and even poorer customer service to tell you what is in-network and what is not. I just got a surprise $370 bill for a provider that supposedly was out of network even though I had checked extensively that they were in-network. That is the first time that has ever happened to me in Mass. Not to mention the confusing and unnerving notices I got the last few months saying I was in danger of losing coverage. A great big ball of Weberian beaureaucratic stress.

bob , January 20, 2019 at 8:04 pm

Non-profit health insurance Company – https://www.democratandchronicle.com/story/money/business/2014/04/25/former-excellus-ceo-package-total-m/8155853/ The final retirement package for former Excellus BlueCross BlueShield CEO David Klein likely will exceed -- by millions -- the $12.9 million the company reported to the state in March. $29.8 Million in retirement. Non-profit for who? It's a complete misnomer and a huge problem in the discourse of healthcare. Hospitals are usually non-profits too. They non-profitly charge you $80,000 for a few stitches and some aspirin.

somecallmetim , January 20, 2019 at 10:08 pm

Health Care Economist / Professor Uwe Reinhardt used to comment that in the current system non-profit hospitals (The Sisters of Mercy, with a token nun on their board, in his telling) were subject to the same forces as for profit hospitals.

He also said Massachusetts has the only adult health care system, and the other states are all adolescents.

johnnygl , January 20, 2019 at 9:10 pm

We've got for-profit hospitals Cerberus took the caritas network. The hospitals dominate this state. The rest of us are just living here.

johnnygl , January 20, 2019 at 9:15 pm

Special thanks to the catholic church for selling such an important institution to a monster that guards the gates of the underworld.

I bet it was to cover the costs of child predator priests.

Joe Well , January 20, 2019 at 10:20 pm

Wow, I'd missed that (moved out of state, then came back). Thanks for the update. It looks like the Catholic Church (former owner of Caritas) has further enhanced its legacy in Massachusetts. However, I believe it is still true that the hospital market in Mass. is dominated by nonprofits (albeit greedy nonprofits).

And yes, hospitals and hospital chains (e.g., Partners Healthcare, which is nonprofit) pose huge challenges to managing healthcare costs in Mass. as the numerous Boston Globe investigative series attest, by using their market power to raises prices.

My concern is when the market becomes dominated by for-profit actors, the profit-seeking, which is already bad with nonprofits, becomes even worse, especially in an ultra-expensive market like Greater Boston.

Brooklin Bridge , January 20, 2019 at 6:16 pm

I should add (if my earlier comment get's posted), it's even more surprising how many doctor's seem just fine with all the negative changes being brought about by insurance companies' intrusive quest for control and I don't mean just the ones who say nothing.

That is, some doctors seem to enjoy the vestiges of the glow of community respect and honor that once went with being a doctor all while doing almost nothing other than sheep herding patients through the office in good file while staff (not the good doctor) attend to making the visit digital and storing it away in some cloud.

Tomonthebeach , January 20, 2019 at 7:07 pm

I agree with Warren Mosler that Elizabeth Warren's apparent ignorance of MMT, much less mastery of it, makes here a lame candidate in my book. She needs to get woke pretty quickly or settle for some cabinet appointment.

Anarcissie , January 20, 2019 at 10:10 pm

Is MMT now Scripture?

ChrisAtRU , January 20, 2019 at 10:22 pm

It's more important than 'scripture' it's how sovereign fiat money actually works .

Joe Well , January 20, 2019 at 10:57 pm

You don't even need MMT. When asked how the federal government can pay for something, people can just answer, "the same way we pay for military and intelligence spending." Any politician who won't say at least this is deeply suspicious.

David in Santa Cruz , January 20, 2019 at 7:40 pm

In The Unwinding , George Packer quotes Elizabeth Warren as describing her political views thusly:

"I was a Republican because I thought that those were the people who best supported markets"

I'm glad that she's out there, I'm glad that she's talking, and we need an open and transparent nomination process, but Bernie Sanders remains the only (potential) nominee who comes close to representing my views. Good piece.

emorej a hong kong , January 20, 2019 at 7:50 pm

The transcript could easily have been a speech by Hillary (and even delivered to Goldman Sachs if Hillary had had the foresight to realize that every speech would become known to everybody in the Internet age -- before Russiagate was leveraged into Social media banning of anti-establishment speech).

The speech's date (May 19 2016), was two days after Bernie won the Oregon primary by 14%, and two days before Hillary won the Washington state primary by 5%.

Synoia , January 20, 2019 at 8:07 pm

It was going to be BS directly after this:

New America (board chair emeritus Eric Schmidt

The Eric Schmidt who took Google down the primrose part of spying on everybody. Warren is centrist.

Synoia , January 20, 2019 at 8:11 pm

It was going to be BE after this phrase

New America (board chair emeritus Eric Schmidt,

The Eric Schmidt who took Google doen the path of spying on everybody. He has nothing to offer by centrist rhetoric. It would be very interesting in how much In-Q-Tel invested in Google.

flora , January 20, 2019 at 8:39 pm

Thanks for this post.
And thanks for the reminder that the 8 hour workday and the 40 hour workweek were not 'given' to workers, they were won by workers.

Matthew G. Saroff , January 20, 2019 at 9:48 pm

I made an a similar observation on my blog .

Compare these two quotes on Pharma looting.

Warren:

Giant companies may hate my Affordable Drug Manufacturing bill – but I don't work for them. The American people deserve competitive markets and fair prices. By fixing the broken generic drug market, we can bring the cost of prescriptions down.

Sanders:

If the pharmaceutical industry will not end its greed, which is literally killing Americans, then we will end it for them.

This is a not an insignificant difference

Mike Barry , January 20, 2019 at 10:30 pm

The best is the enemy of the good.

Yves Smith , January 20, 2019 at 11:17 pm

Tell me what about Warren not understanding how federal taxes work, which is fundamental to formulating sound fiscal policy and spending plans, not being serious about fixing our health care system, or praising the predatory gig economy, is "good".

RepubAnon , January 20, 2019 at 11:32 pm

On a side note: self-employed workers pay more out-of-pocket into Social Security than W-2 employees. W-2 employees only pay half the Social Security tax – employers pay the other half via a "payroll tax."

The self-employed pay both the employee's half of Social Security, and also pay a "Self-Employment tax" (the employer's half of Social Security). The logic is that if you are both employee and employer, you should pay both halves.

Yves Smith , January 21, 2019 at 12:58 am

This is thread jacking, plus an economist would point out that the employer clearly is paying a net wage that reflects his awareness that he is paying the employer side of the FICA taxes.

Ape , January 21, 2019 at 12:31 am

Or lesser of two evils? There really needs to be a good discussion again about reform versus structural change without Chait-like pretensions. The question isn't just whether we'll get there in time, but whether reform even out runs reaction. Once you take out patriotic myth, it's not obvious whethervthe good in the long term is even worth bothering with.

Glen , January 21, 2019 at 12:47 am

Warren 2020 campaign is DOA. If you want Trump for another four years go with Warren 2020. Bernie would have won.

The Rev Kev , January 20, 2019 at 11:01 pm

I can't help but think that if you are talking about the "Next Social Contract", them you should put something in there that if you have children going hungry then something has gone wrong with your society. Not being snarky here as I believe that a fundamental purpose of society is to protect those in need. An earlier society talked about 'women and children first' and they were not too far off the mark here.

She was invited to talk about the gig economy but in reading her speech I was under the impression that she wants the Federal government to underwrite the costs of workers for corporations to ensure that maybe these workers have food to eat while working for these very same corporations. I suspect that this is the thinking behind letting Amazon workers go for Federal assistance for the sheer basics of life while Amazon makes off like bandits.

No. The way to go is to enforce corporations like this pay a living wage and not to have them count on the country to make up the difference. If they start to protest, then start to talk about looking over their accounts for any discrepancies to make them back off. That's how they got Al Capone you know. Not for being a gangster but for not paying his taxes while doing so. And do the same for mobs like Uber and Lyft and all the other corporations.

BoyDownTheLane , January 21, 2019 at 12:16 am

" Elizabeth Warren is Hillary Clinton reborn, and they're both unlikable, because they're both inauthentic scolds who suffer from hall monitor syndrome. They spent their entire lives breaking every rule they could find while awkwardly fantasizing about running every tiny detail of everyone else's lives ."

http://sultanknish.blogspot.com/2019/01/why-no-one-likes-elizabeth-warren.html

Left in Wisconsin , January 21, 2019 at 12:38 am

Sigh. Nail hit squarely on head. The one thing I will say to Warren's credit is that she has learned in some specific ways that the world isn't invariably the pure meritocracy that is so instinctively part of her world view. That said, it seems clear there will always be plenty that she is simply not capable of seeing, so she will always say and support things that are just wrong. She will not be leading the revolution.

[Jan 19, 2019] Three Bernie Sanders Bills to Arrest the Highway Robbery in the Prescription Drug Market

Jan 19, 2019 | economistsview.typepad.com

anne , January 15, 2019 at 05:59 PM

https://prospect.org/article/three-bernie-sanders-bills-arrest-highway-robbery-prescription-drug-market

January 14, 2019

Three Bernie Sanders Bills to Arrest the Highway Robbery in the Prescription Drug Market
Allowing foreign imports, authorizing Medicare bargaining, or setting prices at what other nations pay -- all good options
By DEAN BAKER

The prescription drug market in the United States is an incredible mess. From an economic standpoint, everything is wrong. Drugs that would sell for a few hundred dollars in a free market often sell for tens or even hundreds of thousands of dollars because we give their manufacturers patent monopolies. This leads to the sort of distortions and inefficiency that would be expected from tariffs as high as many thousands percent.

From a heath perspective the situation is no better. The huge markups give drug companies enormous incentive to misrepresent the safety and effectiveness of their drugs and to push them for uses where they may not be appropriate. This is a big part of the story of the opioid epidemic.

Cumulatively, it is a huge deal in both economics and health. We spent more than $430 billion (2.2 percent of GDP) on prescription drugs last year. These drugs likely would have cost less than $80 billion in a free market. The difference of $350 billion is almost five times the annual federal budget for food stamps. This is real money.

This is the backdrop for three bills proposed last week by Senator Bernie Sanders, along with Representatives Elijah Cummings and Ro Khanna, to address the high and rapidly rising cost of prescription drugs. The three measures provide alternative paths for reducing drug prices.

The first one, "The Prescription Drug Price Relief Act," would end the patent monopoly for any drug that sold for a price exceeding the median price in five other major countries: Canada, the United Kingdom, France, Germany, and Japan. This would allow large savings since drug prices in these countries are roughly half as much as in the United States. Drug companies would have a choice of either lowering their prices or losing their patent monopoly.

In the latter case, the competition is likely to push the price well below the levels in the five countries. While these nations do regulate drug prices, patent monopolies still let the companies charge a price that is far higher than the price that would exist in a competitive market with generic competition.

The second bill is "The Medicare Drug Price Negotiation Act." This bill would allow Medicare to negotiate collectively for the drugs purchased through Medicare prescription drug insurance. Since this program spends roughly $100 billion annually on drugs, it should have serious bargaining power.

Anyone designing a rational drug insurance program would have required negotiation when the program was created, but rational design was not necessarily the top priority at the time this program was enacted.

Anyone designing a rational drug insurance program would have required negotiation when the program was created, but rational design was not necessarily the top priority at the time this program was enacted. Representative Billy Tauzin, who headed the Energy and Commerce Committee, which structured the Medicare prescription drug legislation, resigned immediately after the bill was signed into law to become head of the pharmaceutical industry's trade association.

The third bill, "The Affordable and Safe Prescription Drug Importation Act," is also an effort to take advantage of the fact that drugs are so much cheaper in other countries than in the United States. This bill would allow people to freely import drugs from other wealthy countries that have safety standards that are comparable to those in the United States.

This bill both highlights the sharp differences in prices between the United States and other countries and calls out one of the big lies used to justify these differences. Allies of the drug industry often claim that we cannot count on getting safe drugs from other countries, implying that countries like Canada and Germany do not protect their populations from unsafe drugs.

This is, of course, absurd. The standards in these countries are every bit as high as in the United States. And, if we think the quality of imported drugs is a problem, we all should already be very worried because many of the drugs and ingredients in drugs sold in the United States are already imported, largely from China. So the idea that we can't be assured of the safety of imported drugs is simply an industry talking point, not a real concern.

Which of these paths for reducing drug costs is best? Importation is probably the most far-reaching, since it should quickly bring our prices down to the level of other wealthy countries. As a practical matter, however, progressives should back anything that moves the debate forward.

We really need to turn the industry on its head, paying for research upfront and then having drugs sold in a free market, like paper plates and shovels. It is absurd to pay for research that has already been done, at the point when people are suffering from serious conditions jeopardizing their health or their life.

No one thinks it makes sense to pay firefighters based on the value of their work when they come to our burning house with our families inside, yet this is essentially how we pay for drug research under the patent monopoly system. In fact, the story is even worse with drugs, since typically we have a third party payer (either an insurance company or the government) who we are trying to get pick up most of the tab.

These bills would not fully solve the problem, but each would be a big step in the right direction. Sanders, Cummings, and Khanna have done a great service in pushing them forward.

mulp -> anne... , January 16, 2019 at 04:33 PM
"No one thinks it makes sense to pay firefighters based on the value of their work ..."

We value fire fighters as worthless, by not paying most fire fighters in the US.

After all, requiring the people saving your life to be paid kills jobs, so we end up with unpaid life savvers.

We should appply the same principle to people providing life saving food, the people building the roads needed to deliver life savings, the people making the vehicles used by those providing life saving services.

In fact, no one should be paid to work! Thats free lunch economics!

Sarcastic, yes.

Dean Baker meantioned nothing about costs, which are always labor costs.

Look, Keynes argued that when there were unemployed workers, and capital is scarce, government should tax and spend to pay workers to build capital.

For drugs, paying unemployed researchers to build capital, eg, life saving drugs, then taxing the drugs produced to repay the cost of developing the drugs, with so many new drugs developed, the private capital in drug factories, etc will produce so many drugs that drug prices fall to total labor costs per unit, plus the drug tax.

We know there are unemployed drugresearchers because NIH always runs out of money to pay all thre recent collage grads seeking grants to fund their hoped for job as a researcher.

Plp -> mulp ... , January 18, 2019 at 01:41 PM
Mulp what about monopoly profits my friend

Research could rise and marketing cuts pay for it

Yes there's slack created
In marketing jobs and funding entertainment of course

Plp -> anne... , January 17, 2019 at 08:40 AM
Bernie and Liz are too valuable to waste running for
The Dem nom

Leave that for a clever weather vane
Like Harris and that jersey senator

The gal from the Bronx
is another Bill Bryan

She is the future

anne -> Plp... , January 18, 2019 at 09:21 AM
The gal from the Bronx
is another Bill Bryan

She is the future

[ Funny and right and especially clever. ]

Julio -> Plp... , January 18, 2019 at 09:21 AM
Agreed completely.
Warren, in particular, makes a great senator but I doubt would make a great president.
Christopher H. said in reply to Julio ... , January 18, 2019 at 10:01 AM
Disagree, unfortunately in the American system the President gets all the attention and can spread the message.

Either Bernie or Warren would be good. I'd much prefer Bernie.

Plp -> Christopher H.... , January 18, 2019 at 01:43 PM
No problem if they win the POTUS job

Still I'd prefer AOC

[Jan 13, 2019] Libertarian wet dreams and reality of the Us healthcare

Jan 13, 2019 | www.nytimes.com

JB Nashville, Tennessee Jan. 11

@Bill - So you're willing to gamble with your own health and the well-being of any family or loved ones you have and trust in some ambulance chaser against an armada of $3000 suits? Good luck with that.

While I'm often skeptical of our government, I have ZERO faith in any corporation to do right by me.

Their only mission is to make as much money as they can, and even paying out the occasional lawsuit is a reasonable cost of doing business. The only way a capitalist entity can be trusted is if a more powerful authority is looking over their shoulder. The FDA is one of many federal entities standing between us and an indifferent group of shareholders and CEOs.

[Jan 09, 2019] $3.5 Trillion A Year- Is America's Health Care System The World's Largest Money-Making Scam- -

Jan 09, 2019 | www.zerohedge.com

Authored by Michael Snyder via The Economic Collapse blog,

If the U.S. health care system was a country, it would have the fifth largest GDP on the entire planet. At this point only the United States, China, Japan and Germany have a GDP that is larger than the 3.5 trillion dollar U.S. health care market. If that sounds obscene to you, that is because it is obscene. We should want people to be attracted to the health care industry because they truly want to help people that are suffering, but instead the primary reason why people are drawn to the health care industry these days is because of the giant mountains of money that are being made. Like so many other things in our society, the health care industry is all about the pursuit of the almighty dollar, and that is just wrong.

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me title=

In order to keep this giant money machine rolling, the health care industry has to do an enormous amount of marketing. If you can believe it, a study that was just published found that at least 30 billion dollars a year is spent on such marketing.

Hoping to earn its share of the $3.5 trillion health care market, the medical industry is pouring more money than ever into advertising its products -- from high-priced prescriptions to do-it-yourself genetic tests and unapproved stem cell treatments.

Spending on health care marketing nearly doubled from 1997 to 2016, soaring to at least $30 billion a year , according to a study published Tuesday in JAMA.

This marketing takes many different forms, but perhaps the most obnoxious are the television ads that are endlessly hawking various pharmaceutical drugs. If you watch much television, you certainly can't miss them. They always show vibrant, smiling, healthy people participating in various outdoor activities on bright, sunny days, and the inference is that if you want to be like those people you should take their drugs. And the phrase "ask your doctor" is usually near the end of every ad

The biggest increase in medical marketing over the past 20 years was in "direct-to-consumer" advertising, including the TV commercials that exhort viewers to "ask your doctor" about a particular drug. Spending on such ads jumped from $2.1 billion in 1997 to nearly $10 billion in 2016 , according to the study.

As a result of all those ads, millions of Americans rush out to their doctors to ask about drugs that they do not need for diseases that they do not have.

And on January 1st, dozens of pharmaceutical manufacturers hit Americans with another annual round of massive price increases.

But everyone will just keep taking those drugs, because that is what the doctors are telling them to do. But what most people never find out is that the pharmaceutical industry goes to great lengths to get those doctors to do what they want. According to NBC News , the big drug companies are constantly "showering them with free food, drinks and speaking fees, as well as paying for them to travel to conferences".

It is a legal form of bribery, and it works.

When you go to most doctors, they will only have two solutions to whatever problem you have – drugs or surgery.

And since nobody really likes to get cut open, and since drugs are usually the far less expensive choice, they are usually the preferred option.

Of course if doctors get off the path and start trying to get cute by proposing alternative solutions, they can get in big trouble really fast

Today's medical doctors are not allowed to give nutritional advice, or the American Medical Association will come shut them down , and even if they were, they don't know the right things to say, because they weren't educated that way in medical college. So instead, M.D.s just sling experimental, addictive drugs at symptoms of deeper rooted sicknesses, along with immune-system-destroying antibiotics and carcinogenic vaccines.

That's why any medicine that wrecks your health is easy to come by, just like junk food in vending machines. The money isn't made off the "vending" products, the money is made off the sick fools who are repeat offenders and keep going back to the well for more poison – it's called chronic sick care or symptom management. Fact: Prescription drugs are the fourth leading cause of death in America, even when "taken as directed."

Switching gears, let's talk about hospitals for a moment.

When you go to the hospital, it is often during a great time of need. If you are gravely ill or if an accident has happened and you think you might die, you aren't thinking about how much your medical care is going to cost. At that moment you just want help, and that is a perfect opportunity for predators to take advantage of you.

Trending Articles "A Soft Coup Against Donald Trump Is Underway" Declares

Turkey is going on the attack against John Bolton following his weekend antics in the Middle East, which most recently

https://c5x8i7c7.ssl.hwcdn.net/vplayer-parallel/20180830_1458/videojs/show.html?controls=1&loop=30&autoplay=0&tracker=a961647f-7462-418d-84d4-4cdacc725f85&height=362&width=643&vurl=%2F%2Fc5x8i7c7.ssl.hwcdn.net%2Fvideos%2Fdgv_zerohedge%2F20190109100152_5c3583c672640%2Fdgv_zerohedge_trending_articles_20190109100152_5c3583c672640_new.mp4&poster=%2F%2Fc5x8i7c7.ssl.hwcdn.net%2Fvideos%2Fdgv_zerohedge%2F20190109100152_5c3583c672640%2Fdgv_zerohedge_trending_articles_20190109100152_5c3583c672640_new.jpg

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Just consider the example of 24-year-old Nina Dang. She broke her arm while riding her bicycle in San Francisco, and so she went to the emergency room.

The hospital that Facebook CEO Mark Zuckerberg donated so much money to definitely fixed her arm, but later they broke her bank account when they hit her with a $24,000 bill

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50 . Premera Blue Cross, her health insurer, would only cover $3,830.79 of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay , which the hospital threatened to send to collections in mid-December.

Most Americans assume that if they have "good health insurance" that they are covered if something major happens.

But as Dang found out, you can still be hit with crippling hospital bills even if you have insurance.

Today, medical debt is the number one reason why Americans declare bankruptcy. Because of the way our system is set up, most families are just one major illness away from financial ruin.

And this kind of thing is not just happening in California. The median charge for a visit to the emergency room nationally is well over a thousand dollars , and you can be billed up to 30 dollars for a single pill of aspirin during a hospital stay.

Our health care system is deeply broken, and it has been designed to squeeze as much money out of all of us as it possibly can.

Unfortunately, we are stuck with this system for now. The health care industry is certainly not going to reform itself, and the gridlock in Washington is going to make a political solution impossible for the foreseeable future.


the_river_fish , 3 minutes ago link

Healthcare has displaced Retail as the largest employer in the United States

https://thistimeitisdifferent.com/healthcare-us-january-2019

Consuelo , 9 minutes ago link

The ghost of Ted Kennedy that keeps on giving...

He played an outsized role in the trashing of the doctor/patient relationship.

css1971 , 10 minutes ago link

Most big hospital ERs negotiate prices for care with major health insurance providers and are considered "in-network." Zuckerberg San Francisco General has not done that bargaining with private plans, making them "out-of-network." That leaves many insured patients footing big bills.

HMOs.

Constrain supply. Increase the price.

https://en.wikipedia.org/wiki/Health_Maintenance_Organization_Act_of_1973

That was the purpose of the 1973 HMO act. It was at this point, that US medical costs began to escalate far beyond the rest of the world.

https://pusz4frog.files.wordpress.com/2012/04/healthcare-costs-oecdchart_3.gif

LawsofPhysics , 10 minutes ago link

Considering the demographics of the country and the fact that fraud is the status quo now, this should not surprise anyone.

LawsofPhysics , 21 minutes ago link

That's a tough question considering we don't really know how much is flowing to the military industrial complex. My guess healthcare spending is in second place.

[Jan 08, 2019] Risk On Again - Distractions from the Real Problems and Issues

Jan 08, 2019 | jessescrossroadscafe.blogspot.com

Stocks and Precious Metals Charts - Risk On Again - Distractions from the Real Problems and Issues

"On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders -- on the pavement with a broken arm.

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December..."

Sarah Kliff, A $20,243 bike crash: Zuckerberg hospital's aggressive tactics leave patients with big bills

"Monopolies hurt the public and the republic alike; the job of policing that power must be taken seriously."

Elizabeth Warren

Within so many of the corporate dominant monopolies like Healthcare, Banking, Pharmaceuticals, some companies seem to be free to do just about whatever they wish in billing consumers.

Healthcare in the US is bordering on insane when it comes to billing practises and lack of practical recourse or common sense, with Big Pharma running a close second. But the Banks are not all that far behind.

I have met many, many dedicated professionals in the healthcare industry, but like most participants they are just being swept along because they have little practical recourse or power. To speak up is to be punished, and severely.

A simple law that states that when a patient is brought into a hospital emergency room for treatment, their private insurance and the treatments must be provided at the network rates in their insurance policy, or at the prevailing rate for a Medicare patient, whichever is lower. And any uncollectible services to be written off or compensated by government will be done at the Medicare rate and not at some ficitonal billing statement.

I believe that New York State has a law requiring ER and Hospital doctors to accept private insurance for patients as if they are in-network. This includes those 'consultations' which happen during a hospital stay by doctors who accept no insurance and who charge whatever they feel like charging for some service, of which provider or price the patient is never informed beforehand.

The real solution is of course universal healthcare, which has been implemented for years by every major developed nation but the US. This will not happen for the same reason that we are seeing no movement towards meaningful reform in Pharma or Banking. And you know exactly why, unless you have been living in a bubble or are willfully blind.

Stocks managed to extend their rally today despite some setbacks.

We will see what Trumpolini has to say about our 'crisis' at the southern border this evening, and the trade war, and probably whatever else crosses his mind. My only certainly is that it will not involve any meaningful reform in healthcare, finance, insurance, or pharmaceuticals.

Have a pleasant evening.

[Nov 26, 2018] >Revealed: faulty medical implants harm patients around world by Hilary Osborne , Hannah Devlin and Caelainn Barr

Notable quotes:
"... In the US, the Food and Drug Administration (FDA) has collected 5.4m "adverse event" reports over the past decade, some from manufacturers reporting problems in other parts of the world. ..."
"... Interviews with patients and doctors have revealed flaws in how the medical devices industry is regulated. ..."
Nov 25, 2018 | www.theguardian.com
The Implant Files investigation reveals damage caused by poor regulation and lax testing rules

Why we're examining the implants industry

Patients around the world are suffering pain and many have died as a result of faulty medical devices that have been allowed on to the market by a system dogged by poor regulation, lax rules on testing and a lack of transparency, an investigation has found.

Pacemakers, artificial hips, contraceptives and breast implants are among the devices that have caused injuries and resulted in patients having to undergo follow-up operations or in some cases losing their lives.

In some cases, the implants had not been tested in patients before being allowed on to the market.

In the UK alone, regulators received 62,000 "adverse incident" reports linked to medical devices between 2015 and 2018. A third of the incidents had serious repercussions for the patient, and 1,004 resulted in death.

In the US, the Food and Drug Administration (FDA) has collected 5.4m "adverse event" reports over the past decade, some from manufacturers reporting problems in other parts of the world.

These included 1.7m reports of injuries and almost 83,000 deaths. Nearly 500,000 mentioned an explant – surgery to remove a device.

The figures come from research by 252 journalists from 59 media organisations in 36 countries, which has uncovered a litany of problems in the global $400bn (£310bn) industry.

Examples of failure in the market include:

Replacement hips and vaginal mesh products sold to hospitals without any clinical trials. Patients relying on faulty pacemakers when manufacturers were aware of problems. Complications with hernia mesh that ruled one of Britain's top athletes out of competing for years. Regulators approving spinal disc replacements that later disintegrated and migrated in patients. Surgeons admitting they were unable to tell patients about the risks posed by implants because of a lack of central registers. Patients in Australia being given devices that the regulator has approved on the basis they have been approved in Europe.

The findings raise concerns about the level of scrutiny devices undergo before and after they go on the market, and whether regulators detect and act upon findings quickly enough.

Information about problems with devices is, in many countries, kept under wraps, making it difficult for patients to research procedures that have been recommended to them.

Interviews with patients and doctors have revealed flaws in how the medical devices industry is regulated.

Prof Derek Alderson, the president of the Royal College of Surgeons, said there had been enough incidents involving flawed devices to "underline the need for drastic regulatory changes", including the introduction of mandatory national registries for all implantable devices.

"In contrast to drugs, many surgical innovations are introduced without clinical trial data or centrally held evidence," he said. "This is a risk to patient safety and public confidence."

The Guardian and organisations including the BBC , Le Monde and Süddeutsche Zeitung, coordinated by the International Consortium of Investigative Journalists (ICIJ), have trawled through thousands of documents, many obtained through freedom of information (FoI) requests, to unearth some of the biggest problems.

Alongside interviews with patients and doctors, these have revealed flaws in the way the industry is regulated that are unlikely to be fixed by rules due to come into force in Europe.

Among the concerns raised by the Implant Files project are that manufacturers are in charge of testing their own products after faults have developed – and are allowed to shop around for approval to market their products, without declaring any refusals.

The Guardian has also heard about doctors who have close industry ties or seem eager to be early adopters of the latest devices to enhance their professional standing.

Plans for tougher EU rules have been watered down after industry lobbying, according to a huge trove of documents uncovered by the project.

[Mar 21, 2018] Big pharma racket: Bottom line, it's doctors and patients fault for not defending themselves against the ludicrously corrupt health insurance industry

Notable quotes:
"... instruction manual ..."
"... Bottom line, experts say, medical professionals should make the patient aware if they prescribe a high-priced medicine and explain why it's beneficial. Patients should play defense and ask their physicians about the cost of every new prescription. ..."
"... " experts say " ..."
"... medicine is less expensive if you pay the cash price and we don't run it through your health plan ..."
Mar 21, 2018 | www.nakedcapitalism.com

Enquiring Mind , March 20, 2018 at 9:17 am

Shame is a 20th century concept ill-suited to this modern post-tobacco settlement world. Where some saw a consumer victory after decades of warnings on packs by getting big tobacco to acknowledge risks, others saw methodology victory for the neo-liberal machine, and an instruction manual .

Like the Big C, cancer, that machine keeps rolling along. Now it is mainstream, to be emulated instead of castigated. At least that is what appears to have happened among those shame-free star pupils of Big Pharma and their fellow travelers in FIRE, aided and abetted on the Big Screen where deviancy got defined down so far it got erased. Political and economic trends ebb and flow, with some elements of populism appearing on the horizon. Greater awareness of the plight of one's fellow humans may help focus the mind.

RabidGandhi , March 20, 2018 at 6:16 am

Bottom line, experts say, medical professionals should make the patient aware if they prescribe a high-priced medicine and explain why it's beneficial. Patients should play defense and ask their physicians about the cost of every new prescription.

Bottom line, it's doctors and patients fault for not defending themselves against the ludicrously corrupt health insurance industry. Bottom line, medical professionals and patients have to spend their time and effort (increasingly dwindling, because markets) to try to avoid being charged a month's pay for a tube of ointment. Because, bottom line, changing the system is not an option, so keep banging your head against that wall!

notabanker , March 20, 2018 at 6:36 am

Yeah, try getting a straight answer on what this stuff will cost BEFORE you take possession, er , are treated. "$200" has turned into $1000 bills from a third party device company that magically turns to $0 after 3 months of emails and phone calls. I've walked out of hospitals after getting full disclosure of costs minutes before a procedure that was scheduled weeks in advance.

The neolib corruption numbness has to seep through the cartilage into the bones to call these practices anything but criminal.

oh , March 20, 2018 at 2:30 pm

There is really no excuse for the crooks in the medical (health care? nah!) industrial complex not to provide costs of any procedure or service ahead of time. I admire you for walking out minutes before the procedure and more people should do the same. I would do the same and have.

Amfortas the Hippie , March 20, 2018 at 4:15 pm

If there's no "Price Discovery", is it really a "Marketplace"?

towards the end of my six and a half year slog through the disability process(sic), I learned about Cuba. I got a price for a new hip pretty easily from them (around 10 grand, including a "bungalo on the beach with a private nurse for recovery")

so I called the nearest hospital, and asked what a new hip would cost me, cash money, walking in the door.

The person obviously didn't understand the question, and after some time of me waving my arms and trying to word the question in a form she would understand she said" oh insurance takes care of that and it depends on many factors"

"such as?" sez I

Her:" like what kind of replacement they use which is up to the surgeon and many things"

This went on and on, and I finally got her not nailed down at around 300 grand.

Then I asked her what medicare would pay for the same thing and she hung up on me. It ain't a "Market", it's a Racket.

(and, about the toenail fungus my grandmother would tell her to just pee on it .)

Bukko Boomeranger , March 20, 2018 at 7:06 am

By the "logic" of the guest post, bottom line is it's that baby's fault for not being strong enough to defend itself against the big kid who took its candy. It's the woman's fault for dressing that way before she was raped.

The victims should be blamed because they didn't play defence well enough against the criminals who write the rules of the system. I presume your comment is to flesh out the BS justification from the article, Gandhi, not to endorse it. Excuses like the one capping the guest post, instead of rabid outrage, are part of what allows the crimes to continue. I can see why so many Merkins want to burn the (family blog)er down, even though they wind up voting for Trump as a means of expressing that feeling.

HistoricalPerspective , March 20, 2018 at 11:32 am

" experts say "

Seriously, who are these 'experts'!?!? Between the 'experts' , who blame the victims, kick cans down the road and pass the bucks to the lay-people (no one is an expert in everything, i.e. everyone is ignorant about something at some point in their lives) they're suppose to be advising whenever 'expertise' is required, and the 'journalists' who give them a venue to spew their apocryphal twaddle in an attempt to portray themselves as 'experts' when their true intentions are to gaslight, obfuscate and divide common sense and decency. Throw in the politicians, crony capitalists and all the other puppet masters and you have the perfect storm so many Americans, like myself, finds themselves drowning in. Once upon a time expertise inferred wisdom. Those days are history.

jackiebass , March 20, 2018 at 6:31 am

I don't know if it works but I've been told that petroleum jelly will cure toenail fungus. it seems salves or topical medicines are usually expensive. I use a salve that I apply to the rash from my. Eczema. I have used it for years and the price is constantly increasing. When I started using it the cost was $50 per tube. The last tube I got cost $480. I was prescribed an inhaler for Bronchitis. It cost almost $500 and didn't seem to do much to relieve the symptoms. Fortunately my insurance payed for the medicine. It still makes me mad when I think about what was charged for these prescriptions.

divadab , March 20, 2018 at 8:00 am

There are much cheaper alternatives to inhalers for asthma or bronchitis. Buy a "Nebulizer" (we just bought a portable one for $50), which is a vaporiser, and get your doctor to prescribe "nebules" of albuterol sulphate and/or sodium chromalyn to load into the nebulizer. We get a prescription refill of nebules for $3.49 v. over $50 for a ventolin inhaler . And there is no propellant in the nebulizer which there is on an inhaler.

The greed and parasitism of the pharmaceutical cartel is criminal.

Arthur J , March 20, 2018 at 10:13 am

My gp told me to use Vick's VapoRub for my toenail fungus. I asked the pharmacist and she said it has about a 10% success rate, same as the petroleum jelly from which Vick's is made. There was some branded treatment, $40 for a 2ml bottle that she said worked maybe 15% of the time. Only been a few weeks, but so far I haven't seen much of a change.

Eudora Welty , March 20, 2018 at 12:32 pm

Yes, I used Vick's Vaporub on a toe fungus and it worked. I was told it wouldn't work.

home for wayward trout , March 20, 2018 at 1:00 pm

The People's Pharmacy has a lot of information on toenail fungus and also has an article recommending treatment with mentholatum.

I now go to their website before filling any prescription I'm given by a doctor.

RalphR , March 20, 2018 at 8:22 pm

I did (after trying other topical but non-prescription products) and it didn't initially.

But then I used it in conjunction with a lotion with a lot of hyaluronic acid in it. Hyaluronic acid is widely used in cosmetic products to increase penetration of the active ingredients into the skin.

Worked great.

Just by sure to apply any treatment to the cuticle, particularly at the root of the nail. That is where the fungus lives.

donw , March 20, 2018 at 12:42 pm

It is a fungus, so being outside in the sun wearing flip flops might kill it.

Marie Parham , March 20, 2018 at 6:42 am

Last summer I had toenail fungus and researched how to treat it. Soaked my feet is diluted vinegar a few days and scrubbed the area. Then I used https://www.cvs.com/drug/miconazole . It worked. Next time I have an annual checkup I will talk to my nurse practitioner. Web MD was a big help. https://www.webmd.com/skin-problems-and-treatments/guide/fungal-nail-infections-topic-overview#1

So was Mayo clinic

https://www.mayoclinic.org/diseases-conditions/nail-fungus/diagnosis-treatment/drc-20353300

I am not recommending websites replace physicians, but apparently it is necessary to always second guess the physicians.
My treatment cost less than $10.

Normal , March 20, 2018 at 6:42 am

How about requiring every provider to give a firm quotation on every product and service? Every other industry has to live with this constraint.

XXYY , March 20, 2018 at 10:22 am

I'm amazed this simple idea never gets traction. Car mechanics, e.g., are required by law to provide a written estimate before work begins; if something is found that will change the estimate, they have to get your OK. Car repairs are usually much cheaper than medical bills and are often equally or more opaque to diagnose.

Having doctors and medical offices provide you with an estimate after diagnosis but before treatment does not seem like it would be terribly hard. They (uniquely) have visibility into your insurance arrangements, their reimbursement rates, their costs, overhead, profit rates, and so on. Software for this purpose would make pretty short work of boiling this down to the out-of-pocket for the patient. The patient could then either OK it, negotiate other options, or decide to shop around. If the provider later tries to charge more, the patient would have something on paper to justify refusing it.

There's no reason patients should be treated like a bottomless bank account by the medical industry.

sharonsj , March 20, 2018 at 12:58 pm

Many doctors have no clue what things cost. I received a single shot of cortisone for an arthritic shoulder and was charged $200. When I complained to the health care system, I was told that, had I been insured, the cost to me would be $100 less. When I complained to my doctor, he had no idea about any of this.

P.S. I knew the owner of an herb farm who had foot fungus. She visited a podiatrist and was prescribed some expensive salve which didn't work. The woman then went out on her farm, gathered some herbs according to an old remedy, made her own salve and was cured.

oh , March 20, 2018 at 3:02 pm

I was told to get the shot for shoulder pain (was a bad idea from this quacK). The "doctor" had no idea what it would cost!! At any rate it cost me over a $100 even with Kaiser coverage and it did NOT help. It hurt a lot for a few days (in more ways than one). What a fraud this industry is.

I dread the day I'd have to go to the hospital where I it was such an emergency that I'd be at the mercy of this robber baron system

JTMcPhee , March 20, 2018 at 10:25 am

Had any car or truck repair work done lately? Or speaking of things automotive, have any of us had experiences with the sales machinery of car and truck dealers, new or used? Speaking of transparency in pricing, firm quotes and all that? As just one example of how The Machine actually works? Catch-22: "They can do anything to us they want that we can't keep them from doing." http://www.slate.com/articles/life/the_spectator/2011/08/seeing_catch22_twice.html

FluffytheObeseCat , March 20, 2018 at 11:19 am

Big ones twice in the past four years on the RAV4. 2 different shops, in different states. They both gave me firm, up front price quotes. One was wrong on the low side, and the owner called me with the real price and an apology before doing the work. Just like the law requires.

This kind of fair dealing and respect for the customer never happens in medical practices. The doctors rarely soil their highly educated minds with matters of cost; everyone else in the office has little authority, and the chubby young women who sit up front in scrubs do as little as possible for the captives they call patients.

nycTerrierist , March 20, 2018 at 3:07 pm

"This kind of fair dealing and respect for the customer never happens in medical practices. "

This! And stress over billing affects health!
it is stressful and aggravating that doctors can't/won't address cost at the point of service. This destroys patient's trust in the physician as well.
Therapeutic relationship is wrecked as well as health and personal finances.

Paul P , March 20, 2018 at 7:19 pm

This NYS law applies to services, not drugs. It's a start:

Emergency Medical Services and Surprise Bills Law – New York State
https://www.health.ny.gov/regulations/ bill /ems_and_surprise_bills_law_faq.htm
If they do not participate in a patient's health care plan, they must upon request from a patient inform the patient of the estimated amount they will bill absent unforeseen medical circumstances that may arise. Under subdivisions (3) and (4), physicians in private practice also must provide information regarding any other ..

anonymous , March 20, 2018 at 6:57 am

"We're talking about mild toenail fungus. The price tag is difficult to rationalize, experts ( and every breathing human ) said."

Eureka Springs , March 20, 2018 at 7:03 am

We're talking about mild toenail fungus. The price tag is difficult to rationalize, experts said.

What kind of "expert" tries to rationalize cost of prescription on severity, rather than, say, cost of making the product?

16,500 for the course of an eleven month treatment with 6 percent chance of working. Seems like a medical RX vacation almost anywhere else in the world would be prudent.

Enquiring Mind , March 20, 2018 at 9:07 am

What kind of expert, you ask?

Today's fast-paced, stimulating world in pharmaceutical revenue management and marketing needs H1-B visa assistance to hire the kind of expert that is not available in sufficient quantity or quality to allow efficient pursuit of medical excellence. In past years, such personnel were to be found only in select industries such as tobacco and other personal care products. Building the right team, with applicable key performance indicators and mission-critical elements, is too important to be left to chance so every avenue must be explored, every base touched. Consumer options are opened up in the free market of healthy competition for products rather than stifled under excess regulatory and legal layers.

That kind of expert. /s

Jon S , March 20, 2018 at 12:34 pm

I really enjoyed that!

sgt_doom , March 20, 2018 at 1:54 pm

Man oh man!!!!

Had a deja vu moment there -- thought I was back as an employee during a leveraged buyout by the typically sleazy PE firm of Baird Private Equity!!!!!

Lambert Strether , March 20, 2018 at 7:07 am

Sounds like Soloviev wasn't a "smart shopper"!

Miamijac , March 20, 2018 at 7:28 am

Teatree oil, anti fungal. >$3.00. They only have a license to practice.

Croatoan , March 20, 2018 at 8:17 am

Just be careful with the natural stuff

"The results of our laboratory studies confirm that pure lavender and tea tree oils can mimic the actions of estrogens and inhibit the effects of androgens ," said Korach. "This combinatorial activity makes them somewhat unique as endocrine disruptors."

https://www.nih.gov/news-events/news-releases/lavender-tea-tree-oils-may-cause-breast-growth-boys

Kevin , March 20, 2018 at 9:06 am

My wife is a massage therapist and dispenses oils occasionally. NEVER use straight oils – ALWAYS use a carrier oil in conjunction.

BTW – anyone else notice the toe fungus ad placed above the comments we're being watched!

oh , March 20, 2018 at 3:14 pm

Another myth propagated by the hand maidens to the Pharma industry.

cnchal , March 20, 2018 at 8:29 am

The title of the post is a bit misleading.

It should have been "Bill Of The Month: For Toenail Fungus, A $16,500 Prescription and less than 10% effective".

. . . She began swabbing it on the two toenails, as directed, having been told it would take about 11 months to treat the fungus .
– – – –
Unbeknownst to her, Kerydin, which it turned out costs nearly $1,500 per monthly refill . . .
– – – –
In its application for Food and Drug Administration approval granted in 2014, Anacor Pharmaceuticals highlighted that a yearlong treatment of Kerydin completely cured toe fungus in 6.5 percent of patients for one trial, and 9.1 percent of patients in another.

The post's title diminishes the scale of the scam by a factor of at least 100.

sgt_doom , March 20, 2018 at 1:55 pm

Very well articulated and thought out!

Props and kudos!!!

lyman alpha blob , March 20, 2018 at 3:52 pm

That last bit blew my mind. Why in the hell is the FDA approving anything as a treatment that can only be shown to cure what it's supposed to less than 10% of the time!?!? And we know how the approval process scam works – the companies only submit the best results in the first place and leave out the data the shows treatments to be less successful.

That being said, who would like to try out my new wonder drug? It cures absolutely everything that ails you at least 5% ot the time. I call it Plaisibeaux – the ingredients are French and they're a trade secret. Any FDA employess around who can fast track this one for me?

Joel , March 20, 2018 at 8:35 am

My simple stupid solution just avoid them entirely, the docs the tests the meds the hospitals. Advil is cheap and works for most of the pain. A couple of other basic meds for occasional random stuff that I buy when I travel outside the US. Try to work out a bit and eat more or less right. Except for easy obvious stuff I never met anyone that actually got better by going to a doctor. When its time to die I guess I will die.

Stillfeelinthebern , March 20, 2018 at 2:43 pm

X1000

Couldn't agree more.

oh , March 20, 2018 at 3:16 pm

+1

sierra7 , March 20, 2018 at 10:00 pm

In our healthcare system (and I guess totally), when you're healthy you're wealthy!

mark , March 20, 2018 at 8:35 am

It's really worse than the article suggests. Kerydin (tavaborole) isn't even all that effective. In one trial, "cure" was achieved in about 7% of cases and in other trials "completely or almost clear nail rates" were achieved in 15 – 30% of cases:

In clinical trials, tavaborole was more effective than the vehicle (ethyl acetate and propylene glycol) alone in curing onychomycosis. In two studies, fungal infection was eliminated using tavaborole in 6.5% of the cases vs. 0.5% using the vehicle alone, and 27.5% vs. 14.6% using the vehicle alone.

https://en.wikipedia.org/wiki/Tavaborole#Therapeutic_trials

For those interested, this is the original paper that the Wikipedia entry is based on:

https://www.sciencedirect.com/science/article/pii/S0190962215015121

Thomas Briggs , March 20, 2018 at 9:14 am

Last visit was a snake bite. Antivenom was about 60k. Pretty sure same can be had in Mexico for less than $1,000, maybe much less. That was 5 years ago. I refuse to participate any longer, & I have good insurance. I hope eating better, exercise, & homeopathic treatments can work for me. Have not seen a doctor since & won't unless taken unconscious.

oh , March 20, 2018 at 3:18 pm

Agree with you. Eat healthy foods, exercise, homeopathic or ayurvedic treatment when absolutely necessary. No need to go for their "free" physicals. Listen to your body.

Pat , March 20, 2018 at 9:19 am

So a physicians assistant diagnosed a fungus strictly on observation, calls in a prescription for an ineffective and more difficult to use but massively expensive prescription and it is the patient's fault.

Don't know about the rest of you, but I see at least three problems in that that have nothing to do with the patient OR even the obscene greed of the pharmaceutical industry but a whole lot with the Braun Dermotological Center.

XXYY , March 20, 2018 at 10:32 am

I have no proof, but my guess is that these medical centers have sweetheart deals with mail-order pharmacies for various overpriced drugs. We took my son to a dermatology place several times for acne treatment; they would commonly propose something I had never heard of and urge us to order from a particular mail-order pharmacy, often providing coupons. I saw no reason not to get it from our local pharmacy but they were strangely insistent on us doing it by mail.

One obvious problem with mail-order pharmacies is made clear in this piece: by the time you find out how much things cost, it's already a done deal. At a retail pharmacy, you can walk away without paying. This is obviously a feature of mail-order pharmacies, not a bug.

Kevin , March 20, 2018 at 11:02 am

The proliferation of specialty medical centers around the western Chicago suburbs has been amazing to witness – similar to the proliferation in the number of bank outlets prior to the crash

Katniss Everdeen , March 20, 2018 at 11:33 am

No kidding. How is prescribing a drug, even a cheap one, that's "effective" only 7% of the time even considered medical "treatment?"

And what in the world is that "statement" pictured above? It's flat out false. Is it somehow supposed to be official? Where did it come from?

"Total Rx cost" in January: $56.52???? No, it was $1,496.09–same as in February.

"You paid" (Patient paid?) in January: $56.52? No, the patient paid $1,439.57, "funded" through her HRA and shown with an asterisk at the bottom. $56.52 was apparently a drug company rebate / coupon.

About the only true thing in January was that the insurance paid $0.

The "You paid" in February was not, in fact paid by the patient, but by another drug company rebate / coupon. She was not even asked to write a check for the copay, an expense she would have expected.

The "Your Cost" of $620.43 at the top appears to be the sum of the two drug company coupons for January and February, although no time frame is specified. At this point, the patient had written NO checks, even for the copays.

As an aside, where is the $60 "Copay/Co-insurance for January?

The patient's actual "cost" over the two months would most accurately be represented as the sum of the two months' Rxs–about $3000–plus two $60 copays. "You Paid" should be what she actually paid, either out of pocket or through the HRA, and any fees or copays that were covered by drug company rebates should be clearly noted as CHARGED but ABROGATED.

I'd suggest that deliberately confusing and understating seemingly obvious terms such as "cost" and "paid"
deliberately obfuscates the situation in order to sell expensive drugs that people would balk at purchasing if they knew the true "cost."

And all of this is before figuring out, for a Medicare recipient, how all these worthless, expensive drugs, coupons and rebates propel the patient toward the "donut hole," an entirely different kettle of fish in which nobody pays for nuthin' except the patient.

Joel , March 20, 2018 at 4:45 pm

+1 These "statements" web pages or whatever are designed by either morons or sadistic fiends. Probably the same ones that design cell phone bills

anonymous , March 20, 2018 at 9:48 am

This reminds me of the time I was billed $300 for a foot splint by a podiatrist that my insurance refused to pay for. I could have bought a foot splint off Amazon for $30.

Always ask for prices for any treatments or medicines. I trust my dentist way more than any doctor I've been too.

vidimi , March 20, 2018 at 10:05 am

this stuff is free in france for anyone with a social security number

Bugs Bunny , March 20, 2018 at 10:46 am

Kerydin has not been approved by the European Medicines Agency. You shouldn't state things as fact unless you can back them up.

Jon S , March 20, 2018 at 12:40 pm

I'm sure he meant "medicine that fixes toe fungi" is free in France, not Kerydin. And of course Kerydin isn't approved in Europe, with a 7% efficacy rate, it's doesn't really have medicinal value. It would only be prescribed in the US.

crittermom , March 20, 2018 at 10:15 am

Stories such as this are infuriating.

I went to a Podiatrist a couple years ago for a different problem but mentioned I thought I had a toenail fungus, too.

The Dr confirmed that but instead of prescribing something he recommended coconut oil. He said it worked much better & faster than any pills he could prescribe & he was right.

I had a large jar of solid coconut oil (around $6) & applied it with a Q tip.
In very short time the fungus was gone.

A girlfriend had gone to her Dr who prescribed pills.
Her fungus returned within a few months.
Mine hasn't.

Lord Koos , March 20, 2018 at 1:08 pm

This is not surprising – before I read your post I was thinking, there is probably a simple home remedy for that condition. There are a lot of useful drugs out there, but there are probably just as many that are useless, ineffective, or that have dangerous side effects and unintended consequences. I took over-the-counter anti-allergy meds for my hay fever for years, only recently reading that they (Claritin, etc) are now implicated in the onset of Alzheimer's. Thanks a lot

JamesG , March 20, 2018 at 10:41 am

I caught a similar prescription with a high co-pay and refused to pick up the merch from the pharmacist.

I then treated my fungus with Lamisil an OTC product which works for me.

Steve Roberts , March 20, 2018 at 10:42 am

I was written a script for a tube of cream that supposedly cost nearly $3k. It's hard to know what the pharmacy benefit manager actually paid because they are pretty secretive about that sort of thing. Per a friend she estimated it at probably $50 which is still idiotic. It was an anti-itch cream and wasn't any better than a $2.50 tube of cortisone cream.

otis , March 20, 2018 at 11:22 am

For the love of Pete. Isopropyl alcohol costs $1.79. Cut your toenails then apply with q tip. No more nail fungus. One bottle = many years supply.

I'm amazed people will take pills to cure nail fungus. So Dumb.
$14.000 annual toe cream. Dumb dumb dumber.
Thanks for posting these absurd bills. It lays bare the financialized health care holocaust underway in the USA.

perpetualWAR , March 20, 2018 at 11:32 am

Toenail fungus? Get apple cider vinegar.
Why do people not first look at home remedies?
Apple cider vinegar clears that up in a snap.

Synoia , March 20, 2018 at 11:49 am

Fungus can be treated by soaking in a 25% solution of vinegar, twice a day for two weeks.

Change the pH, kill the fungus.

That was my prescription for a fungus on my foot, by my doctor. And it worked.

Fred , March 20, 2018 at 1:00 pm

I pay less for my medicines when I pay cash as the pharmacy gives me a discount. But, because Part D has a penalty for not enrolling, I use it for 5 of medicines and then pay cash for one of them and pay about $5 more per month. Not to mention my doctor offered to do my stints for half price if I paid for cash. The whole healthcare system is a mess.

Pogonip , March 20, 2018 at 1:16 pm

I don't know about other countries, but here in the U.S. you should always, always, always assume that in any transaction you engage in, the seller has been financialized and will actively try to squeeze more money out of you, the ideal being to take all your available money and give you nothing in return. Be wary.

There are plenty of honorable exceptions, like the honest doctors and the mechanics described above. Cherish those sellers, patronize them, spread the word of mouth, especially if you think capitalism is the best of all possible economic worlds. The rent-seekers, if they continue unchecked, will destroy capitalism, because it requires some minimum level of trust to work. The odds that the seller will provide a good product or service have to be at least better than even.

Anonymous , March 20, 2018 at 1:54 pm

Philia is a necessary casualty of identity politics. Society depends on the collective will of people to take actions that are not in their direct benefit because they know others will make them. The "Tragedy of the Commons" does not occur when philia is strong because people know they can trust others not to abuse common resources. Once people do not trust others to act for the greater good it is a race to the bottom. The problem with identity politics is that it creates distrust of others outside ones own identity group as 'others' who cannot be trusted.

jrs , March 20, 2018 at 3:51 pm

oh yes identity politics created that, as if there wasn't far stronger prejudice by dominant groups long before identity politics was even a glimmer in it's dad's eye.

CrosslakeJohn , March 20, 2018 at 3:12 pm

Ten years ago or so in Corte Madera California, I was very lucky to find a podiatrist who was doing research on toenail fungus. I had nine of ten toe nails involved, some since high school (so for decades). His protocol for this was
1) pulse dose of two Lamasil tablets at the start of treatment
2) OTC bottle of fungoid tincture (with little brush built into the cap) from drug store with half a Lamasil tablet dissolved in it
3) every morning in the shower, scrub the nail ends with a toothbrush and a chlorine powder cleaner like Comet
4) brush a small amount fungoid tincture onto nail ends after morning shower and at night before bed.
5) keep nails short with clean cut ends

As I recall, the Lamasil pulse dose kills the fungus in the nail bed right away, and the fungoid tincture wicks into the nail every time and carries the anti-fungal drug to the fungus residing within the nail. The chlorine cleaner acts as a dessicant and pH modifier.

Ultimately, he gave me the few necessary Lamasil tablets as free samples, and back then the fungoid tincture was maybe $4/bottle at walgreens.

The new nails grew in from the nail beds perfectly, and after many months I had perfect toe nails and ceased treating them. They have remained so ever since.
I have always wondered if this approach was ever published in a medical journal. No significant money to be made from it by the manufacturer of Lamasil, so it's hard to see who had an incentive to promote it.
Disclaimer: I am not a doctor and am not giving medical advice. Pursue at your own risk.
Thanks!!

rps , March 20, 2018 at 4:48 pm

Why your pharmacist can't tell you .
WASHINGTON -- As consumers face rapidly rising drug costs, states across the country are moving to block "gag clauses" that prohibit pharmacists from telling customers that they could save money by paying cash for prescription drugs rather than using their health insurance The pharmacist cannot volunteer the fact that a medicine is less expensive if you pay the cash price and we don't run it through your health plan ."

The White House Council of Economic Advisers said in a report this month that large pharmacy benefit managers "exercise undue market power" and generate "outsized profits for themselves."

P Fitzsimon , March 20, 2018 at 4:57 pm

I'm going to get in trouble for saying this but toenail fungus isn't exactly leprosy. I've had a case continuously for 40 years after damaging my toenails in an accident. About 20 years ago I went to a doctor to see what could be done to get rid of it. He said I can give you a prescription that may cure it . But would you rather risk your liver or take the fungus with you to the grave after a full and healthy life with the fungus. I dont know what it would have cost because I chose the fungus. If it had cost $1500 and he hadn't told me the cost I would have been most unhappy.

Bill Carson , March 20, 2018 at 6:09 pm

This is shameful and absurd. However, the article mentions that there are "pills" that can be prescribed to treat the toe fungus, but some people taking those pills (terbinafine aka lamisil) have developed severe liver damage leading to liver transplant or death.

How much does it cost to just remove the toenail?

Bill Carson , March 20, 2018 at 6:28 pm

Why does this prescription cost $1,650 per month and not $16,500? Or $165,000? Or $1,650,000? Who decided that $1,650 was reasonable and $1,650,000 wasn't?

Bill Carson , March 20, 2018 at 6:46 pm

Oops, I meant $1,500 per month. But it probably costs more now anyway.

And how do they make an ointment last only a month? I've got some ointments under my sink that are 30 years old.

Bill Carson , March 20, 2018 at 6:39 pm

I'm a lawyer. I took Contracts 25 years ago in law school, but I seem to remember that there are certain elements to a contract that have to be present before the parties can be bound. Let's see

1. Offer
2. Acceptance
3. Consideration
4. Mutuality

Now, it seems to me that Consideration can't just be left blank. It is a very rare (non-medical) contract indeed where the buyer says, "I want X, no matter what it costs."

If I stay at a hotel and they have a mini-fridge with various refreshments and snacks, and I take a Diet Coke and a Milky Way, they can't legally charge me $10,000 for that.

I don't know why this isn't considered defrauding the consumer. We should be able to sue the crap out of these companies.

mtnwoman , March 20, 2018 at 7:40 pm

Give the medical practitioners a break! So now they need to puruse the Wall St Journal daily to see what pirate has acquired what formerly cheap generic drup to monopolize it and raise the price 500%?

Yes, the price was outrageous. How is the practitioner supposed to know every patients health care coverage and what one particular insurance carrier will cover for what drug? What's $50 for one person is $1500 for another, depending on their insurance.

Our entire health care system sucks. The only people who like it are the Insurance and Pharma execs.

Tim , March 20, 2018 at 9:09 pm

I won't give a doctor a break that prescribes a non-essential medicine with a 6% success rate.

[Mar 17, 2018] How to negotiate directly with physicians and hospitals

That's a fantasy: "It is important to lock this agreement in, quickly, before my account is sold to a third-party collection agency, which is nowhere near as likely to accept such a deep discount" Many hospitals sells you to collection immediately.
Mostly this is a cheap self-promotion of a yet another snake oil salesmen... Some more tidbit still might be useful You are warned.
If you try to fight medical-industrial complex alone most of the time you will be crushed. As a minimum you need a legal help. Often you need insurance too: at the end it is cheaper to have insurance then to fight astronomic bills. But those bottom feeders still can get to you via balance billing. and in most case, when you stay in hospital they do get back to you with the additional biils. That's why you will need a lawyers to fight this.
The usual trick of this scammers is to get "out of the network" ambulance and bill you $5K or more. Even the transfer from one hospital to another via ambulance can cost you tons of money.
Unnecessary procedures is another important danger. Stents is one such danger, in case of suspicion for the heart attack. You can get several several of them even if do not need them as a courtesy of those greedy jerks ;-)
And they will never agree for Medicare rates. Forget about it.
Notable quotes:
"... As we have already learned, all healthcare services have been assigned a code by the AMA, a five digit CPT code. So, if you trip and fall off your patio, you might get a doctor's bill like the following table located in your handouts: ..."
"... You may receive other bills from several doctors such as anesthesiologists and radiologists, as well as laboratory services, therapists, and the ambulance company. The bills all look similar, and the strategy and tactics I am presenting, today, should work for each of them as well. ..."
"... The purpose of this overpricing by the medical providers is to force the insurance companies to the negotiating table. The insurance company is bringing a large volume of patients to the medical providers, the members in their network, so they are able to negotiate a lower discounted allowable fee from the medical providers. However, if the insurance carrier is not able to negotiate a contractual allowable fee schedule, then they will end up paying the higher billed charges of the out-of-network provider for the members that still end up being treated by that medical provider in emergencies when precertification is not required. ..."
"... Now, on to where you can find these prices. Well, if you have insurance, then after you receive medical care and the healthcare providers send their claims to the insurance carrier, you should receive from the payer an Explanation of Benefits (EOB), or you probably can go online and view an Electronic Remittance Advice (ERA). For every CPT code that the providers billed , you will see both a billed charge and allowable. ..."
"... Fortunately, as you will now learn, there is a much more simple and better way to be 100% certain of your diagnosis, diagnosis code, procedure, procedure code, and even the medications the physician will offer you, at least for elective conditions. Here it is. If it isn't an emergency, then make a doctor's appointment! ..."
"... Does this sound unlikely? Too good to be true? Then consider this: Medical providers are highly incentivized to give the patients they treated huge discounts. Why? Because they know that collecting money from patients foments malpractice litigation. They would rather have you pay them pennies, than have you sue them for millions. ..."
"... I recently had breakfast with a pharmacist friend of mine that has worked as a manager for Walgreens for more than a decade. mrs_horseman is probably smiling when she hears that I have a pharmacist friend, because she knows how I feel about most of the people in that industry. Nonetheless, I told him about this presentation I am making, and asked if he had any advice for negotiating directly with the pharmacies for medications. It turns out, he does, and I would have never guessed the tactic he described. ..."
Mar 17, 2018 | www.zerohedge.com

... ... ...

Approximately 63% of Americans have no emergency savings for things such as a $1,000 emergency room visit or a $500 car repair, according to a survey released Wednesday of 1,000 adults by personal finance website Bankrate.com, up slightly from 62% last year. Faced with an emergency, they say they would raise the money by reducing spending elsewhere (23%), borrowing from family and/or friends (15%) or using credit cards to bridge the gap (15%).

http://www.zerohedge.com/news/2016-01-07/sad-state-affairs-two-thirds-a

... ... ...

You are going to need five things, which I am going to give to you, today, free of charge!

  1. Some absolutely critical industry vocabulary
  2. A clear understanding of how healthcare is priced in the USA
  3. Insight into to actual pricing
  4. A proven negotiation strategy, including:
    • a. The point of contact
    • b. Foreknowledge of what prices medical providers will usually agree to
    • c. A sample offer and agreement
  5. The confidence to successfully negotiate

Unfortunately, I couldn't come up with a better way to impart to you an understanding of the industry lingo, other than these simple handouts. However, this information is so important for you to be able to understand any negotiation strategy that I simply must slog through each term with you now. Please, I ask that you hold your questions and comments until I get through the vocabulary. Many of the terms are cross-referenced, and will become more clear after we here them all.

... ... ..

To begin to understand how healthcare is priced, we are going to look at

  1. the doctor's bill given to a patient,
  2. the claim forms the doctor and hospital send to the insurance carrier, and
  3. ERAs that the insurance carrier then send back to the patient and the providers.

As we have already learned, all healthcare services have been assigned a code by the AMA, a five digit CPT code. So, if you trip and fall off your patio, you might get a doctor's bill like the following table located in your handouts:

On the hospital's bill you might see something like this:

It is important to understand that the amounts shown on both of these bills are un-discounted Billed Charges (Usual and Customary Fees). They are the highest price the provider might ever hope to receive for the service, also known as full retail, or MSRP. Don't panic when you get these bills, because as everyone knows, "Never pay retail."

You may receive other bills from several doctors such as anesthesiologists and radiologists, as well as laboratory services, therapists, and the ambulance company. The bills all look similar, and the strategy and tactics I am presenting, today, should work for each of them as well.

If you have insurance, the providers will send your carrier a claim with essentially the same data as is on the bill they will provide to you if you are not insured, or if you simply request a copy.

An important fact is that Federal Law, as a requirement for the medical provider's participation in Medicare, requires that a medical provider charge every patient the same amount for a given CPT item. What it does not require, however, is that a medical provider accept the same payment amount from every patient for a given CPT item. This allows insurance companies, government payers, and you to negotiate a discounted fee, known as a contracted allowable, and not be in violation of the law.

The purpose of this overpricing by the medical providers is to force the insurance companies to the negotiating table. The insurance company is bringing a large volume of patients to the medical providers, the members in their network, so they are able to negotiate a lower discounted allowable fee from the medical providers. However, if the insurance carrier is not able to negotiate a contractual allowable fee schedule, then they will end up paying the higher billed charges of the out-of-network provider for the members that still end up being treated by that medical provider in emergencies when precertification is not required.

This creates a tiered-pricing structure for medical services that looks very much like this table in your handouts:

At this point, if you are paying close attention, then it should start to dawn on you where I am leading you with this talk, which, after all, is titled: How to negotiate directly with physicians and hospitals.

Spoiler Alert: You are learning how to negotiate for Medicare rates, at worst, and Medicaid rates, at best. In our example, a bilateral elbow fracture patient in Texas received surgeon and hospital bills totaling $179,219. Medicare allows $30,542 and Medicaid $22,600, which means the government negotiated an 83% or 87.4% discount, respectively. You can too!

Before we move on to providing you with access to these fee schedules, and then a negotiation strategy, do you have any questions about how healthcare is priced in the USA?

Now, on to where you can find these prices. Well, if you have insurance, then after you receive medical care and the healthcare providers send their claims to the insurance carrier, you should receive from the payer an Explanation of Benefits (EOB), or you probably can go online and view an Electronic Remittance Advice (ERA). For every CPT code that the providers billed , you will see both a billed charge and allowable.

Quick show of hands: how many of you have received a medical bill, or an EOB, and threw it away because you could not understand it? That is intentional! They want you to be confused. However, after today, I doubt that you will ever do that again.

What if we do not have insurance, or we want to know the allowable, because we think this is important information to know so that we can negotiate before receiving healthcare? Think having a baby or elective surgery. Do not worry! The federal government provides us with the Medicare rates online, and I believe that each state provides its Medicaid fee schedules online.

You would soon discover, however, that it is much easier to determine the allowable for a physician service than a hospital service, for which you will likely need to look up the DRGs for the ICD codes and then try to cross-reference them with the IPPS Fee Schedule, at a minimum, or you may even need to look up and calculate conversion factors. It is not easy, again, intentionally so!

Regardless, we would first need the CPT codes for the services you are seeking from the physician, and probably the ICD codes, too, in order to price hospital services. You could try to guess at the diagnosis and the services you think the doctor is going to provide to you, and then try to use a search engine to determine the ICD codes and CPT codes, or buy a coding book.

"I know I need a hip replacement. My trainer at the gym told me so. I'll just Google, hip replacement ICD and CPT code."

Good luck with that! The odds of you guessing the correct diagnosis and appropriate procedures (without going to medical school) are incredibly slim, especially with the new ICD-10 diagnosis codes. Also, chances are good that your athletic trainer doesn't know what the hell she is talking about when it come to medicine, and in reality, you probably just need a new athletic trainer, and not a new hip.

Is your head spinning, yet? Good! Now, stop it, because you will see that we don't need to do any of that! It's all just a red herring designed to keep us confused and the health insurers in business and profitable. Sounds a lot like our banking system, no?

Fortunately, as you will now learn, there is a much more simple and better way to be 100% certain of your diagnosis, diagnosis code, procedure, procedure code, and even the medications the physician will offer you, at least for elective conditions. Here it is. If it isn't an emergency, then make a doctor's appointment!

You may be thinking, "Isn't that putting the cart before the horse? Don't we want to know the costs in order to negotiate the fees before the services are provided?" The surprising answer is, no! Why? Well, because we only need to negotiate the fee schedule, specifically, Medicare or Medicaid, and not the exact fee. This is very important. Think back to the tiered-pricing structure.

Eventually, we may want to know the actual (or sometimes estimated) allowable amounts in order to budget for elective procedures, but this occurs after, or at the time of the physician's office visit, when they can provide us with the ICD codes, CPT codes, and usually the allowable amount, too! Later, we may choose to audit the allowable amount they give us, to make sure it is correct, and we were not over charged, but this is seldom done, as most people still trust their doctor, and the discounts you will be receiving are so HUGE you may feel a little guilty. Also, I will tell you, the auditing process is very tedious, not to mention the appeal process.

Therefore, we are now going to start talking about a negotiating strategy before we even attempt to access any pricing data. Again, we first need to know the diagnoses and proposed treatments. So, the solution is to start with a simple negotiation with the physician's office, probably just for the cost for the initial office visit, at the very least, and maybe some expected diagnostic tests. This is best done over the telephone, is easier and more successful than you might think, and is analogous to finding a mechanic to, "just take a look," at your car and tell you what is wrong with it, and then getting an estimate to repair it. Just like we expect to pay a little bit for the mechanic to diagnose our car, we should expect to pay a little bit for the doctor to diagnose us. The funny thing is that my mechanic and Medicare both charge or allow about $100 for a diagnosis. This is not so funny if you are the surgeon that spent 13 more years in school than the auto mechanic with a high school diploma.

Here we go, step by step:

1) I usually prefer to skip the added expense of going to a GP or family practice intermediary just to get a referral to a specialist that can actually help, especially when I can determine what medical specialty is likely to be most helpful for by medical condition by visiting the website of the American Board of Medical Specialties. (Is your ignition system acting up, your suspension riding a little rough, need new tires, brakes squeaking, transmission grinding?)

http://www.abms.org/member-boards/specialty-subspecialty-certificates/

2) Use the links on abms.org to visit the appropriate specialty board's website, and then use their "find a physician" with the sub-specialty likely to be most helpful for the condition

3) Start calling the sub-specialty physician offices listed, tell them you are a prospective new patient, and ask to speak to the Business Office Manager. Ask him or her the following questions:

a) "Do you accept Medicare and/or Medicaid insurance?" If yes, then...

b) "Super! Do you accept cash payment at the time of service?" If yes, then...

c) "Great! Then, of course, you will accept as payment in full, the Medicaid allowable, but paid in cash by me to you, directly, at the time of service? Correct?" If yes, then (e). If no then (d).

d) "I guess I understand. Well, then surely you will at least accept as payment the Medi­care allowable, paid in cash by me to you, directly, at the time of service? If yes, then (e). If no then conclude the call, because you cannot fix stupid.

e) "Thank you! Can you please tell me what the estimated amount is for an office visit, using this fee schedule, so I can know how much money to bring, and please make a note on my account that we have negotiated a Single Case Agreement for me to pay these rates to you, in cash, at the time of service?

f) Tell him or her your specific reason for the visit (I am leaking red fluid on the floor of my garage) and that you want to be fully prepared for the visit. Ask what diagnostic tests, if any, are usually required for this type of problem, lab, X-ray, CT, MRI, ultrasound, etc., and which ones would probably need to be done outside the physician's clinic?

g) Make sure to get the BOM's name and contact information, and the appointment time and date.

After your office visit, if it turns out that you need a procedure such as day surgery at an Ambulatory Surgery Center (ASC), an inpatient admission at a hospital, a diagnostic test like an MRI or CT, or a series of treatments such as physical therapy, then you simply repeat the above negotiation, starting with the facility your physician recommends, and in the case of a hospital or ASC, always where he or she has privileges. ASC's allowable rates are always much lower than a hospital, so act accordingly. When telling the BOM that you are a prospective new patient, make sure to give the name of your physician. Instead of just making a note of any negotiated agreement in your account, the BOM and you should execute a written Single Case Agreement. It is usually a one-page agreement that looks something like this sample found in your handouts:

It should be obvious to you why, when possible, these negotiations should occur before treatment, which is more often than you might imagine. In general, elective conditions are negotiated in advance in this manner. Next, we are going to look at emergency conditions, which are more than likely negotiated after examination and treatment.

Before we do, are there any questions?

Ok, so I experience some kind of true medical emergency, where my life or limb is in jeopardy, like a heart attack. mrs_horseman puts me in an ambulance that rushes me to the Emergency Room at the hospital, and they run all kinds of tests, and give me some very expensive medications. Fortunately for me, a long enough timeline has not yet passed, my survival rate has not dropped to zero, and I don't even get to go to the cath lab or have emergency heart surgery. However, we do get several large medical bills from the hospital, ER doctor, ambulance, laboratory, and cardiologist. I either have no insurance, am self-insured, or I have a catastrophic insurance plan with a very high deductible that I am not likely to meet with this event, or this year. What do I do?

When I receive each bill, I immediately call each provider and get the name and address of the BOM. I then draft a Single Case Agreement Offer and Acceptance, and I offer to pay the estimated Medicaid allowable clearly labeled as such (by using the tiered-pricing structure I covered earlier) and expiring 10 days after it is received. I may also include some horseshit narrative about how I just received a small windfall, and was advised by my attorney to settle my hospital bill before I piss it away on fast women and slow horses, or worse, squander it. I send this to the BOM, Certified Mail-Return Receipt Requested , with my attorney copied on the bottom of the offer. The BOM may argue the accuracy of my Medicaid estimate, and make a counter offer with a more accurate Medicaid allowable, but the odds are very, very, high that he or she either agrees to the Medicaid allowable, or counters with something like a Medicare allowable. Either way, at this point I have successfully negotiated somewhere around an 83% - 87% discount on average, less for doctors, more for hospitals.

It is important to lock this agreement in, quickly, before my account is sold to a third-party collection agency, which is nowhere near as likely to accept such a deep discount, and far better than a healthcare provider at actually getting blood from a turnip. Medical providers are now turning their accounts over to collections as soon as 90 days from the date of service, which can mean that you are still being treated for this condition when this happens! Do not let this happen to you! Open the bills! Mail the offer! Maybe they say no, but that is not likely. On the other hand, the collections agencies are working very hard to get you on a payment plan for Billed Charges, with interest, for the rest of your life!

Does this sound unlikely? Too good to be true? Then consider this: Medical providers are highly incentivized to give the patients they treated huge discounts. Why? Because they know that collecting money from patients foments malpractice litigation. They would rather have you pay them pennies, than have you sue them for millions.

There it is. I said it. Think about that for a moment.

Now, considering the minimal risk of negotiating, and the large potential reward, do you now have the confidence to successfully negotiate directly with physicians and hospitals?

Before I spend just a few more minutes talking about pharmacies, and then finally some self-insurance goals, are there any questions or comments?

I recently had breakfast with a pharmacist friend of mine that has worked as a manager for Walgreens for more than a decade. mrs_horseman is probably smiling when she hears that I have a pharmacist friend, because she knows how I feel about most of the people in that industry. Nonetheless, I told him about this presentation I am making, and asked if he had any advice for negotiating directly with the pharmacies for medications. It turns out, he does, and I would have never guessed the tactic he described.

Are you ready? Coupons and free discount cards. He explained that if one simply goes online and searches for Walgreens coupons, it is usually possible to save between 5% and 60%. He specifically recommends Good Neighbor Pharmacy Prescription Savings Club.

http://www.mygnp.com/prescription-savings-club

He says that when you purchase medications, then you have 5 days to return to the same location Walgreens and bring a coupon for reimbursement of any savings. He says that if you are paying cash, then you must be sure to request a generic, if available. For long term meds, he explains that the drug manufacturer's web sites will often offer a free co-pay assistance card. If you have insurance, then you can present the free card from the manufacturer to the Walgreens pharmacy, and it will cover your co-pays. In closing, I want to talk just a bit about insurance and one of the situations where we would want to be able to negotiate directly with physicians, hospitals, and pharmacies.

As we have discussed, today, one of the primary benefits of having health insurance is to take advantage of the discounts negotiated by the insurance company or government. However, we just learned that providers are usually willing to accept similar discounted rates from cash pay patients.

The other big benefit of health insurance is to share with other people the risk of having to pay large bills that are the result of serious and unexpected injuries or illnesses. This is the traditional role of insurance. However, the costs and benefits of sharing risk are directly related to the health and healthcare consumption habits of all the members of the risk pool. As the post-vasectomy head of a healthy household, do I really want to be swimming in the Obamacare risk pool with millions of morbidly obese, perpetually pregnant, HIV infected drug abusers? No. It is too expensive!

What to do? Well, what do many smart employers in Texas do to save money with Worker's Compensation Insurance? They self-insure! They have money put away in case of an emergency. If they have an employee that is injured, then they negotiate directly with the healthcare providers, and pay deep discounts well below the statutory Worker's Compensation allowable, which we learned earlier is usually the highest allowable. They pay themselves a premium each month, which is effectively a forced savings plan. Sometimes, these companies may also purchase a relatively inexpensive health insurance plan called catastrophic, just in case a really big and expensive event occurs, like the whole oil refinery blows up and puts a few hundred employees in the hospital. However, if nothing happens, and the employees don't have any accidents, the company gets to keep most of the money, instead of giving it all to the insurance companies!

Hmmm. I wonder. Could I do that for my health insurance? Yes, and in fact mrs_horseman and I do exactly this. We have a high-deductible catastrophic health insurance plan and a $600 savings line item in our budget that we pay ourselves every month. We bet on ourselves to be healthy, unlike an HSA, where you bet on yourself to be unhealthy. This is true, and why we simply refuse to take the pre-tax bait of an HSA.

... ... ...

[Nov 30, 2017] Healthcare Costs and Its Drivers Today by run75441

Notable quotes:
"... We no longer care for patients, but we care about what's going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures ..."
"... Now before you start on insurance companies and doctors; understand, this is not as free a market place as many would assume. ..."
"... In all of their political wisdom, Congress favors pharmaceutical companies over doctors, insurance companies, and the welfare of the constituents. ..."
"... Through legislation, Congress has made it impossible for insurance companies to negotiate pharmaceutical pricing in Medicare Part D insurance and also the ACA ..."
"... So we spend more for healthcare than any other country in the world; but, Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician's knowledge or judgment. They are being driven by what payers are willing to pay for. ..."
Nov 25, 2017 | angrybearblog.com

I have been doing my typical reading on healthcare in the US and ran across several articles which seemingly come together at various points in the dialogue and are written by different authors. I decided to tie them together into a much wider and telling story.

An interesting point being was made by MedPage Today's Dr. Milton Packer on his blog, " people suffer and die because Payors (Healthcare Insurance) is cost effective ." He starts his discussion on the opiate epidemic in the US, opiates are being prescribed by doctors for pain relief and . . .

"Patients are becoming addicted to opiates after the initial 10 day prescription with one-fifth of patients still using opiates a year later. There is no need to prescribe opiates as other less addictive pain-relief formulations are available, which are not commonly prescribed." This raises the question of why?

Payers will not pay for the alternatives. The less-addictive opiates are more expensive and payers have declined to support them. Patients get addicted because prescribing for the lower cost and highly addictive opiates saves the payers money initially (me) .

September 17, 2017, the New York Time and ProPublica (independent, nonprofit investigative journalism organization) collaborated on an article concerning the opiod epidemic in the US.

At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications.

The reason given: Opioid drugs are generally cheap while safer alternatives are often more expensive.

While the pharmaceutical manufacturers, distributors , and doctors have come under scrutiny; insurance companies and the pharmacy benefit managers (CVS Caremark, Express Scripts and OptumRx) make the final decisions as to what is covered. It could be something as simple as a higher tier and deductible to block usage.

A little side trip here and a continuation of the above. A week or so ago, I ran across another MedPage Today article by Dr. Packer; " Who Actually Is Reviewing All Those Preauthorization Requests and How the System Works ." Dr. Packers was giving a talk on advances in medicine with regard to heart failures to a room of about 20 or so doctors who were retired.

Since many of them were no longer involved in active patient care, he wondered why they might want to hear a presentation on new advances in heart failure. Here was their answer:

Doctors: " We no longer care for patients, but we care about what's going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures ."

" Dr. Packer: I just gave a talk about new drugs for heart failure. Are you responsible for preauthorizing their use for individual patients? "

The answer; "Yes."

" So did I say anything today that was helpful? I talked about many new treatments. Did I say anything that you might use to inform your preauthorization responsibilities? "

"Oh, we've heard about those drugs before. We are asked to approve their use for patients all the time; but, we don't approve most of the requests. Nearly all of them are outside of the guidelines we are given."

" I just showed you evidence that these new drugs and devices make a real positive difference in people's lives. People who get them feel better and live longer. "

"Yes, you were very convincing. But the drugs are too expensive. So we typically reject requests, at least the first time. We figure that, if doctors are really serious, then they should be willing to make the request again and again."

" If the drugs will help people, how can you say no? "

"You see, if it weren't for us, the system would go broke. Every time we say yes, healthcare becomes more expensive, and that isn't a good thing. So when we say no, we are keeping the system in balance. Our job is to save our system of healthcare."

" But you are not saving our healthcare system. You are simply making money for the company that you work for. And patients aren't getting the drugs that they need. "

"You really don't understand, do you? If we approve expensive drugs, then the system goes broke. Then no one gets healthcare."

"Plus, if I approve too many expensive drugs, I won't get my bonus at the end of the month. So giving out too many approvals wouldn't be a smart thing for me to do. Would it?"

Now before you start on insurance companies and doctors; understand, this is not as free a market place as many would assume.

In all of their political wisdom, Congress favors pharmaceutical companies over doctors, insurance companies, and the welfare of the constituents.

Through legislation, Congress has made it impossible for insurance companies to negotiate pharmaceutical pricing in Medicare Part D insurance and also the ACA .

Furthermore with the consolidation happening in healthcare, negotiation by insurance companies with a consolidating and growing healthcare industry is becoming more and more difficult as the former does not have as great of leverage. You have read my argument calling out of Single Payor, Medicare-for-All, Public Option, etc. as the cure for today's healthcare issues and rising cost not being enough as the ACA and Part D were specifically blocked or the cost issue unaddressed in the legislation written by Congress. If these issues are not addressed from the very beginning, we will be fighting the same issues with rising costs a decade later with other programs.

At this point, I begin to disagree with Dr. Packers as he goes on to say:

" So we spend more for healthcare than any other country in the world; but, Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician's knowledge or judgment. They are being driven by what payers are willing to pay for. "

It is true that patients may not get some of the healthcare they need at the time due to denial, which can be appealed to the ACA, and can be a tiring process. It could be approved, passed on to patients, resulting in higher premiums the following year, and the Part D Risk Corridor program pay for it if excessive for the present year. What Dr. Packers does not mention is the rising prices and cost of drugs being blamed by pharmaceutical company on R&D, tooling up to manufacture, etc. The counter argument is much of the R&D is funded by the US government through tax deductions and write-offs for pharmaceutical R&D and capital Overhead. Pharmaceutical profits are double digit at ~25% beating out hospital supplies and healthcare insurance, which is already limited in what can be charged back to the insured by the MLR. To blame insurance companies totally for the higher costs in healthcare is false. Furthermore, a doctor's decision do not always lead to less costly cures or practices.

Maggie Mahar of Health Beat Blog would take the subject of costs a step farther and state Medicare will approve anything the FDA approves for usage regardless of the quality of outcome when measured against older proven treatments. Notably the VA does limit its pharmacy and its care is rated higher than that of today's commercial, for-profit healthcare to which most citizens are exposed.

Dr. Donald Berwick, President Obama's proposed appointment for Medicare and who was in charge of Medicare and Medicaid for 17 months stated;

"20 to 30 percent of health spending is 'waste' that yields no benefit to patients, and that some of the needless spending is a result of onerous, archaic regulations enforced by Medicare and Medicaid.

He listed five reasons for what he described as the 'extremely high level of waste.' They are overtreatment of patients, the failure to coordinate care, the administrative complexity of the health care system, burdensome rules and fraud .

Much is done that does not help patients at all and many physicians know it."

That is the same Medicare/Medicaid being touted by many proponents today as an alternative.

Speaking of costs and pricing for pharmaceuticals, there have been recent incidents of skyrocketing costs on particular drugs. A short while ago, I wrote a post concerning the appointment of Alex Araz as the new HHS Secretary replacing Dr. Tom Price. Formerly, Alex Araz was the CEO of the pharmaceutical giant Eli Lilly & Co.'s U.S. division . He also served under George W. Bush administration as the HHS General Counsel and Deputy Secretary. During that stint, he received praise for his management competence with the HHS; although, he did not have a healthcare background prior to this position.

Here it gets interesting when examining what took place during his tenure with Eli Lilly. One of the leading costs identified in pharmaceuticals increases has been in the rising cost of diabetes medication.

"While the Tweeter-in-Chief, Trump tells us presidential campaign contributor Alex Azar will be a 'star' who will lower prescription prices,"

Public Citizen's Peter Maybarduk (Director) had this to say: " Eli Lilly is notorious for spiking prices of a century-old isolated hormone during Azar's tenure as president and vice president. Eli Lilly raised the price of Humalog by 345%, from $2,657.88 per year to $9,172.80 per year.

Maybe President Trump in appointing Alex Azar to be HHS Secretary should have asked the 6 million diabetic Americans whose insulin prices have more than tripled under Azar's watch at Eli Lilly."

This has nothing to do with R&D and has more to do with pharmaceutical companies controlling the market regardless of supply and throughput restricted manufacturing (capacity).

What I have tried to do is tie these articles together into one cohesive story of how the pharmaceutical industry, insurance, and healthcare can have an impact on healthcare costs. For those who are interested, my background does include working in the manufacture of hospital supplies and pharmaceuticals. Using various citations from these articles, I have tried to touch upon the impact of insurance companies, the healthcare industry, government intervention under the HHS, one particular Med in the market place, etc. Overall, what is going on in the marketplace.

Another article, I read the other day gets into the foundation of what is happening based upon a recently completed study by JAMA. Using this study, the Methods Man, Dr. Perry Wilson (MedPage Today) examines what is driving healthcare costs in his article Here's What's Really Driving Healthcare Costs using data from Factors Associated With Increases in US Health Care Spending, 1996-2013 and the US Disease Expenditure Project . Dr. Wilson breaks it down using three simple charts which I have consolidated to one.

Dr. Perry Wilson starts off making an overall point about the rising cost of healthcare from 1996 to 2013 and stating; "after accounting for inflation, healthcare expenditures increased $933.5 billion from 1996 to 2013."

Going on: "Healthcare expenditures in the US being high and rising rapidly is nothing new, but the study appearing in the Journal of the American Medical Association identifies the exact components of healthcare that are driving those soaring costs. The data from this study suggests traditional economic forces break down in the US healthcare market.

Different chronic diseases have different patterns of price increases. The biggest increase was seen in diabetes care, as you can see here, driven largely by the rising costs of pharmaceuticals."

The Chart breakdowns reveal the various impacts of healthcare costs moving from left to right and then downward:

• 50% of the increase in healthcare costs was simply due to higher prices.

• Inpatient care or Service Utilization (purple) went down from 1996 – 2013 as outpatient treatment increased; however, the price of the remaining inpatient care went up much more – increasing overall inpatient care spending by around $250 billion.

• Different Chronic Diseases have different patterns of price increases. The biggest increase was seen in diabetes care and driven largely by the rising prices of pharmaceuticals.

The takeaway drawn by Dr Perry Wilson: "Regardless of the disease, it is clear, the price of what we're buying – whether a drug, an ED visit, or a hospital stay – not the amount of what we're buying is the major driver of cost increases . Efforts to reduce the consumption of healthcare may not bend the cost curve as much as efforts to reduce its price."

You can not make an argument about the regulation of costs "not" being one of the dynamic components of a healthcare plan given the continuous unhindered industry driven rising cost of healthcare. Yet, every healthcare plan I have read fails to mention cost regulation specifically, provide remedy for it, and many assume a natural occurrence of control.

Tags: run75441 Comments (9) Digg Facebook Twitter Comments (9)

Longtooth , November 26, 2017 12:59 am

Run thanks for this, but in my opinion you're avoiding the central problem , though you briefly touched upon it without being more explicit:

"This has nothing to do with R&D and has more to do with pharmaceutical companies controlling the market regardless of supply and restricted manufacturing throughput. "

The market can't be controlled by the pharmaceutical companies unless the government lets them. So this is a government sourced and caused problem unless you believe laissez-fair is the gov'ts job to promote and endorse.

You can't blame the pharmaceutical companies for doing precisely what the gov't lets them do by law.. the pharmaceuticals company's owners are in this to be philanthropic are they?

What you are essentially not coming to grips with is that our government is not designed to be democratic but designed by it's concept to be a system to ingratiate those who pay the most to keep the gov't in power which is to say those that represent them are paid to do their bidding in other words a gov't controlled by the sources of wealth to maintain it. if it were anywhere near a democratic system, how could 1% control it?

Longtooth , November 26, 2017 1:08 am

Run, sorry I forgot that there's never been a democratic system from the Spartan through the Athenian to the present that hasn't been controlled by the wealth. There have only been moments brought about by extreme deprivation that have had to deal with that deprivation to avoid revolution.

When we want to fix U.S. healthcare costs and quality we know how to do it, but you have to fix the system of government we employ to do it. Address the source of the problem rather than effects of it.

Longtooth , November 26, 2017 1:36 am

Run, let me only add that I don't know how we can have a free market based and biased system of government and anything even approximating a democratic system at the same time. That is the actual dilemma since they are mutually exclusive.

If you think about how to "comprise" one with the other then you have to decide how such compromise is made and sustained (sustained being key word) and I can't see or find any evidence in U.S. history that suggests such compromise has ever worked to provide for the greater good on a sustained basis.

Perhaps its not even possible among human systems of civilized government .. but then why the charade as if it is? If the public wants to improve the healthcare system then why does it elect Presidents and representatives who don't want to improve it? If the public want's to improve the healthcare system why do Supreme Court interpret the Constitutional "law" to prevent it? Or if the 200+ year old constitutional law is so outdated as to be irrelevant than why doesn't the pubic demand to change it?

Or does the pubic want it's cake and eat it too? The public may be confused (I'm sure of this in fact) because they want simultaneously mutually exclusive conditions.

Denis Drew , November 26, 2017 9:29 am

Run, great major post.

Long, " I don't know how we can have a free market based and biased system of government and anything even approximating a democratic system "

No? Look at continental Europe -- look at across the board labor union density -- look at sector-wide labor agreements. Come to think look at our northern neighbor.

Mostly all other problems from health care to student debt to everything are just symptomatic of the same economic/political-union free pathology. Bernie and Eliz don't spend a lot of time looking abroad either -- or even looking at 1973 stateside.

Come a Dem Congress I think the best idea is:
Why Not Hold Union Representation Elections on a Regular Schedule?
Published November 1st, 2017 – Andrew Strom

https://onlabor.org/why-not-hold-union-representation-elections-on-a-regular-schedule/

This can be sold as taking a page from Repub govs (e.g., Walker) who force government employee unions to re-certify every year -- with majority of union members, not just those who vote, required to retain.

I'm playing with the idea of proposing (via spam mail*) re-certification for every union in the country every year -- oh, of course, that would include certification elections for every nonunion workplace: that's the Trojan Horse .

We really want to certify/recertify every three or five years (three at first while we are trying to build density -- maybe five later on). Once we organize enough we can write the rules any way we want. By proposing re-certification every year (from my spider hole in Chicago) maybe I can get union members dander up and thereby at least wake them up to the issue. Cab driver political drama.

(* I have about 2000 email addresses, journalists, union, academic, politicians -- in WA, OR, CA, NV -- that I like to hit with new ideas.)

run75441 , November 26, 2017 11:40 am

Denis:

You may want to look at this again. A portion of it was blocked due to an error in linking to an article on Pharma costs which was kind of important. I have another article coming out which will discuss Pharmaceutical companies pulling advertising from medical news sites and mags if they are critical of pharma. As I read each of these articles, I could see a similar thread in them.

in 2015, AARP broke ties with MetLife over LTC insurance which MetLife discontinued in 2011 (no new applications). No big deal except AARP never told its membership of the AARP sponsored insurance break with MetLife. AARP now has a new LTC insurer New York Life announced as of 2015 and no letter to its members holding MetLife policies. Those who had AARP sponsored MetLife are now left with MetLife who is requesting a 21.75% increase just for cost over 3 years in addition to the normal inflation factor which was ~10% for 2018. AARP refers all inquiries to MetLife even though documents from MetLife still has AARP logos on it. Another interesting post of companies and Organizations screwing people.

Longtooth , November 26, 2017 5:48 pm

Dennis,

FWIW I come from a long line of union activists, members, and in one case a major union leader in the western U.S. and California in particular -- Building & Construction Trades Council.

I've been and remain a hugely strong union supporter. However my uncle (the Western US major union leader) was a realist and well understood the nature of economics viz-a-viz unions and capital owners.

In a series of discussions while I resided with he and his wife during one summer college break, he made me understand those trade-offs, and what drove them. At the time the college educated workforce in the US was 10% (4 year or better degree). He said a major factor in union's was the level of the college educated workforce and he said in 1966, that if the rate of college degree growth reached the then unprecedented rate of ~ 0.5%/year than in a few decades 1/3rd of the workforce would have college degrees -- the upshot of which is that they would very unlikely be persuaded to join unions or create new ones. His prognosis in 1966 turns out to be pretty close to reality even though he had little historic information to go on., .. he was not a pie in sky type, but a practical and major proponent of the general working class an working poor.

He also told me in 1966 that if unions demanded too much of the capital owners profits, they would resort to capital invested in automated methods -- his primary example of which was the hift to lath & plaster skilled union members to wall board which required no skill per-se and that forced union wages for interior "plasterers" down as lower skill and more efficient "sheetrock" hangers too over.

He cited other examples of automation replacing skilled union labor and without elaborating it was an eye-opener for me to see that unions were on their way down He not only knew the economics of building and construction business and labor, but of mining and manufacturing.

This was all long before Reagan's anti-unionism push (which in reality was Reagan using what was already well underway as a means of pumping up is conservative credentials).

My uncle's wisest advice was that if unions demanded more than capital owners were able to profit, they would simply use their capital in other enterprises where profits were greater -- this included not only investing in automated methods in mfg'ing and the building and construction trades (remember "sheetrock") , but in foreign low wage labor regions where especially mfg'ed goods could be produced at lower costs IF(the big IF in 1966) transportation and import duties made it more profitable to do so. He cited Mexico as the primary source of low transport cost low wage labor at the time, and at that time import duties from the few mfg'ed goods produced in Mexio were excessive which was the only reason mfg'ing hadn't shifted to use Mexican labor in Mexico for production and also why mfg'ing was investing more and more capital in automation. BUT, he said sooner or later it would become clear that capital owners would push to chane US import policies from Mexican roduced goods and the this would reduce mfg'ing's need for U.S. labor, thus Union's would have far less leverage to take a share of capital profits.

So he was a few decades off in his estimates, but he was right in 1966.. My uncle was among those in the U.S. union leaders who all understood all this very well what they said in public was different that what they saw occurring and would continue to occur they just didn't know then the rate of occurrence -- the computer age hadn't started . semi-conductors were being invented and barely developed for example. China's opening up hadn't occurred yet either. Clinton's NAFTA was still far in the future.

Through al the years since 1966 I've watched the progression of what my Uncle told me during our discussions in the summer of 1966. take place, for precisely the reasons he (and other major union leaders) knew they would.

In hindsight what fails in the U.S. relative to Europe is Germany's constitutional protections of labor unions. which by osmosis transfers to the other major European nations just as U.S. union wages and benefits transferred by the same osmosis to non-union wages and benefits rising to keep pace.

Keep up the good fight, Dennis, but you're forgetting about the economic realities in the US and it's individualism worship and constitution that protects it. .

JackD , November 26, 2017 9:22 pm

Run, as you know, nothing substantive on controlling medical costs can possibly occur with Republicans in charge. With Democrats in charge, it's tough enough. Witness the ACA's development and the impact of the blue dogs.

JimH , November 27, 2017 10:28 am

JackD wrote "Run, as you know, nothing substantive on controlling medical costs can possibly occur with Republicans in charge."

I could not agree with you more.

The Republicans' implementation of Medicare Part D which forbids negotiation of drug prices was asinine. Where was their concern for the national deficits and debt?

On heath care President Obama was negotiating with the duplicitous. His opposition had only one concern, their oath to Grover Norquist.

Daniel Becker , November 27, 2017 5:22 pm

It's not just that pharma has some say on what gets published, but in the health literature world, the trend was to only publish positive results.

As you can imagine, this has left a major void in truly understanding what happens in the body when a treatment is applied. There is a push to change this. Additionally, there is the push toward the idea of "numbers to treat". That is, how many have to receive the treatment to create one positive results. Outcomes can look a lot more different when looking at numbers to treat.

[Nov 30, 2017] A comprehensive health care program for social services recipients can be provided for about 3-4% of the cost of services. Private medical insurance providers rake 20%. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets its just so damn easy to cheat and cheaters are never in short supply.

Nov 30, 2017 | marknesop.wordpress.com

Patient Observer , November 27, 2017 at 5:12 pm

Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.

[Nov 30, 2017] I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties.

Nov 30, 2017 | marknesop.wordpress.com

anon@gmail.com , November 27, 2017 at 6:02 pm

I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.

[Nov 30, 2017] The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system)

Nov 30, 2017 | marknesop.wordpress.com

Ryan Ward , November 28, 2017 at 3:40 am

With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 30, 2017] The most interesting insight into healcare in the USA: The cost is shocking

Nov 30, 2017 | marknesop.wordpress.com

James lake , November 28, 2017 at 12:21 am

This is s very interesting insight into healcare in the USA. The cost is shocking.
I live in the UK and the healthcare system is paid for from taxation.
When it was established over 70 years ago it's
The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means.
It was the best thing in my view that government has ever done.
Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.
Which many people do not mind.
-Elderly care was also privatised as it's the most expensive
-care for the disabled also is a issue for local councils
-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.
And yet still more and more taxation is needed for the NHS!
The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.

[Nov 30, 2017] Looks like the rot in the US healthcare system is terminal

Nov 30, 2017 | marknesop.wordpress.com

kirill , November 27, 2017 at 8:38 pm

Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

[Nov 30, 2017] Looks like the rot in the US healthcare system is terminal

Nov 30, 2017 | marknesop.wordpress.com

kirill , November 27, 2017 at 8:38 pm

Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

[Nov 30, 2017] The most interesting insight into healcare in the USA: The cost is shocking

Nov 30, 2017 | marknesop.wordpress.com

James lake , November 28, 2017 at 12:21 am

This is s very interesting insight into healcare in the USA. The cost is shocking.
I live in the UK and the healthcare system is paid for from taxation.
When it was established over 70 years ago it's
The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means.
It was the best thing in my view that government has ever done.
Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.
Which many people do not mind.
-Elderly care was also privatised as it's the most expensive
-care for the disabled also is a issue for local councils
-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.
And yet still more and more taxation is needed for the NHS!
The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.

[Nov 30, 2017] The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system)

Nov 30, 2017 | marknesop.wordpress.com

Ryan Ward , November 28, 2017 at 3:40 am

With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 30, 2017] I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties.

Nov 30, 2017 | marknesop.wordpress.com

anon@gmail.com , November 27, 2017 at 6:02 pm

I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.

[Nov 30, 2017] A comprehensive health care program for social services recipients can be provided for about 3-4% of the cost of services. Private medical insurance providers rake 20%. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

Nov 30, 2017 | marknesop.wordpress.com

Patient Observer , November 27, 2017 at 5:12 pm

Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.

[Nov 29, 2017] The Best Health Care You Can Afford by marknesop

Notable quotes:
"... "No, I mean I'm sorry that you've inherited such a miserable, collapsing Old Country. A place where rich Bankers own everything, where you've got to be grateful for a part-time job with no benefits and no retirement plan, where the most health insurance you can afford is being careful and hoping you don't get sick ..."
"... "Until fairly recently, every family had a cornucopia of favorite home remedies–plants and household items that could be prepared to treat minor medical emergencies, or to prevent a common ailment becoming something much more serious. Most households had someone with a little understanding of home cures, and when knowledge fell short, or more serious illness took hold, the family physician or village healer would be called in for a consultation, and a treatment would be agreed upon. In those days we took personal responsibility for our health–we took steps to prevent illness and were more aware of our bodies and of changes in them. And when illness struck, we frequently had the personal means to remedy it. More often than not, the treatment could be found in the garden or the larder. In the middle of the twentieth century we began to change our outlook. The advent of modern medicine, together with its many miracles, also led to a much greater dependency on our physicians and to an increasingly stretched healthcare system. The growth of the pharmaceutical industry has meant that there are indeed "cures" for most symptoms, and we have become accustomed to putting our health in the hands of someone else, and to purchasing products that make us feel good. Somewhere along the line we began to believe that technology was in some way superior to what was natural, and so we willingly gave up control of even minor health problems." ..."
"... The Complete Family Guide to Natural Home Remedies: Safe and Effective Treatments for Common Ailments ..."
"... "The vast wealth of the financial oligarchy, expressed in their ownership of massive corporations, must be seized and expropriated, while the complex technologies, supply chains, and advanced transportation systems must be integrated in an organized, planned manner to harness the anarchic force of the world economy and eliminate material scarcity. ..."
"... Interesting article. Looks like the rot in the US is terminal. ..."
"... This is s very interesting insight into healcare in the USA. The cost is shocking. I live in the UK and the healthcare system is paid for from taxation. When it was established over 70 years ago it's. The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means. It was the best thing in my view that government has ever done. Good healthcare should be available to all and not dependent on peoples ability to pay. ..."
"... Privatisation has meant profits for businesses, poor services to vulnerable groups. ..."
Nov 27, 2017 | marknesop.wordpress.com

"The art of medicine consists of amusing the patient while nature cures the disease."

"No, I mean I'm sorry that you've inherited such a miserable, collapsing Old Country. A place where rich Bankers own everything, where you've got to be grateful for a part-time job with no benefits and no retirement plan, where the most health insurance you can afford is being careful and hoping you don't get sick

Cory Doctorow; Homeland

"Until fairly recently, every family had a cornucopia of favorite home remedies–plants and household items that could be prepared to treat minor medical emergencies, or to prevent a common ailment becoming something much more serious. Most households had someone with a little understanding of home cures, and when knowledge fell short, or more serious illness took hold, the family physician or village healer would be called in for a consultation, and a treatment would be agreed upon. In those days we took personal responsibility for our health–we took steps to prevent illness and were more aware of our bodies and of changes in them. And when illness struck, we frequently had the personal means to remedy it. More often than not, the treatment could be found in the garden or the larder. In the middle of the twentieth century we began to change our outlook. The advent of modern medicine, together with its many miracles, also led to a much greater dependency on our physicians and to an increasingly stretched healthcare system. The growth of the pharmaceutical industry has meant that there are indeed "cures" for most symptoms, and we have become accustomed to putting our health in the hands of someone else, and to purchasing products that make us feel good. Somewhere along the line we began to believe that technology was in some way superior to what was natural, and so we willingly gave up control of even minor health problems."

Karen Sullivan; The Complete Family Guide to Natural Home Remedies: Safe and Effective Treatments for Common Ailments

No, I haven't abandoned Uncle Volodya, or shifted my focus to American administration; what follows is a guest post on the American healthcare system, by our friend UCG. As I've mentioned before – on the occasion of his previous guest post, in fact – he is an ethnic Russian living in the Golden State.

As an American in America, naturally his immediate concern is going to be healthcare in America; but there are lessons within for everyone. Don't get me wrong – doctors have done a tremendous amount of good, and medical researchers and many others from the world of medicine have made tremendous advances to which many of us owe their lives. Sadly, though, once a field goes commercial, the main focus of attention eventually becomes profit, and there are few endeavors in which the customer base will be so desperate. While there are obvious benefits to 'socialized medicine' such as Canada enjoys and American politicians scorn as 'Commie' – enough to earn the admiration of many – it results in such a backlog for major operations that those who don't like their chances of dying first, and have the money or can somehow get it, often flee to America, where you can get a good standard of medical care without running out of time waiting for it.

Without further ado, take it away, UCG!!

Healthcare in America

This article is my opinion. My hope is that others will do their own research on America's Healthcare Industry, because this is an issue that needs to be addressed, and for this article to be a mere starting point in this research. The reason for my citations is so that you, the reader, can verify them. Once again, this is my opinion. I write this in the first paragraph, so that I can avoid stating "in my opinion" before every sentence.

Let's start with Owen Davis who was charged $14,018 for going to a hospital because he sliced his hand, and they fixed it . A study published by Johns Hopkins showed that for $100 of ER treatment, some hospitals were charging patients up to $1,260 . A redditor claimed that :

I tore my ab wall a month ago and didn't think much of it until my pain kept worsening. I went to an immediate care facility to rule out a hernia (I had all the symptoms) and they told me to get to ER ASAP. I go to the ER and they give me a CT scan and one x-ray and say it's not a hernia and let me go. Fast forward to today and I got a bill for $9,200 and $3,900 of it is out of pocket. $9,200 for two tests???? No pain meds were administered; it was literally those two tests. What should I do to contest it? I will be calling tomorrow to demand an itemized bill, but is there anything else I should do in the meantime?

All of these took me a few minutes on Google to find, and another few minutes to post. The reason I chose that reddit, is because one of the readers offered an ingenious solution: Next time you hurt yourself – book a return ticket to NZ – go to accident and emergency, say you're a tourist and you hurt yourself surfing, pay nothing – fly home and pocket $8,000 in spare change. If that was me, I'd spend at least $2,000 on tourism in New Zealand. You guys have that system, so you clearly deserve the money! Anyone interested in a startup?

But I am not done with examples just yet. Shana Sweney described her experience in the emergency room : I delivered in 15 minutes. During that time, the anesthesiologist put a heart rate monitor on my finger and played on his phone. My bill for his services was $3,000. $200/minute. I talked to the insurance company about it – and since I ran my company's benefit plans, I got a little further than most people, but ultimately, that was what their contract with the hospital said so that's what they had to pay. Regardless of if he worked 15 minutes or 3 hours. Similarly, my twins were born prematurely and ended up in the NICU for 2 weeks. While the NICU was in-network for my insurance, for some mysterious reason, the neonatologists that attended the NICU were out of network. I think that bill was $16k and they stopped by to see each kid for an average of about 30 min/day.

Almost done with the examples, just please bear with me. How would you like a hospital billing you $83,046 for treating a scorpion sting , if a Mexican ER might have treated you for the same type of sting for $200? Perhaps being charged $546 for six liters of saltwater is more to your liking? $1,420 for two hours of babysitting ? $55,000 for an appendicitis operation ? $144,000 to deliver a perfectly healthy, albeit quite impatient baby? According to my interpretation of the sources linked, all of these actually happened. I encourage you to do your own research.

The World's Biggest Legalized Corruption (IMHO)

$984.157 billion. That's $984,157,000,000. That is how much money I believe the United States wastes on Healthcare. Not spends; wastes. As in money down the drain. The astute reader figured out that equates to five percent of America's 2016 GDP . Said reader is absolutely correct. How did I estimate such a gargantuan amount? According to the OECD data , in 2013 the United States spent 16.4 percent of its GDP on Healthcare; the two next biggest spenders, Switzerland and the Netherlands spent 11.1 percent. Even if one was to give the United States the benefit of doubt, and claim that the United States healthcare is just as efficient as that of Switzerland or the Netherlands – which is most likely not true according to an article from Business Insider , but even if it was – that meant that the United States wastes 5.3% of its GDP on healthcare. Wastes. I just want to make sure that the amount of this alleged legalized corruption, which will most likely reach a trillion dollars by 2020, is noted.

Let me place those funds into perspective: it's almost as much as the amount that the rest of the World spends on the military, combined . The SCO member states, including China, Russia, India, and Pakistan spent roughly $360 billion on the military . The wasted amount is equivalent to the GDP of Indonesia, and greater than the GDP of Turkey or Switzerland . In 2016, the US Federal Government spent $362 billion, or 36.8% of the wasted amount, to run all Federal Programs , including the Department of Education and NASA, with the exception of Social Security, Medicare/Medicaid, Veteran's Affairs, the military, and net interest on the US debt. All other Federal Programs were covered with the $362 billion. The US Federal Debt stands at $20.4 trillion , meaning that the debt can be paid off in 30 years, merely if the Healthcare Waste is eliminated.

But why stop there? The US Housing Crisis started partly because loans were allowed to be taken out without the 20% down payment. Could this funding, if applied directly to the housing market, stop the 2008 Great Recession? Absolutely, and all the Federal Government had to do was to gear these funds towards down payment on subprime mortgage loans to meet the 20 percent barrier. I can go on and on about what can be accomplished, like making collegiate attendance free, or at least very inexpensive, or drastically improving the quality of education, paying off the national debt, reinvesting into the economy, reinvigorating the rural sector, and so on, and so forth. A trillion dollars is a lot of money.

Lobbyists, the Media and the Waste

Any guess how much was spent on lobbying by the Healthcare, Insurance, Hospitals, Health Professionals, and HMOs? How about 10.5 billion dollars? I knew that was your guess! That's a lot of money, and that does not include "speaking fees", or when a politician who constantly made calls beneficial to the Healthcare Lobby gets $150,000 to speak in front of an audience after they retire from politics. Obama made a speech in front of Wall Street, netting $400,000 . And by pure coincidence, only one Wall Street Broker was jailed as a result of the scandal. That $10.5 billion is just a tip of the iceberg, because "speaking fees" are notoriously hard to track, and not included in said amount.

Obama genuinely tried to reform US Healthcare to the Swiss Model. He was going to let Wall Street slide, he was going to let Neocons conduct foreign policy, just please, let him have healthcare! First, the lobbyists laughed in his face. Second, they utilized the Blue Dog Coalition to block Obama's attempt at Healthcare Reform, until it was phenomenally nerfed, and we have the disaster that we have today. As a result, Obama's Legacy, Obamacare is having major issues, including the rise of racism.

Obamacare helped the poor, (mostly minorities,) at the expense of the middle class, (mostly whites,) thus transferring funding from whites to minorities. While the intent was not racial, it is being called out as racial by the mainstream media . This probably suits the lobbyists, because if the debate is about racism, one cannot have a genuine discussion about Healthcare Reform.

Racism strikes both ways. Samantha Bee came out with a "fuck you white people" message right after the election. Jon Stewart, without whom she probably wouldn't have her own show, pointed out that it was simply economics, like the healthcare insurance premium increase , that brought Donald Trump to power. Interestingly enough, James Carville made the same argument when Bill Clinton beat George Bush, but when Hillary Clinton lost, Carville was quick to blame Russia. These delusions on the Left are letting the Right mobilize stronger than ever before. And all of this takes away from the Healthcare Debate.

In an attempt to blame Trump's Election on white racism, rather than basic economics, numerous outlets simply fell flat. For instance, Eric Sasson writes : white men went 63 percent for Trump versus 31 percent for Clinton, and white women went 53-43 percent. Among college-educated whites, only 39 percent of men and 51 percent of women voted for Clinton What's more, these people hadn't suffered under Obama; they'd thrived. The kind of change Trump was espousing wasn't supposed to connect with this group.

Did this group thrive? The collegiate debt went from $600 billion to $1.4 trillion under Obama's Administration, while the health insurance increased from $13,000 to $18,000 per family . This is thriving? Was the author experimenting with medical marijuana when said article was written? Nevertheless, the parade of insanity continued, with Salon assuring us that it was blatant racism that gave us Trump . The Root, which also claimed that Russians attempted to hack election machines, pointed out that Russia exploited America's racism , and thus Trump won the election. Washington Post claimed that racism motivated white people more than authoritarianism . Comedian Bill Maher tried to sway the discussion back to economics, by pointing out that outrage over Pocahontas or Halloween should not stop the Democrats from working for the working man . Sadly, Maher and Stewart are in the minority, and instead of a Healthcare Debate, the US is now stuck in a debate over racism, which isn't even three-fifths as effective. Meanwhile the US continues to waste almost a trillion dollars on healthcare .

Who Benefits?

Let's start with the banks. Medical students graduate with an average of $416,216 in student debt . The average interest rate on said loan is seven percent. Roughly 20,055 students go through this program, per year . Presuming a twenty year loan, the banks are looking at about $7.185 billion in interest payments. It really is a small fraction of the cost. Prescription drug prices are another story. In 2014, Medicare spent $112 billion on medicine for the elderly . Oh la la! Cha-ching. I would not be surprised if at least half of that was wasted on drug price inflation. You know the health insurance companies? It's a great time to be one, since profits are booming – to the tune of $18 billion in projected revenue for 2017.

Of course the system itself is quite wasteful, with needless hours spent on paperwork, claim verification, contractual review, etc, etc, etc. Humana's revenue was $54.4 billion , Aetna's was $63.2 billion , Anthem's was $85 billion , Cigna's was $39.7 billion , and UnitedHealth's was $184.8 billion . Those are just the top five companies. None of them ia a mom-and-pop shop or small business store. Do any of these insurers support Obamacare? Even if they do, it is without much enthusiasm . They are leaving, and leaving quite quickly. Thirty-one percent of American counties will have just one healthcare insurer . Welcome to a monopoly that is artificially creating itself. And despite the waste, 28.2 million Americans remain uninsured . Mission accomplished!

Who else benefits? Those who hire illegal immigrants instead of American workers, since illegal immigrants cost the United States roughly $25 billion in Healthcare spending . Meanwhile those who hire them can avoid certain types of taxes and not have to cover their Healthcare; communism for the rich, capitalism for the rest of us. Of course that is just a rough estimate, since this spending is also quite hard to track.

The Future

The problem with changing Healthcare is that too many people have their hands in the proverbial pie. There is not a single lever of power that isn't affected by Healthcare, and most of the levers that are affected, benefit quite a bit. Insurance companies will fight to the death, because Universal Healthcare will be their death knell. Banks will defend it, because who doesn't want to make billions from student loans? Medical schools too – since it lets them charge higher and higher tuition. Pharmaceutical companies can use the increase in Healthcare expenditure to justify their own price hikes, even though a major reason for those price hikes is artificial patent based monopoly.

What is an artificial monopoly? In my opinion, it's when a patent is utilized to prevent competitors from manufacturing the same exact drug. In less than a decade, the price of Epi-Pen soared from $103.50 to $608.61. When asked the justify said increase, one of the reasons provided by the CEO was that the price went up because we were making investment; as I said, about $1 billion over the last decade that we invested in the product that we could reach physicians and educate legislatures. "Reaching" doctors and legislators; I wonder, how was said "education funding" spent? According to US News, a website that is extremely credible when it comes to internal decision making within the United States, drug companies have long courted doctors with gifts , from speaking and consulting fees to educational materials to food and drink. But while most doctors do not believe these gifts influence their decisions about which drugs to prescribe, a new study found the gifts actually can make a difference – something patient advocates have voiced concern about in the past. Do you feel educated? Would you feel more educated if I paid you a $150,000 consulting fee? What about $400,000? What? It's just consulting; no corruption here!

Everyone knows that this is going on. But there is not going to be change. Why not? The same reason that there was not change with Harvey Weinstein, until Taylor Swift came along. Remember how I said that almost everyone has their hands in the Healthcare Pie? It was not much different with Weinstein. Scott Rosenberg explained why it took so long for people to speak out against Harvey , and the reasons were numerous. First, Harvey gave many people their start in Hollywood, and treated all of his friends like royalty. That drastically increased their loyalty. Second, he ushered the Golden Age of the 1990s, with movies like Pulp Fiction, Shakespeare in Love, Clerks, Swingers, Scream, Good Will Hunting, English Patient, Life is Beautiful – the man could make phenomenal movies. Third, even if one was willing to go against his own friends, workers, mass media, and so on, there was no one to tell. There was no place to speak out. Fourth, some of the victims took hefty settlements.

That fourth reason enabled mass media to portray rape victims as gold diggers. Rape Culture is alive and well. In California, a Judge gave minimal sentencing to a convicted rapist , because he was afraid a harsher sentence would damage the rapist's mental psyche for life. Uh dude, from one Californian to another, he, uh, raped. His mental psyche is already damaged; for life. That's the kind of pressure that Rose McGowan had to deal with. She had a little kerfuffle with Amazon , and she thinks it was partially because of Harvey Weinstein. How many times had the word "socialism" been thrown around to describe Universal Healthcare? Switzerland has it – are they Socialist?

Enter Taylor Swift . In order to destroy allegations that women are filing sexual harassment claims as gold diggers, she sued her alleged sexual assaulter for a buck; one dollar. She won. Swift stated that the lawsuit was to serve as an example to other women who may resist publicly reliving similar outrageous and humiliating acts. On top of that, Weinstein was no longer as popular as he used to be, and an avenue to tell the story, an outlet was created. The additional prevalence of the internet caused the stories of Weinstein's sexual abuse to leak. Within a month, the giant fell.

Something similar is needed to change Healthcare in America. But until that comes along, racism will increase, the cost of Healthcare will rise, emergency room costs will most likely double every ten years, and the future remains bleak. As if that was not enough, more and more upper class Americans, (like yours truly,) are seeking treatment abroad. It cost me less money to lose five weeks of wages, spend three weeks partying in Eastern Europe, (Prague to be more specific,) after my two weeks of treatment, buy a roundtrip plane ticket, and stay in a five star, all-inclusive hotel, than the cost of the same treatment in the US. If anyone wants to utilize this as a startup – let me know!

Of course its effects on Healthcare will hurt, since it is a huge chunk of business that will be traveling across the Atlantic. But what can be done to stop it? One cannot stop Americans from traveling to other countries. One cannot force the poor to work for free. Perhaps this is the change that is needed to make those who benefit from the Healthcare Waste realize that this cannot continue. Perhaps not. What we do know, is that Obamacare insured the poor, at the expense of the middle class . And that is regarded as a failure in America.

Northern Star , November 27, 2017 at 3:12 pm
As for Obongo Care ??:

"In trying to show that he was successfully managing the Obamacare rollout, the president last week staged a high-profile White House meeting with private health insurance executives -- aka Obamacare's middlemen. The spectacle of a president begging these middlemen for help was a reminder that Obamacare did not limit the power of the insurance companies as a single-payer system would.
****The new law instead cemented the industry's profit-extracting role in the larger health system -- and it still leaves millions without insurance."*** (THAT is the Achille's lower torso of the ACA)

https://www.healthcare-now.org/blog/single-payer-healthcare-vs-obamacare/

https://www.dailykos.com/stories/2016/2/11/1483523/-Single-Payer-Healthcare-vs-The-Affordable-Care-Act-A-Simple-Comparison

ucgsblog , November 28, 2017 at 3:58 pm
Exactly! That's why I stated that they're now oligapolizing the market, and will slowly start to increase their insurance rates and profits once again.
Northern Star , November 27, 2017 at 3:23 pm
"Prince Harry..Do you take this American mulatto negress -aka raghead untermensch-as your lawfully wedded royal wife?*
http://www.newsweek.com/prince-harrys-worst-moments-meghan-markle-rogue-723177
https://www.sbs.com.au/guide/sites/sbs.com.au.guide/files/styles/body_image/public/nazi.jpg?itok=q1oxMi44&mtime=1503879842

Ummm Advice to Meghan .make sure the honeymoon motorcade stays clear of tunnels in Paris
or elsewhere!!!

Northern Star , November 27, 2017 at 3:52 pm
Appurtenant to many of the issues raised in Mark's post:

http://www.wsws.org/en/articles/2017/11/27/pers-n27.html

(Socialist or not..the WSWS writers continue to state that which NEEDS to be hammered home)

"The vast wealth of the financial oligarchy, expressed in their ownership of massive corporations, must be seized and expropriated, while the complex technologies, supply chains, and advanced transportation systems must be integrated in an organized, planned manner to harness the anarchic force of the world economy and eliminate material scarcity.

Amazon is a prime example. Its supply lines and delivery systems could distribute goods across the world, bringing water, food, and medicine from each producer according to his or her ability, to each consumer according to his or her need.

The massively sophisticated computational power used by the technology companies to censor and blacklist political opposition could instead be used for logistical analysis to conduct rescue and rebuilding missions in disaster zones like Houston and Puerto Rico. Drones used in the battlefield could be scrapped and rebuilt to distribute supplies for building schools, museums, libraries, and theaters, and for making Internet service available at no cost for the entire world.

The ruling class and all of the institutions of the political establishment stand inexorably in the way of efforts to expropriate their wealth. What is required is to mobilize the working class in a political struggle against the state and the socio-economic system on which it is based, through the fight for socialism.
Eric London "

Particularly for American Stooges:

Patient Observer , November 27, 2017 at 5:17 pm
Advanced technology is helpful but not essential for a humane and just society. Its what we believe and feel that matters. FWIW, I like socialism on a national/international level and individual accountability on a personal level.
saskydisc , November 27, 2017 at 4:04 pm
While general medical care is single payer in Canada, dental services are not. For major work on teeth, it is cheaper to fly to Mexico. The downside is for Mexicans -- such practices will drive the costs up in Mexico.
Patient Observer , November 27, 2017 at 5:12 pm
Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.
anon@gmail.com , November 27, 2017 at 6:02 pm
I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.
kirill , November 27, 2017 at 8:38 pm
Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

Jen , November 27, 2017 at 11:15 pm
Thanks very much UCG, for your article. Very interesting reading for us Australians as the Federal Government eventually wants to shove us kicking and screaming into a US-style privatised healthcare insurance model.

Funnily enough I'm currently considering changing my private health insurer. I'm with Medibank Private at present but considering maybe going with a smaller non-profit health fund like Australian Unity or Phoenix Health Fund.

Fern , November 28, 2017 at 7:02 am
I was just about to post along the lines of "I don't know if Jen has experienced this in Australia but here in the UK ." so I'll finish the thought. In the UK, successive governments, not just Conservative ones, have been trying to dismantle the NHS and move us to the American system. It is pure ideology – no amount of the very abundant evidence of the inefficiencies of the US system, its waste etc makes any dint in the enthusiasm of those pressing for change.
ucgsblog , November 28, 2017 at 4:17 pm
Thank you Jen! My advice: don't let the Government cajole you into wasting your money on Corporate Greed. Share the article with your fellow Australians, if you must, but don't let our wasteful system be replicated. Interestingly enough, one of my friends, Lytburger, send me a meme right after Ukraine adopted America's Healthcare System, it said: "ISIS refused to take responsibility for Ukraine's Healthcare Reform!" I'd be happy to provide other data or answer questions about the Healthcare System here.

As for insurance, I'm not sure if Australia has the in-network and out-of-network rules. Does it? Whatever insurance you get, make sure that it has good coverage. If you own a home in the US, and you end up in a hospital's emergency room that's not covered by your insurance, the hospital can take your house under certain circumstances. Ironically, even the Government cannot. All of my real property is in various Trust Accounts, just in case, and I make sure that I have insurance where all major hospitals are in-network and that's the best I can do.

James lake , November 28, 2017 at 12:21 am
This is s very interesting insight into healcare in the USA. The cost is shocking. I live in the UK and the healthcare system is paid for from taxation. When it was established over 70 years ago it's. The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means. It was the best thing in my view that government has ever done. Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.

Which many people do not mind.

-Elderly care was also privatised as it's the most expensive

-care for the disabled also is a issue for local councils

-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.

And yet still more and more taxation is needed for the NHS!

The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.
Ryan Ward , November 28, 2017 at 3:40 am
With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 15, 2017] Alex Azar Can There Be Uglier Scenarios than the Revolving Door naked capitalism

Notable quotes:
"... By Lambert Strether ..."
"... So should Mr Azar be confirmed as Secretary of DHHS, the fox guarding the hen house appears to be a reasonable analogy. ..."
"... In this post, I'd like to add two additional factors to our consideration of Azar. The first: Democrat credentialism makes it hard for them to oppose Azar. The second: The real ..."
Nov 15, 2017 | www.nakedcapitalism.com

Alex Azar: Can There Be Uglier Scenarios than the Revolving Door? Posted on November 15, 2017 by Lambert Strether By Lambert Strether

Clearly, Alex Azar, nominated yesterday for the position of Secretary of Health and Human Services by the Trump Administration, exemplifies the case of the "revolving door," through which Flexians slither on their way to (or from) positions of public trust. Roy Poses ( cross-posted at NC ) wrote, when Azar was only Acting Secretary:

Last week we noted that Mr Trump famously promised to &#8220;drain the swamp&#8221; in Washington. Last week, despite his previous pledges to not appoint lobbyists to powerful positions, he appointed a lobbyist to be acting DHHS Secretary. This week he is apparently strongly considering Mr Alex Azar, a pharmaceutical executive to be permanent DHHS Secretary, even though the FDA, part of DHHS, has direct regulatory authority over the pharmaceutical industry, and many other DHHS policies strongly affect the pharmaceutical industry. (By the way, Mr Azar was also in charge of one lobbying effort.)

So should Mr Azar be confirmed as Secretary of DHHS, the fox guarding the hen house appears to be a reasonable analogy.

Moreover, several serious legal cases involving bad behavior by his company, and multiple other instances of apparently unethical behavior occurred on Mr Azar&#8217;s watch at Eli Lilly. So the fox might be not the most reputable member of the species.

So you know the drill&#8230;. The revolving door is a species of conflict of interest . Worse, some experts have suggested that the revolving door is in fact corruption. As we noted here , the experts from the distinguished European anti-corruption group U4 wrote ,

The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy , especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door from industry to the Trump administration once again suggests how the revolving door may enable certain of those with private vested interests to have excess influence, way beyond that of ordinary citizens, on how the government works, and that the country is still increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism.

Poses is, of course, correct. (Personally, I've contained my aghastitude on Azar, because I remember quite well how Liz Fowler transitioned from Wellpoint to being Max Baucus's chief of staff when ObamaCare was being drafted to a job in Big Pharma , and I remember quite well the deal with Big Pharma Obama cut, which eliminated the public option , not that the public option was anything other than a decreasingly gaudy "progressive" bauble in the first place.)

In this post, I'd like to add two additional factors to our consideration of Azar. The first: Democrat credentialism makes it hard for them to oppose Azar. The second: The real damage Azar could do is on the regulatory side.[1]

First, Democrat credentialism. Here is one effusive encomium on Azar. From USA Today, "Who is Alex Azar? Former drugmaker CEO and HHS official nominated to head agency" :

"I am glad to hear that you have worked hard, and brought fair-minded legal analysis to the department," Democratic Sen. Max Baucus said at Azar's last confirmation hearing.

And:

Andy Slavitt, who ran the Affordable Care Act and the Centers for Medicare & Medicaid Services during the Obama administration, said he has reason to hope Azar would be a good secretary.

"He is familiar with the high quality of the HHS staff, has real-world experience enough to be pragmatic, and will hopefully avoid repeating the mistakes of his predecessor," Slavitt said.

So, if Democrats are saying Azar is "fair-minded" and "pragmatic" -- and heaven forfend that the word "corruption"[2] even be mentioned -- how do they oppose him, even he's viscerally opposed to everything Democrats supposedly stand for? (Democrats do this with judicial nominations, too.) Azar may be a fox, alright, but the chickens he's supposedly guarding are all clucking about how impeccable his qualifications are!

Second, let's briefly look at Azar's bio. Let me excerpt salient detail from USA Today :

1. Azar clerked for Supreme Court Justice Antonin Scalia .

2. Azar went to work for his mentor, Ken Starr , who was heading the independent counsel investigation into Bill and Hillary Clinton's Whitewater land deal.

3. Azar had a significant role in another major political controversy when the outcome of the 2000 presidential election hinged on a recount in Florida . Azar was on the Bush team of lawyers whose side ultimately prevailed [3]

For any Democrat with a memory, that bio provokes one of those "You shall know them by the trail of the dead" moments. And then there's this:

When Leavitt replaced Thompson in 2005 and Azar became his deputy, Leavitt delegated a lot of the rule-making process to Azar.

So, a liberal Democrat might classify Azar as a smooth-talking reactionary thug with a terrible record and the most vile mentors imaginable, and on top of it all, he's an effective bureaucratic fixer. What could the Trump Administration possibly see in such a person? Former (Republican) HHS Secretary Mike Leavitt explains:

"Understanding the administrative rule process in the circumstance we're in today could be extraordinarily important because a lot of the change in the health care system, given the fact that they've not succeeded legislatively, could come administratively."

We outlined the administration strategy on health care in "Trump Adminstration Doubles Down on Efforts to Crapify the Entire Health Care System (Unless You're Rich, of Course)" . There are three prongs:

1) Administratively, send ObamaCare into a death spiral by sabotaging it

2) Legislatively, gut Medicaid as part of the "tax refom" package in Congress

3) Through executive order, eliminate "essential health benefits" through "association health plans"

As a sidebar, it's interesting to see that although this do-list is strategically and ideologically coherent -- basically, your ability to access health care will be directly dependent on your ability to pay -- it's institutionally incoherent, a bizarre contraption screwed together out of legislation, regulations, and an Executive order. Of course, this incoherence mirrors to Rube Goldberg structure of ObamaCare itself, itself a bizarre contraption, especially when compared to the simple, rugged, and proven single payer system. ( Everything Obama did with regulations and executive orders, Trump can undo, with new regulations and new executive orders . We might compare ObamaCare to a child born with no immune system, that could only have survived within the liberal bubble within which it was created; in the real world, it's not surprising that it's succumbing to opportunistic infections.[2])

On #1, The administration has, despite its best efforts, not achieved a controlled flight into terrain with ObamaCare; enrollment is up. On #2, the administration and its Congressional allies are still dickering with tax reform. And on #3 . That looks looks like a job for Alex Azar, since both essential health benefits and association health plans are significantly affected by regulation.

So, yes, there are worse scenarios than the revolving door; it's what you leave behind you as the door revolves that matters. It would be lovely if there were a good old-fashioned confirmation battle over Azar, but, as I've pointed out, the Democrats have tied their own hands. Ideally, the Democrats would junk the Rube Goldberg device that is ObamaCare, rendering all of Azar's regulatory expertise null and void, but that doesn't seem likely, given that they seem to be doing everything possible to avoid serious discussion of policy in 2018 and 2020.

NOTES

[1] I'm leaving aside what will no doubt be the 2018 or even 2020 issue of drug prices, since for me that's subsumed under the issue of single payer. If we look only at Azar's history in business, real price decreases seem unlikely. Business Insider :

Over the 10-year period when Azar was at Lilly, the price of insulin notched a three-fold increase. It wasn't just Lilly's insulin product, called Humalog. The price of a rival made by Novo Nordisk has also climbed, with the two rising in such lockstep that you can barely see both trend lines below.

The gains came despite the fact that the insulin, which as a medication has an almost-century-long history, hasn't really changed since it was first approved.

Nice business to be in, eh? Here's that chart:

It's almost like Lilly (Azar's firm) and Novo Nordisk are working together, isn't it?

[2] Anyhow, as of the 2016 Clinton campaign , the Democrat standard -- not that of Poses, nor mine -- is that if there's no quid pro quo, there's no corruption.

[3] And, curiously, "[HHS head Tommy] Thompson said HHS was in the eye of the storm after the 2001 terrorist attacks, and Azar had an important role in responding to the resulting public health challenges, as well as the subsequent anthrax attacks "

MedicalQuack , November 15, 2017 at 10:31 am

Oh please, stop quoting Andy Slavitt, the United Healthcare Ingenix algo man. That guy is the biggest crook that made his money early on with RX discounts with his company that he and Senator Warren's daughter, Amelia sold to United Healthcare. He's out there trying to do his own reputation restore routine. Go back to 2009 and read about the short paying of MDs by Ingenix, which is now Optum Insights, he was the CEO and remember it was just around 3 years ago or so he sat there quarterly with United CEO Hemsley at those quarterly meetings. Look him up, wants 40k to speak and he puts the perception out there he does this for free, not so.

diptherio , November 15, 2017 at 11:25 am

I think you're missing the context. Lambert is quoting him by way of showing that the sleazy establishment types are just fine with him. Thanks for the extra background on that particular swamp-dweller, though.

a different chris , November 15, 2017 at 2:01 pm

Not just the context, it's a quote in a quote. Does make me think Slavitt must be a real piece of work to send MQ so far off his rails

petal , November 15, 2017 at 12:52 pm

Alex Azar is a Dartmouth grad (Gov't & Economics '88) just like Jeff Immelt (Applied Math & Economics '78). So much damage to society from such a small department!

sgt_doom , November 15, 2017 at 1:21 pm

Nice one, petal !!!

Really, all I need to know about the Trumpster Administration:

From Rothschild to . . . .

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

Since 2014, Ross has been the vice-chairman of the board of Bank of Cyprus PCL, the largest bank in Cyprus.

He served under U.S. President Bill Clinton on the board of the U.S.-Russia Investment Fund. Later, under New York City Mayor Rudy Giuliani, Ross served as the Mayor's privatization advisor.

Jen , November 15, 2017 at 7:56 pm

Or from a "small liberal arts college" (which is a university in all but name, because alumni).

Tim Geitner ('82 – Goverment)
Hank Paulson ('68 – English)

jo6pac , November 15, 2017 at 2:13 pm

Well it's never ending game in the beltway and we serfs aren't in it.

https://consortiumnews.com/2017/11/15/trump-adds-to-washingtons-swamp/

Alfred , November 15, 2017 at 2:53 pm

I don't believe that the President's "swamp" ever consisted of crooked officials, lobbyists, and cronies I think it has always consisted of those regulators who tried sincerely to defend public interests.

It was in the sticky work of those good bureaucrats that the projects of capitalists and speculators bogged down. It is against their efforts that the pickup-driving cohort of Trump_vs_deep_state (with their Gadsden flag decals) relentlessly rails.

Trump has made much progress in draining the regulatory swamp (if indeed that is the right way to identify it), and no doubt will make considerably more as time wears on, leaving America high and dry. The kind of prevaricator Trump is may simply be the one who fails to define his terms.

Henry Moon Pie , November 15, 2017 at 4:13 pm

I think we've moved past the revolving door. We hear members of the United States Senate publicly voice their concerns about what will happen if they fail to do their employers' bidding (and I'm not talking about "the public" here). In the bureaucracy, political appointees keep accruing more and more power even as they make it clearer and clearer that they work for "the donors" and not the people. Nowhere is this more true than the locus through which passes most of the money: the Pentagon. The fact that these beribboned heroes are, in fact, setting war policy on their own makes the knowledge that they serve Raytheon and Exxon rather than Americans very, very troubling.

I suspect Azar's perception is that he is just moving from one post to another within the same company.

Watt4Bob , November 15, 2017 at 5:28 pm

Perfect cartoon over at Truthout

I'm amazed there is enough private security available on this planet to keep these guys safe.

Larry , November 15, 2017 at 8:01 pm

Big pharma indeed has so much defense from the supposed left. It combines their faith in technological progress, elite institutions, and tugs on the heart strings with technology that can save people from a fate of ill health or premature death. Of course, the aspect of the laws being written to line the pockets of corrupt executives is glossed over. While drug prices and medical costs spiral ever higher, our overall longevity and national health in the US declines. That speaks volumes about what Democrats really care about.

[Jun 28, 2017] Prescription Drug Spending is Consuming a Bigger Share of Wages

Notable quotes:
"... The three percent of annual wage income lost to higher drug spending over the past 40 years makes a big difference to working individuals and families. This increase in annual spending averages out to roughly $2,400 per household. CMS projections, combined with projections on wage income growth from the Congressional Budget Office, suggest that spending on prescription drugs will increase further through 2025. This ratio is expected to exceed five percent by 2024. ..."
Jun 28, 2017 | economistsview.typepad.com

anne

, June 27, 2017 at 05:19 PM
http://cepr.net/blogs/cepr-blog/prescription-drug-spending-is-consuming-a-bigger-share-of-wages

June 27, 2017

Prescription Drug Spending is Consuming a Bigger Share of Wages
By Brian Dew and Dean Baker

Prescription drugs are a large and growing share of national income. While it is generally recognized that drugs are expensive, many people are unaware of how large a share of their income goes to paying for drugs because much of it goes through third party payers, specifically insurance companies and the government.

The Centers for Medicare & Medicaid Services (CMS) produce projections of national expenditures on prescription drugs through 2025, along with historical estimates dating back to 1960. As shown below, prescription drug spending from 1960 to 1980 was equivalent to about one percent of total wage and salary income. In the years leading up to the passage of the Bayh-Dole act in 1980, wage income was rising faster than spending on prescription drugs. As a result, the share of wages spent on prescription drugs was actually falling, reaching a low in 1979 of 0.86%.

[Graph]

However, after 1980, prescription drug spending rose rapidly relative to wage income. The ratio of drug spending to wages rose each year from 1980 to 2007. In 2007 wage growth finally outpaced drug expenditures, with the ratio again increasing in the Great Recession. By 2010, prescription drug spending had climbed above four percent of wage income.

The three percent of annual wage income lost to higher drug spending over the past 40 years makes a big difference to working individuals and families. This increase in annual spending averages out to roughly $2,400 per household. CMS projections, combined with projections on wage income growth from the Congressional Budget Office, suggest that spending on prescription drugs will increase further through 2025. This ratio is expected to exceed five percent by 2024.

While an aging population has been a factor increasing spending on drugs, demographics alone cannot explain the sharp increase in prescription drug spending. Inflation-adjusted prescription drug spending per household has increased more than eightfold since 1980, far outpacing any demographic trend surrounding age. The share of people over age 65 in the population has increased from 9.2% in 1960 to 14.8% in 2015. This can at most explain a small part of the increase in spending on drugs over this period.

[Graph]

It is important to recognize that the high cost of drugs is the result of a conscious policy decision to give drug companies monopolies in the form of patents and other forms of exclusive marketing rights. Without these protections drugs would almost invariably be cheap, likely costing on average less than one fifth as much as they do now. Even worse, the perverse incentives resulting from patent monopolies distort the research process and can lead drug companies to misrepresent evidence on the safety and effectiveness of their drugs.

[Jun 22, 2017] Playing Games with Drugs at the Wall Street Journal

Jun 22, 2017 |