With the advancements in medical science and technology, why do Americans still suffer the brunt
of an ineffective health care system? The patient is not the priority in today's medical world. The
Doctor is not heeding the Hippocratic Oath --- but instead is motivated by money. Medical
profiteering has driven medical costs to unsustainable levels while eroding the quality of care.
Russell Andrews' book
Too Big to Succeed: Profiteering in American Medicine provides an interesting analysis of
this trend. He
reveals the rotten core of health care system hidden from outsiders. Discover why health care costs are increasing while
medical benefits are dwindling.
Problems arise when there is a mismatch between reality
and our perception of reality. In the scientific world, there
are paradigms that guide the pursuit of knowledge.
Experiments are constructed based on rules (guidelines
based on prior experiences) to further support or disprove
those paradigms. Based on how ingrained a paradigm is (“Is
it based on fact or on ideology?”), changing the paradigm can
be very difficult. Examples of paradigm shifts from the
scientific world include the shift from “the earth is flat” to
“the earth is round” and the shift from “the earth is the
center of the solar system” to “the sun is the center of the
solar system.” People have paid dearly for their correct but
unpopular point of view (e.g., Galileo was placed under
house arrest for insisting that the sun, not the earth, was the
center of the solar system). Scientific paradigms may not
shift easily, as documented by Thomas Kuhn in The
Structure of Scientific Revolutions.1
Similar problems arise in the socioeconomic world when
there is a mismatch between reality and our perception of
reality. Here there is not only ideology that may hinder
acceptance of the mismatch, but also one’s perception of his
or her own personal economic benefit. In the game of life,
societal good rarely trumps personal gain (or, perhaps more
accurately, one’s perception of personal gain). This appears
The current health-care system in the United States has a
significant mismatch between the reality of the health care
provided to the populace as a whole and the perception of
that reality—at least the perception in the minds of many
people in this country.
Though we spend 50% more on
health care per capita than other developed countries, a
multitude of measures—such as life expectancy and infant
mortality—indicate that we in the United States are not
getting health-care value for our money. Yet many argue,
often with religious fervor, against change in our health-care
system. One must have “choice” (more accurately, perceived
choice rather than actual choice) not “socialized
medicine” (whatever “socialized medicine” means) at all
costs—even if adequate health care becomes a dream for the
majority of Americans because of the phenomenal personal
expense. When an industiy constitutes upward of one-fifth
Medicine today in the United States is big business. To see
how far it has deviated from its origins in the Western
tradition, we do well to consider the Hippocratic Oath:
I swear to fulfill, to the best of my ability and
judgment, this covenant:
I will respect the hard-won scientific gains of those
physicians in whose steps I walk, and gladly share
such knowledge as is mine with those who are to
follow.
I will apply, for the benefit of the sick, all measures
[that] are required, avoiding those twin traps of
overtreatment and therapeutic nihilism.
Understand how we can change the trend in doctor-patient relationships all over the country, where
individuals can start to realize that great emphasis should be placed on “the healing art and science
of medicine,” instead of on the profitability of the health care delivery system.
We need to learn how the profit has trumped the patient in American medicine, and fight back.
Profit is now the most imporant agent of change for real health care in America, which corrupts the
whole system. We need to know the typical pitfalls and fight against them. In the US medical system
the patient life is often depends on how well he/she understand the ropes. Yes, your life depends on it!
It is very early to gat expensive and unnecessary surgery in the USA those days. Which can be
deadly. The number of cardiologists sentenced to jail in the USA is in dozens. And they are
just the tip of the iceberg. Cardiatic stents are probably the most glaring example. But other
"lucrative" areas, in such field as gastroenterology exists too. Another huge area is
pharmacology abuse ("big-pharma" corrupting influence).
Here's another one to remember when someone tells you that our "private" health care system works: The Wall Street Journal ran a front-page story last week with the headline that said it all: "As
Patients, Doctors Feel Pinch, Insurer's CEO Makes a Billion." The story, datelined Minnetonka, Minn., was about William McGuire, a doctor who stopped practicing
in 1986 to take a management job with UnitedHealth Group Inc., one of the largest HMOs in the country.
He's now the chief executive officer of the corporation, makes $8 million a year in salary
plus bonus, has personal use of the company's private jet and has amassed what the Journal describes
as "one of the largest stock options fortunes of all time." According to the newspaper, those options
total $1.6 billion.
"Even celebrated CEOs such as General Electric Co.'s Jack Welch or International Business Machines
Corp.'s Louis Gerstner never were granted so much during their time at the top," the WSJ story said.
But the gist of the story is that while McGuire and other UnitedHealth
execs are raking in millions, their company is putting the squeeze on everyone else.
"Dr. McGuire's story shows how an elite group of companies is getting rich from the nation's fraying
health care system," the bible of the business world reported. "Many of them aren't discovering drugs
or treating patients. They're middlemen who process the paperwork, fill the pill bottles
and otherwise connect the pieces of a $2 trillion industry."
The newspaper's research shows that UnitedHealth has particularly benefited in recent years as
health care inflation eased somewhat.
Insurers still raised premiums at double-digit rates. At UnitedHealth, for example, its stock
price tripled from January of 2003 to January of this year and its net income rose to $3.3 billion.
Hence, the nice board-of-director-approved windfall for McGuire. (Interestingly, former UW-Madison
Chancellor Donna Shalala is a member of UnitedHealth's board.)
"In Minnesota, such riches have infuriated some people," the story continued. "Joel Albers, a
Minneapolis pharmacist, regularly impersonates Dr. McGuire at state fairs, donning a tuxedo, holding
up an enlarged picture of Dr. McGuire on a stick and handing out leaflets denouncing corporate greed."
Of course, this is just one more anecdote that serves to describe our broken health care system,
which leaves more than 40 million Americans without coverage and an embarrassment of riches for those
who know how to milk that system.
On one hand we have Medicare, which provides universal single-payer coverage to all Americans
over age 65 at about a 2 percent administrative cost. On the other hand we have a hodge-podge of
plans with layer after administrative layer that gobbles up close to 20 percent in overhead costs
(Dr. McGuire's just a piece of that) and leaves millions out in the cold.
How hard can it be to choose in which direction we need to go?
Dave Zweifel is editor of The Capital Times. E-mail: [email protected]
The HMOs and their managed care systems -- first supported in the Nixon years -- ballooned from
a headache to a plague beginning about ten years ago. Their pitch was that they would end the inefficiencies
of the past.However, the period in which they have come to dominate the health care system is precisely that
in which its costs -- and its inefficiency (unless you count mountains of paperwork something other
than waste -- began the acceleration that continues.
Some of the rising costs were due to factors other than the HMOs, not least the gouging prices
set by the pharmaceutical giants. OK, but all of them are part and parcel of the "for-profit health
care system." Nonetheless, the HMOs have done at least their share in bringing about today's mountainous
costs.
What started out as annual one-digit overall cost increases became two-digit as the 1980s ended,
rising to 15.3 percent for 2002. Not good enough: In mid-2002 the NYT reported that "Health maintenance
organizations are demanding rate increases of 22 percent in their ongoing negotiations with employers
for 2003... which will be passed on to consumers." They were "passed on," and they continue to be.
As the tendency of always higher costs and prices continues, it needs repeating that the provision
of health care to the average person has decreased both quantitatively and qualitatively. What's
good for their profits is bad for our health.
What is it about the HMOs that such is the case? What was the system they presumed to replace
with great savings to all, and profits to them as a reward? It was called the "fee-for-service" system:
Other than those covered by Medicare and Medicaid, health insurance for those who had it was selected
and paid by one's employer, which used to be so for about two-thirds of workers.
As the numbers of insured rose from the 1950s on, so did doctors' incomes: the insured could choose
their own doctors and the doctors soon realized that the more treatments they gave the better off
they -- but not necessarily their patients -- were. As Ellen Frank pointed out two years ago, "American
doctors performed invasive tests and procedures at rates far exceeding international norms....Caesarean
sections, surgerized ulcers, hysterectomies and tonsillectomies far above the rates in other countries,
etc." (Dollars & Sense, 5/6, 2001)
Adding to that, past and present, is the friendly corruption between doctors and labs and drug
companies. The pleasant consequence for doctors from 1960 to 1990 was that their incomes rose two
to three times faster than the nation's, bringing them up to a lovely $200,000 annual average. So
that's what the Hippocratic Oath was about!
One might think that such an evolution -- or, better, devolution -- would have led everyone but
the doctors and labs and drug companies to open their minds to a national health service/single-payer
system. But that overlooks certain large facts:
1) Employers as a whole tend to have a knee-jerk negative reaction against anything do with government
(unless it is in the nature of a subsidy), and just as "instinctive" a response in favor of "private
enterprise," which is what HMOs are;
2) the average citizen lives in the same society, and has been taught to think in much the same
way, if not for the same reasons;
3) the major insurance companies have always been opposed to any form of social insurance -- beginning
with their adamant fight against social security from 1935 to the present; and
4) this created a new industry for thousands of lobbyists. They have been very successful indeed
in their efforts on behalf of the "Big Five" insurance companies (Aetna, Cigna, Metropolitan, Prudential
and Travelers) and related managed care companies -- which, taken together, now "cover" 90+ percent
of those receiving care. Here a lucid and crisp summary review of what brought us to our present
state, and how it happened (as related by Ellen Frank):
The early 1990s saw a wave of mergers and acquisitions among health insurers that left large regions
of the country with only two or three competing health plans. Their superior bargaining power allowed
insurers to negotiate sharp reductions in fees, which were passed on to employers in the form of
lower premiums. In 1994 the average health-insurance premium /paid by employers/ fell for the first
time in years; premiums increased at or below the inflation rate for the rest of the 1990s.
Hospitals, facing lower reimbursement rates, cut staff and beds for traditional inpatient care
while expanding facilities for expensive services like outpatient surgery. Still, hospitals throughout
the country suffered operating losses. Large urban hospitals in low-income areas were especially
hard-hit.../some like that of Los Angeles, closing entirely/. For-profit hospital chains moved in
quickly, buying up scores of non-profit community hospitals.
So, with patients and providers (doctors, labs, and hospitals) getting the dirty end of the stick,
that leaves the HMOs, drug companies, and top insurance companies getting the sweet end -- their
owners, their CEOs and their countless lobbyists, that is.
Business being business, another rising tendency is that of HMOs dropping Medicare patients, more
than 2.5 million 1998 to the present. Plus, "Medicare patients can expect 'major changes -- that
is, reductions of -- benefits, even if they are still enrolled: cutbacks in drug coverage /already
cruelly inadequate/, and increases in premiums and co-payments." (ibid.)
So there we are. Or are we? Although there is a rising tide of anger, frustration, and worry among
our people at the costs of medical care in the USA, with some emerging movement toward universal
coverage, most still see the U.S. system, though costly, as the best.
The best is none too good: "According to a recent study of the Institute of Medicine, medical
errors in hospitals kill up to 98,000 patients yearly, while injuring perhaps a million more." (Washington
Post, Editorial, "America's medical scandal," 12-10-02). Such deaths and injuries are called "iatrogenic";
that is, caused by the docs themselves.
That was a few years ago. Now, as the USA's entire health care system becomes always more privatized
and always more expensive to those needing it, those years are coming to look like paradise lost;
and we ain't seen nothin' yet.
Patients receiving emergency medical care would no longer get surprise medical bills from providers outside their insurance network
under a rule issued Thursday by the Biden administration.
The long-awaited rule is the first to follow the so-called No Surprises Act, passed in December 2020 by Congress that sought
to protect patients from receiving significant medical bills when they are unwittingly treated by an out-of-network doctor, lab,
or other type of provider.
The rule seeks to implement key parts of the legislation protecting patients from being billed by out-of-network doctors who provide
treatment at in-network hospitals, as well as protecting them from surprise bills for both emergency and nonemergency care. The
interim final rule will
undergo 60 days of public comment and largely go into effect on Jan. 1, 2022, when the law takes effect.
"No patient should forgo care for fear of surprise billing," said Health and Human Services Secretary Xavier Becerra in a statement.
"Health insurance should offer patients peace of mind that they won't be saddled with unexpected costs."
Congress and policy makers
have sought to tackle surprise medical bills because patients are paying more out-of-pocket for their care, and many out-of-network
charges can occur when patients are unaware that they are being treated by a provider who isn't covered by their health insurance.
Out-of-network charges have added to medical debt and rising out-of-pocket payments for consumers: An April 2021 study in the
journal Health Affairs found that patients receiving a surprise out-of-network bill for emergency physician care paid more than 10
times as much as in-network emergency patients paid out-of-pocket .
The interim final rule is expansive. Emergency services, regardless of where they are provided, would have to be billed at lower,
in-network rates without requirements for prior authorization.
The rule also bans higher out-of-network cost-sharing, such as copayments, from patients for treatment they receive either
in an emergency or nonemergency situation. Under the rule, any coinsurance or deductible can't be higher than if such services were
provided by an in-network doctor.
The interim final rule also stipulates that patients can't be charged out-of-network for "ancillary" care, which can happen when
an out-of-network anesthesiologist or assistant surgeon provides treatment at an in-network hospital.
Regulations that will be released at a later time will implement a procedural process so medical providers and insurers can arbitrate
out-of-network payment disputes, a solution that was so contentious it threatened to scuttle passage of the No Surprises Act. Insurers
raised concerns that arbitration could put them at a disadvantage and instead favored linking out-of-network reimbursement to a benchmark
rate.
The legislative fight over the No Surprises Act that spurred the interim rule was contentious. The American Medical Association
and some state medical associations worried it could financially hurt small physician practices that were still reeling from the
pandemic. The American Hospital Association supported the arbitration provision but raised concerns about the possibility for uneven
enforcement of the law.
The bill will lead to "dangerous, unintended consequences, right in the middle of a surging pandemic," according to a Dec. 15,
2020, letter to then-Senate Majority Leader Mitch McConnell (R., Ky.) from conservative groups such as Action for Health.
Cost-sharing includes deductibles, copayments paid at the time of treatment, and coinsurance, which is the percentage of a bill
that consumers pay that isn't covered by insurance. Patients are paying increasingly more for their own care because cost-sharing
has increased over time, research shows. Most workers also face additional cost-sharing for a hospital admission or outpatient surgery.
Sixty-five percent of workers with employer-sponsored coverage have coinsurance and 13% have a copayment for hospital admissions,
according to a 2020 survey by the Kaiser Family Foundation.
Out-of-network charges from anesthesiologists, pathologists, radiologists and assistant surgeons increase spending by $40 billion
annually, according to researchers at the Yale School of Public Health.
Congress in its legislation sought to protect patients from unknowingly receiving care from an out-of-network provider. To that
end, the rule bans other out-of-network charges without advance notice.
The regulations issued Thursday will take effect for healthcare providers and facilities Jan. 1, 2022. For group health plans,
health-insurance issuers and Federal Employees Health Benefits program carriers, the provisions will take effect for plan, policy
or contract years beginning on or after Jan. 1, 2022.
Truetox Laboratories of Garden City Park performed tests for drugs in urine on more than
140,000 samples between Jan. 1, 2015 and June 30, 2018, the audit said. It is one of Medicaid's
highest paid providers of laboratory services.
While Truetox was charging other payers $3 per test, it billed the New Jersey Medicaid
program between $1,300 and $1,500 for the same test, the state's audit found. Medicaid didn't
pay the full charges, but it paid Truetox $250 for each test.
State law prohibits Medicaid providers from charging Medicaid higher fees than other payers
for the same service.
Repayment of the overcharges to the state is "especially important given New Jersey's
ongoing opioid crisis," said the acting State Comptroller, Kevin D. Walsh. "By our office
recouping these funds, more money will go back to the Medicaid program, which will in turn
provide more services for this population in suffering."
Lindy Washburn is a senior health care reporter for NorthJersey.com. To keep up-to-date
about how changes in the medical world affect the health of you and your family, please
subscribe or activate your digital account today.
Non-profits hospitals are actually wolfs in sheep skin. Hospital administrators are basically
real estate developers, and that is where the profits go. They have become monsters, quite
uninterested in serving the public good. The average CEO makes well more than an order (or two)
of magnitude more than the average physician and has much less time and money invested in
training. Most of the CEO's are grossly over compensated.
It is time to rein in aggressive tactics used by nonprofit hospitals to collect unpaid bills,
including suits and garnishing of wages. The fees are not published. The rates for procedures are
unknown until you get the bill. The bill, when it finally arrives, has absolutely stupid figures
on it, such as $700 for 1 bag of intravenous saline. Which actually costs about $1. At such
prices any discout is meaningless and actually is a cruel joke on sick people.
It is asinine that hospitals don't provide pricing information before you have treatment
(obviously, emergencies would be an exception).
Nonprofits in 2016 received an estimated $9 billion in federal tax breaks
Another issue is why those people do not have health insurance. With Medicaid expansion and
liberalization there is no excuse for not having it. The one thing Obamacare did was give people
the opportunity to get insurance. There is a difference between "can't" pay and "I want to spend
my money on something else besides my medical insurance."
Maryland recently added new restrictions on
hospital debt collection , after a state report said hospitals wiped out less than half of
their charges to patients who were eligible for free care under state law in 2018.
Washington state's attorney general sued hospitals over patients' access to financial aid.
Under a 2019 consent decree, nonprofit hospitals refunded about $1.6 million to patients.
Hospitals nationally face ongoing scrutiny for their billing and pricing practices, with new
rules this year
requiring hospitals to publish prices they have previously
negotiated in secret with insurance companies. The Trump administration policy sought to
boost transparency for consumers, but
many hospitals haven't complied . According to Turquoise Health Co., a startup working with
the newly public pricing data, Ballad hospitals have generally complied with the new
transparency regulations.
Hospitals can sell unpaid bills to debt buyers in the secondary debt market, where RIP
Medical Debt typically buys portfolios for pennies on the dollar. Terms of the deal with Ballad
weren't disclosed.
... ... ...
Federal requirements for nonprofit hospitals to provide financial assistance and inform
patients about it are limited. Nonprofits have freedom to set eligibility as they choose, and
can also create their own process and forms, said Jenifer Bosco, an attorney at the National
Consumer Law Center. They are supposed to take steps to alert patients, including making their
policies widely available on their websites, Ms. Bosco said. State rules for nonprofit hospital
financial aid vary.
Please not that stent insertion is often unnecessary procedure performed not to save the life of the patient but to earn money.
The system is criminal indeed.
Non-profits hospitals those day are also governed by Wall-street sharks.
Please note that Abdominal CT scan with insurance like CIGNA would cost you $300-$600 out of the pocket depending on the
facility.
Notable quotes:
"... abdominal and pelvic scan at Avera St. Luke's cost $6,422, the highest out of a wide range of rates the Avera hospital charges for that service ..."
"... Some dominant local and regional nonprofits, including Mass General Brigham, based in Boston, and Avera, based in Sioux Falls, S.D., billed the uninsured at their general hospitals some of their highest prices while also setting some of the most restrictive financial-aid policies for free care nationwide, according to tax filings, Turquoise data and patients' medical bills. ..."
"... "It's really criminal, the mess that our current system is in," said Mary Daniel, chief executive of ClaimMedic, which helps patients negotiate payment with hospitals. "It is a deliberate attempt for these hospitals to gouge the uninsured." ..."
"... for expensive procedures like angioplasty and drug-coated stenting, the difference in the cash price within a single county can be over $100,000. ..."
"... The cash prices for patients who must pay for their own care can be equal to the sticker prices or sometimes represent a percentage lopped off that top rate. Sometimes, those cash rates are also applied to people who have some form of insurance but get a service that the insurance doesn't cover. ..."
"... The quarter of hospitals with the most generous free-care policies write off the entire bill for those with monthly incomes under about $2,600 a month, and even up to roughly $6,400 a month, for a one-person household, the Journal found. ..."
"... Those that rank in the quarter of hospitals with the most-restrictive policies draw the line at or below about 160% of the federal threshold for poverty, disqualifying for free care patients with monthly income of more than around $1,700 for a one-person household, according to a Journal analysis of nonprofit hospital tax filings. ..."
"... A patient paying cash at the hospital for the stenting procedure is charged $84,792. Local insurer Fallon Health spends $36,755 for the procedure under one of its health-maintenance organization plans. A Medicare insurance plan from Aetna, part of CVS Health Corp. , pays $16,648. ..."
"... Patients who don't qualify for financial aid at nonprofit hospitals also aren't protected by pricing limits under federal law. The Affordable Care Act requires nonprofit hospitals to cap prices for patients who qualify for financial aid. ..."
"... Hospitals apply financial aid and discount policies inconsistently, say consumer advocates and patients. Offers may be one-time-only, or discounts may emerge only when a skilled negotiator is pushing for them. ..."
"... In January 2018, Joannie Berthiaume spent two days at Broward Health Imperial Point hospital in Fort Lauderdale, Fla., and got emergency surgery to remove her appendix. She was uninsured and the hospital charged Ms. Berthiaume its highest prices. Her bill totaled about $42,000, including a $6,033 abdominal CT scan. For that same scan, an Aetna subsidiary gets a 24% break, according to the newly public data from Broward Health. That discount would have meant a fee of around $4,600 for the scan, based on the price charged in 2018. ..."
"... "If you charge me $42,000 and your costs are justified, how can you knock it in half in a matter of minutes," Ms. Berthiaume says. "You must be overcharging." ..."
"... High cash prices inflate bills that uninsured patients often struggle to pay. Hospitals collected 5% of the amount they billed uninsured patients before writing off bills after a year of seeking payment, according to Crowe LLP, an accounting, technology and consulting firm, based on an analysis of 600 client hospitals. That is compared with collecting 40% of bills sent to patients with insurance for amounts owed under deductibles, copays and other out-of-pocket costs, based on a separate analysis by Crowe of about 1,500 hospitals. ..."
"... Hospitals closely track their "payer mix," or the mix of patients with commercial insurance, Medicare, Medicaid and the uninsured, who might be unlikely to ever pay for their treatment. That could play a role in how hospitals set prices. ..."
"... Resolve also offered about $8,000, or slightly more than the company estimated Medicare would pay, for Mr. Macias's $24,800 emergency-room bill at Avera St. Luke's, Mr. Pan said. The hospital said no, and despite denying financial aid, offered to reduce the bill by 50%, Mr. Pan said. The amount excluded another $34,994 he owes Avera's heart hospital. ..."
"... Have you or someone you know faced a challenging hospital billing situation? Tell us about your experience in the form below. ..."
The 32-year-old's abdominal and pelvic scan at Avera St. Luke's cost $6,422, the highest out of a wide range of rates the Avera
hospital charges for that service based on the new data. The price billed to Mr. Macias was roughly three times the best deal negotiated
by an insurance company.
Another scan of his chest came to $4,194, approximately $280 to $2,800 more than any prices negotiated between St. Luke's and
an insurer. The prices for identical scans performed at Avera's heart hospital were also among the highest that the hospital charged. His total hospital bills came to $59,800.
... ... ...
Services including emergency-room visits, imaging scans and procedures such as an angioplasty and stenting often performed on
heart-attack patients have been identified by researchers and federal data as commonly needed in emergencies by those without insurance.
The Journal analysis looked at the 1,550 hospitals in the Turquoise data that released both insurance and cash-payment rates.
Among the Journal's findings:
Hospitals routinely bill uninsured patients at their highest rates. About 21%, or 319, of the hospitals did so for the majority
of the services included in the analysis. At 171 of those hospitals, the cash rate was higher than all of the rates billed to
insurers, or tied for the highest rate, for every service in the analysis. That was true at some hospitals owned by major systems
including Sanford Health and Yale New Haven Health System.
On average, across the 1,166 hospitals that included rates for Medicare Advantage plans in their disclosures, the fees for
uninsured patients were 3.6 times the average rates paid by the Medicare Advantage plans. Medicare rates are typically set by
the government to at least cover hospital costs and are considered a baseline for comparing prices. Rates for Medicare Advantage
plans, which are administered by private insurers, are generally close to these mandated prices.
Some dominant local and regional nonprofits, including Mass General Brigham, based in Boston, and Avera, based in Sioux
Falls, S.D., billed the uninsured at their general hospitals some of their highest prices while also setting some of the most
restrictive financial-aid policies for free care nationwide, according to tax filings, Turquoise data and patients' medical bills.
Cash prices, which haven't been available publicly to help patients choose where to seek medical care, often vary widely even
among hospitals in the same county. In the 270 counties where at least two hospitals have disclosed their cash prices, the average
spread between the lowest and highest rates for a complex emergency-room visit is $1,852.
In Shelby County, Tenn., home to Memphis, the spread for that type of ER visit is $2,054. It would cost an uninsured patient $884
at any of the three Baptist Memorial Health Care hospitals; $1,480 at Regional Medical Center; $2,653 at Saint Francis Hospital-Memphis;
and $2,938 at Saint Francis Hospital-Bartlett.
... ... ...
Hospitals that offer additional discounts for the uninsured don't always automatically make the cuts to patient bills, leaving
cash-pay patients with significantly higher charges, the Journal found. It can take long negotiations, often by hiring lawyers or
professional advocates, to bring about reduced charges.
... ... ...
Those discounts slash bills by an average of 85% off its top price, the company said in a recent statement to the Journal. But
patients must apply to receive the discount. The vast majority of cash prices for emergency services at Tenet hospitals reviewed
by the Journal instead reduced bills by 20% to 30%.
"It's really criminal, the mess that our current system is in," said Mary Daniel, chief executive of ClaimMedic, which
helps patients negotiate payment with hospitals. "It is a deliberate attempt for these hospitals to gouge the uninsured."
The differences between the prices for uninsured people and insurance companies can be wide.
At Ephraim McDowell Regional Medical Center in Danville, Ky., an uninsured person getting a stent after a heart attack could be
billed around $66,226 for the procedure. An Anthem Inc.
health-maintenance organization plan would pay just $17,895 at the hospital, and the insurer's Medicare plan even less -- $12,445.
Ephraim McDowell Health said the cash prices are the highest rates but that it offers discounts and bill forgiveness for those
who qualify for financial assistance. In a written statement, the hospital system said, "it is rare that an uninsured patient would
pay the total gross charge amount due to the variety of financial assistance programs available."
Eligibility under the program cuts off at three times the federal poverty level, according to the hospital system, which is an
annual income of $38,640 for a single person.
Prices typically haven't been publicly available before now. Yet for expensive procedures like angioplasty
and drug-coated stenting, the difference in the cash price within a single county can be over $100,000.
The reasons for high cash prices are complex and, even to many healthcare experts, baffling.
Hospitals typically have a sticker price, often called the "chargemaster" price, that can be the starting point for negotiations
with insurers. Discounts off that sticker price tend to be steeper for those that bring large volumes of patients. Insurance plans
offered under government programs like Medicare and Medicaid get even lower rates, tied to prices mandated by federal and state agencies.
The cash prices for patients who must pay for their own care can be equal to the sticker prices or sometimes represent a percentage
lopped off that top rate. Sometimes, those cash rates are also applied to people who have some form of insurance but get a service
that the insurance doesn't cover.
Will Fox, who advises hospitals on pricing as an actuary with Milliman Inc., says hospitals often keep cash prices above the rates
negotiated by big insurers.
"They don't want to give away too much of a discount because they really want the best discounts to go to these larger volume
negotiated insured rates," he said. "Somebody walking off the street, we'll give you a 20% discount, but we're going to give our
favorite customer, who sends us millions or even billions of dollars in business, we're going to give them a much bigger discount."
Yale New Haven Health offers cash prices that represent a discount off sticker rates, but it keeps them above all of the prices
negotiated by insurers, says Pat McCabe, the system's senior vice president of finance. "We didn't want there to be that tension,
for an insurer to look at that data and say, 'you're providing better rates to uninsured patients than you are to our insureds, how
do we justify that to our members and/or employer partners?' "
For individuals who struggle to pay, financial aid is hard to get at some hospitals with high cash prices, the Journal analysis
found. That is true even among the nearly 3,000 nonprofit hospitals that get tax breaks on the condition they give back to the community.
Hospitals typically set household income limits for financial aid, with free care for patients below a cutoff.
The quarter of hospitals with the most generous free-care policies write off the entire bill for those with monthly incomes
under about $2,600 a month, and even up to roughly $6,400 a month, for a one-person household, the Journal found.
Those that rank in the quarter of hospitals with the most-restrictive policies draw the line at or below about 160% of the
federal threshold for poverty, disqualifying for free care patients with monthly income of more than around $1,700 for a one-person
household, according to a Journal analysis of nonprofit hospital tax filings.
Brigham and Women's Hospital, affiliated with Harvard Medical School, falls in this most-restrictive group, with income cutoffs
for free care at $1,610 a month for a one-person household. For 12 of 17 emergency services at Brigham and Women's reviewed by the
Journal, its highest rates are for uninsured patients, and insurance companies pay significantly less.
Brigham and Women's Hospital, in Boston, Mass., is among the group of nonprofit hospitals with the most-restrictive income cutoffs
for free care.
A patient paying cash at the hospital for the stenting procedure is charged $84,792. Local insurer Fallon Health spends $36,755
for the procedure under one of its health-maintenance organization plans. A Medicare insurance plan from Aetna, part of
CVS Health Corp. , pays $16,648.
Mass General Brigham, the system that includes Brigham and Women's, said in a written statement it has policies to prevent
someone without insurance from paying full price.
Some hospitals, including Brigham and Women's, also partially discount patients' bills for some who earn too much for free care.
Others write off bills that are large relative to a patient's income. But policies vary widely. The most-restrictive quarter of hospitals
cut off discounts at 2.5 times the federal poverty level, the Journal found.
Patients who don't qualify for financial aid at nonprofit hospitals also aren't protected by pricing limits under federal
law. The Affordable Care Act requires nonprofit hospitals to cap prices for patients who qualify for financial aid.
Hospitals apply financial aid and discount policies inconsistently, say consumer advocates and patients. Offers may be one-time-only,
or discounts may emerge only when a skilled negotiator is pushing for them.
In January 2018, Joannie Berthiaume spent two days at Broward Health Imperial Point hospital in Fort Lauderdale, Fla., and
got emergency surgery to remove her appendix. She was uninsured and the hospital charged Ms. Berthiaume its highest prices. Her bill
totaled about $42,000, including a $6,033 abdominal CT scan. For that same scan, an Aetna subsidiary gets a 24% break, according
to the newly public data from Broward Health. That discount would have meant a fee of around $4,600 for the scan, based on the price
charged in 2018.
Ms. Berthiaume, who is Canadian but was living in Florida at the time of her illness while finishing graduate school, went in
person to Broward Health to ask about the bill. She was told it could be cut in half, to about $21,000 total -- if she paid in full
right then. Ms. Berthiaume, then working in a part-time bookkeeping job, says she couldn't do that. The hospital later continued
to seek the full amount, including in letters sent by a law firm and reviewed by the Journal.
"If you charge me $42,000 and your costs are justified, how can you knock it in half in a matter of minutes," Ms. Berthiaume
says. "You must be overcharging."
Ms. Berthiaume hired attorney Jacqueline Grady to negotiate on her behalf, and in October 2019 the hospital offered to accept
$20,000, in addition to $2,000 she had already paid, if she paid within 16 days. Ms. Berthiaume declined.
Broward Health declined to comment on the details of Ms. Berthiaume's case, although she signed a consent form allowing the hospital
system to do so. The hospital system said that U.S. citizens and people with a permanent U.S. residence who come to its hospitals
for unplanned care, and don't qualify for its financial assistance program, are offered a discounted rate.
In the pricing data files Broward Health has disclosed under the federal transparency requirement, the cash prices are shown as
Broward's highest rates. However, the hospital system pointed the Journal to a consumer tool on its website that displays lower prices
for self-pay patients. Broward Health said in a written statement that the tool "provides the most current pricing for consumers,"
and "discounted prices may not be reflected" in the data files. The system didn't respond to questions about the reasons for the
discrepancy.
High cash prices inflate bills that uninsured patients often struggle to pay. Hospitals collected 5% of the amount they billed
uninsured patients before writing off bills after a year of seeking payment, according to Crowe LLP, an accounting, technology and
consulting firm, based on an analysis of 600 client hospitals. That is compared with collecting 40% of bills sent to patients with
insurance for amounts owed under deductibles, copays and other out-of-pocket costs, based on a separate analysis by Crowe of about
1,500 hospitals.
Hospitals closely track their "payer mix," or the mix of patients with commercial insurance, Medicare, Medicaid and the uninsured,
who might be unlikely to ever pay for their treatment. That could play a role in how hospitals set prices.
For Mr. Macias, debt from Avera hospitals plus other bills related to his November hospitalization amount to about 75% of his
annual income, according to Resolve Advocates, one of a growing number of companies that patients hire to negotiate hospital medical
bills on their behalf.
Mr. Macias, a superintendent for a construction company, suffered a potentially life-threatening tear in the lining of his largest
artery. He said he has largely recovered.
Avera's hospital in Aberdeen charged him the highest price for some emergency room services, according to a review of medical
bills for Mr. Macias and the Journal's analysis of Avera's negotiated rates with insurers.
Avera in some cases has multiple contracts with a single insurer and said the prices it made public are the average price it charges
an insurer for each service.
The Avera Heart Hospital of South Dakota, in Sioux Falls, gave Mr. Macias a 20% discount. Even with the discount, some of the
heart hospital prices were in the top third of what the hospital charged patients with insurance for some services.
Mr. Macias, a superintendent for a construction company, earned too much for free care at Avera, where the income cutoff is among
the lowest nationally for nonprofit hospitals, ranking in the bottom quarter, according to the Journal analysis.
But he appears to qualify for other financial assistance, such as a partial discount based on income or because Mr. Macias's medical
debts are large when compared with his household finances, said Resolve's chief executive, Braden Pan.
Avera rejected the request, saying that Mr. Macias could have had workplace health benefits but didn't enroll, according to Resolve.
Mr. Macias said in an interview that he missed the sign-up after miscommunication with his former employer. Buying insurance in the
marketplace was too costly, he said.
Avera also rejected an appeal, after factoring in his assets alongside his income, according to Resolve. Mr. Macias said he needs
his years of savings for a house down payment.
Resolve also offered about $8,000, or slightly more than the company estimated Medicare would pay, for Mr. Macias's $24,800
emergency-room bill at Avera St. Luke's, Mr. Pan said. The hospital said no, and despite denying financial aid, offered to reduce
the bill by 50%, Mr. Pan said. The amount excluded another $34,994 he owes Avera's heart hospital.
Mr. Macias, citing his unhappiness about the fight, told the Journal he wouldn't give Avera permission under federal privacy laws
to speak about his interactions with it.
"Health care delivery comes with a cost -- and when individuals have the means to pay, it allows us resources to help those
most in need," Lindsey Meyers, a spokeswoman for Avera, said in a written statement. "We have thoroughly reviewed the case you
have mentioned and identified that all processes were followed as described, and we made every effort to work with the patient."
Mr. Macias said he has largely recovered with new blood-pressure medication and months of rehab exercises he devised on his own.
He now lives in Austin, Texas, with his fiancée and their children, ages 6 and 3. Avera's debt collectors call constantly, he said.
"They're still blowing me up."
"... De Garay explained that after receiving the second coronavirus vaccine dose, her daughter started developing severe abdominal and chest pains. Maddie described the severity of the pain to her mother as "it feels like my heart is being ripped out through my neck." ..."
"... The Ohio mother added her daughter experienced additional symptoms that included gastroparesis, nausea, vomiting, erratic blood pressure, heart rate, and memory loss. "She still cannot digest food. She has a tube to get her nutrition," De Garay said to Carlson. "She also couldn't walk at one point, then she could I don't understand why and [physicians] are not looking into why...now she's back in a wheelchair and she can't hold her neck up. Her neck pulls back." ..."
"... De Garay said she had joined a Facebook support group to help people cope with the unexpected events happening from the coronavirus vaccine trial, and she said it was shut down. "It's just not right," she said. ..."
"... Sen. Ron Johnson , R-Wis., has sent letters to the CEOs of Pfizer and Moderna seeking answers about adverse reactions to the COVID-19 vaccine following a June 28 press conference with affected individuals. The conference in Milwaukee included stories from five people, including De Garay ..."
"... The Wisconsin senator noted that some adverse reactions were detailed in Pfizer's and Moderna's Food and Drug Administration (FDA) emergency use authorization (EUA) memorandums following early clinical trials ..."
"... Those reactions included nervous system disorders and musculoskeletal and connective tissue disorders for the Pfizer EUA memo. The Moderna EUA memo included reactions such as nervous system disorders, vascular disorders and musculoskeletal and connective tissue disorders, according to Johnson's letter. ..."
"... You missed the whole point! The issue is that the government is not acknowledging and and not reporting these side effects of the vaccine. Instead they are lying about the safety. If you are young, you are much more likely to get sick and injured by the vaccine than COVID. ..."
"... anyone under 25 should not get the vaccine because the percentages are about the same or worse having a negative impact from the vaccine versus the actual virus. ..."
"... With the Covid19 mortality rate among the children why even vaccinate? As a Chemist / Biochemist I learned that there is always unintended consequences. ..."
"... Vaccines may have long term effects that are not known today. ..."
"... The CDC's generic guidelines for getting a vaccine for any reason are very restrictive, first being, the disease you're getting vaccinated against has to pose a real, immediate danger. CV-19 poses virtually no danger whatsoever to kids under 14. Of all the deaths of children 14 and under in the last 18 months only .8% of them had a case of CV-19. That's 367 deaths out of over 46,000. (Data from CDC website) Forcing them to take an experimental vaccine that they absolutely don't need is criminal. As a parent, allowing your child to take the vaccine without spending a few hours doing some research is criminally negligent. This is like some terribly warped Kafka novel but it's real. ..."
Mother Stephanie De Garay joins 'Tucker Carlson Tonight' to discuss how her 12-year-old
daughter volunteered for the Pfizer vaccine trial and is now in a wheelchair.
An Ohio mother is speaking out
about her 12-year-old daughter suffering extreme reactions and nearly dying after volunteering
for the Pfizer coronavirus
vaccine trial.
Stephanie De Garay told "Tucker Carlson Tonight" Thursday
that after reaching out to multiple physicians they claimed her daughter, Maddie De Garay,
couldn't have become gravely ill from the vaccine.
"The only diagnosis we've gotten for her is that it's conversion disorder or functional
neurologic symptom disorder, and they are blaming it on anxiety," De Garay told Tucker Carlson.
"Ironically, she did not have anxiety before the vaccine."
De Garay explained that after receiving the second coronavirus vaccine dose, her daughter
started developing severe abdominal and chest pains. Maddie described the severity of the pain
to her mother as "it feels like my heart is being ripped out through my neck."
The Ohio mother added her daughter experienced additional symptoms that included
gastroparesis, nausea, vomiting, erratic blood pressure, heart rate, and memory loss. "She still cannot digest food. She has a tube to get her nutrition," De Garay said to
Carlson. "She also couldn't walk at one point, then she could I don't understand why and
[physicians] are not looking into why...now she's back in a wheelchair and she can't hold her
neck up. Her neck pulls back."
Carlson asked whether any officials from the Biden administration or representatives from
Pfizer company have reached out to the family. "No, they have not," she answered.
"The response with the person that's leading the vaccine trial has been atrocious," she
said. "We wanted to know what symptoms were reported and we couldn't even get an answer on
that. It was just that 'we report to Pfizer and they report to the FDA.' That's all we
got."
After her heartbreaking experience, the Ohio mother said she's still "pro-vaccine, but also
pro-informed consent." De Garay mentioned she's speaking out because she feels like everyone
should be fully aware of this tragic incident and added the situation is being "pushed down and
hidden."
De Garay said she had joined a Facebook support group to help people cope with the
unexpected events happening from the coronavirus vaccine trial, and she said it was shut
down. "It's just not right," she said.
"They need to do research and figure out why this happened, especially to people in the
trial. I thought that was the point of it," De Garay concluded. "They need to come up with
something that's going to treat these people early because all they're going to do is keep
getting worse."
Sen. Ron
Johnson , R-Wis., has sent letters to the CEOs of Pfizer and Moderna seeking answers
about adverse reactions to the COVID-19vaccine
following a June 28 press conference with affected individuals. The conference in Milwaukee
included stories from five people, including De Garay.
The Wisconsin senator noted that some adverse reactions were detailed in Pfizer's and
Moderna's Food and Drug Administration (FDA) emergency use authorization (EUA) memorandums
following early clinical trials.
Those reactions included nervous system disorders and musculoskeletal and connective tissue
disorders for the Pfizer EUA memo. The Moderna EUA memo included reactions such as nervous
system disorders, vascular disorders and musculoskeletal and connective tissue disorders,
according to Johnson's letter.
Pfizer and Moderna did not immediately respond to inquiries from Fox News about Johnson's
letters.
J jeff5150357 6 hours ago
My daughter had the same thing happen to
her after getting a flu vaccine 9 years ago. Within days of getting it, she went from being as
healthy as an ox to years of awful, unexplained illness. The short version is they concluded
that she had a severe adverse reaction to the vaccine, but from the delivery chemicals, not the
flu content itself. Formaldehyde was the likely major cause. Now she is getting ready to begin
college and is being required to get the Covid vaccine by her university and the NCAA for
athletics. It is causing her, my wife and I horrible anxiety and we feel like we are being
railroaded into something that could be very dangerous for her. Any discussion or concern
expressed on social media is immediately blocked. I know from years of working in the research
grants office at Yale University that the big pharma industry is powerful and will go to great
lengths to control the narrative. What I don't understand is why mainstream media and social
media are so willing to help them these days!
jeff5150357 4 hours ago
While the college experience is great for a young adult. I would look at getting a degree
online. Her future earnings will be based on her merit, not where she went to school. If
someone was telling me what to do with my personal health, and I was uncomfortable with their
prescription, I would follow my instincts.
LoraJane92649 jeff5150357 5
hours ago
If her flu vax is well documented she should be able to get a waiver. Hopefully you
have an able bodied family physician or medical team to advocate on your behalf.
G gunvald 7 hours ago
You know when you take it that there can be adverse
reactions. So, in that sense, you are informed. Any one of us could be the odd person. That
said, I have a problem with any child getting these vaccines, especially when most people
recover from the disease. It's one thing for me as an elderly person to make the decision to
take it as covid affects the elderly person more and I wanted to avoid that ventilator. Most of
my life has been lived and that's how I evaluated it. This will always come down to putting it
in God's hands.
TheTruthAsItIs gunvald 6 hours ago
You missed the whole point! The
issue is that the government is not acknowledging and and not reporting these side effects of the
vaccine. Instead they are lying about the safety. If you are young, you are much more likely to
get sick and injured by the vaccine than COVID.
D DontDestoryUSA
gunvald 4 hours ago
It's not being informed when you are forced to take a vaccination that they
clearly had trouble with past vaccination sounds like a lawsuit for the university is on the
horizon. With a big pay day
Tony5SFG 7 hours ago
"Ohio
mother said she's still "pro-vaccine, but also pro-informed consent." " And as a pediatrician
for over 40 yrs (retired now) and a 10 year member of my medical school's Institutional Review
Board (which had to approve all human research), THAT is a problem I have been bringing up As
far as requiring all young people, such as entering or in college, to get the vaccine Children
are a protected class and the informed consent for research on them is much more strenuous than
for adults And, requiring young people to take these new vaccines is the equivalent of doing
research on them. The issue of myocarditis is quite troubling. And while it has been seen in
natural infections, I have not yet seen an adequate risk - benefit evaluation regarding risking
natural infection versus vaccination And people say that the myocarditis is not severe, no one
can be sure of the long term effects of a young person getting it. The vaccines that we give
children have been used for decades and the risks/benefits have been well established
D DallasAmEmail Tony5SFG 6 hours ago
A friends daughter who just went through internship as
Physicians assistant based on the percentages in age groups believes anyone under 25 should not
get the vaccine because the percentages are about the same or worse having a negative impact
from the vaccine versus the actual virus. Yes, older age groups the percent having negative
impact from the virus is much greater than the vaccine, so yes older age groups should get the
vaccine. What really is bothersome is when Youtube removes Dr. Robert Malone video who helped
create the mrna vaccine express concern that normal testing has not happened and be cautious
about taking it, especially for the young.
marinesfather601 Tony5SFG 5
hours ago
With the Covid19 mortality rate among the children why even vaccinate? As a Chemist /
Biochemist I learned that there is always unintended consequences.
Hilltopper9 7 hours ago
Vaccines may have long term effects that are not known
today. The same could be said of all the chemicals we apply to our body daily through shampoos,
hair dyes, body lotions, and suntan lotions. Life's a gamble. It's up to each individual to
make the best decisions possible given the facts available.
A akbushrat
Hilltopper9 6 hours ago
The CDC's generic guidelines for getting a vaccine for any reason are
very restrictive, first being, the disease you're getting vaccinated against has to pose a
real, immediate danger. CV-19 poses virtually no danger whatsoever to kids under 14. Of all the
deaths of children 14 and under in the last 18 months only .8% of them had a case of CV-19.
That's 367 deaths out of over 46,000. (Data from CDC website) Forcing them to take an
experimental vaccine that they absolutely don't need is criminal. As a parent, allowing your
child to take the vaccine without spending a few hours doing some research is criminally
negligent. This is like some terribly warped Kafka novel but it's real.
F
Fauxguy930 Hilltopper9 5 hours ago
☢️ N-butyl-N-(4-hydroxybutyl)nitrosamine is a
nitrosamine that has butyl and 4-hydroxybutyl substituents. In mice, it causes high-grade,
invasive cancers in the urinary bladder, but not in any other tissues. It has a role as a
carcinogenic agent. Ingredient in all shots. How did a carcinogen get FDA approved, oh it was
an emergency.
R RussellRika 6 hours ago
I have a
twelve year old, and not a chance I'd allow her to volunteer for any vaccine trial, and
especially not this one. She very much wanted to get a vaccine, until she started reading about
some of the adverse reactions. Sorry, but I'm a child, the benefit does not outweigh the risk.
MrEd50 6 hours ago
I took the vaccine because I'm 60 years old and work with special ed kids. My 18 year old child
refuses to take it and I support him on this. COVID shouldn't be an issue for most of us.
"... 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. ..."
"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.
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.
$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.
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.
"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)
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.
(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 "
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.
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.
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:
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.
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.
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.
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.
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.
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.
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.
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 privatized 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.
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.
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.
This is s very interesting insight into healthcare 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 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 privatize 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.
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.
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
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.
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.
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
Quite different from my expectation of spartan if not rudimentary medical care and overworked staff in
a small Russian town. The blog on schools was interesting as well. Given where Russia was in the 90's
compared to now, it is easy to understand the strong popular support for the government and Putin in
particular.
Off topic but just saw a 2-3 minute piece on CBS news (a very long story for an American
national news show) about a Russian woman (former Playboy "model') who is challenging Putin. The
reporter assured us the if she became too popular, Putin would never allow her to win. The last time
Russia was allowed to protest, according to the reported was back in 2011 where the masses were
demanding change. The implication being that a subsequent crackdown has suppressed further protest.
The piece showed her speaking to a group (the camera view was such that is was impossible to
determine the audience size but it had to be at least 10 and possibly up to 30 people). The reporter
also speculated that the woman coud be a Kremlin plant to create a fake opposition. Just a mishmash of
a story all in all.
Speaking as someone who has been hospitalized 3 times in Russia and still live
to talk about, I have no complaints.
In the twilight years of the USSR everything was deficit, including medicine, and the hospitals were
often dilapidated, understaffed and lacking modern equipment. It was socialized medicine, of course, but you
only got the basics for "free". They would not let you die, but if you wanted any "extras", you had to pay
or provide "gifts" to the staff. The doctors were and still are good, but were grossly underpaid.
I was first in hospital here, in isolation because I had diphtheria, in 1993. They saved me. I thought my
number was up. When I was recovering, a nurse asked me when my wife would visit me.
"I have no wife."
"Your friends, then?"
"No friends. I only arrived here 3 weeks ago."
"You're going to be hungry!"
Our first child was born in 1999. The maternity wing of Moscow Hospital №1, opened 1837, was nightmarish.
I paid the anaesthetist so that he could ensure that my wife did not suffer during her labour: it was a
long, slow painful birth.
Our last child was born in 2008: brand new hospital; my wife had her own room; everything state-of
the-art. I paid nothing. My wife came out healthy with a healthy baby. I gave the obstetrician a "present"
after delivery.
A bribe? Not in my opinion: just a token of gratitude for a job well done.
I broke my left collarbone at the dacha that same year. I was in a village/small town (Ruza) hospital. It
was only 2-years old. There were problems because I have broken both collarbones before. Anyway, the
orthopaedic surgeon did a good job, and I didn't pay anything: emergency treatment is free for British
citizens, likewise Russians in the UK. A remnant of when the UK and the USSR were glorious allies against
the Beast.
I have also had varicose veins removed. Only 2 days in hospital. A job well done. I gave the surgeon a
present. He didn't ask me for one, but I thought it was right that I do so.
There have been great improvements in treatment and medical technology here. And the doctors and nursing
staff are well trained and competent.
Not perfect -- nothing is -- but more than satisfactory.
Yes, you do hear horror stories, as you do about the British National health Service, but all in all,
satisfactory.
And there is a private health system now financed by private insurance.
And I have had dental treatment here "on the state": no complaints -- and "free", paid by taxation.
An old Russian colleague of mine has lived in Germany many years now, but he comes back to Moscow to see
an orthodontist.
"They are just as good as in Germany, sometimes have even trained there, and much, much cheaper", he
says.
PS I paid the anaesthetist so he could get the best stuff to help a woman in labour and was unavailable
on the state health service. I forget what it was called now: some German manufactured stuff, I suppose.
My wife said it was the norm in Romania to provide small gifts to bureaucrats – too small to be
considered a bribe but a necessary gesture of appreciation. Its not entirely different from the custom
of bringing a small gift when visiting friends (bottle of wine, flowers, box of chocolate, etc.).
Very much so; I'm sure I mentioned before the controversy surrounding my marriage in Russia; the
waiting period that must follow an application to marry is 30 days (I guess this is a period during
which anyone opposing the marriage may make their case), while a tourist visa is also for a maximum
of 30 days. Therefore, I could not legally remain in Russia long enough to get married. Sveta was
very matter-of-fact about it; we would just, she said, announce that she was pregnant, which is one
of the exceptional conditions which will override the waiting period.
I said she would never get
a doctor to sign a certificate that she was pregnant if she was not. Within a week she had her
choice of three. We gave the doctor who furnished the certificate some flowers and a box of
chocolates. I never considered it a bribe, and still do not, and the gift followed the act. We
would have gotten the certificate anyway.
I notice that Russians typically take such a gift with them whenever they visit friends;
Ukrainians do, too. They never arrive empty-handed, and it seems much more a ritualized courtesy.
It seem odds to me how Russia or Romania can be stifling bureaucratic (as ME can attest) yet
rules will often be bent with hardly a blink to facilitate a reasonable request.
The healthcare system in a country probably reflects the dominant elements in said country's culture. Our
family's longtime GP was a buffoon. In my interactions with him his enthusiastic "hands-on" gung-ho approach
caused several problems, not least when I visited him to get a "line" certifying I was unfit for work a week
after a total hip replacement operation (he insisted on examining the wound and re-dressing it with a
dressing whose adhesive I had been tested for in hospital and deemed allergic to it; fun and games, anxiety
and discomfort ).
Nevertheless he made an immediate decision to admit a close relative of mine for surgery on the basis of
his examination of her.
Johnson &
Johnson has agreed to pay $230 million to the state of New York to resolve an opioid
lawsuit slated to go to trial Tuesday, as negotiations intensify with the company and three
drug distributors to clinch a
$26 billion settlement of thousands of other lawsuits blaming the pharmaceutical industry
for the opioid crisis.
Johnson & Johnson's New York deal removes it from a coming trial on Long Island but not
from the rest of the cases it faces nationwide, including a continuing trial in California. The
New York settlement includes an additional $33 million in attorney fees and costs and calls for
the drugmaker to no longer sell opioids nationwide, something Johnson & Johnson said it
already stopped doing.
States have been trying to re-create with the opioid litigation what they accomplished with
tobacco companies in the 1990s, when $206 billion in settlements flowed into state coffers.
More than 3,000 counties, cities and other local governments have also pursued lawsuits over
the opioid crisis,
complicating talks that have dragged on since late 2019 and that have been slowed down by
the Covid-19 pandemic.
The current crop of vaccines only target the spike protein, which has a surprisingly high mutation rate. No disease has ever
been extinguished using this approach. Key examples â€" smallpox, measles, mumps, chicken pox, polio, etc. â€" all have been eradicated
using whole virus vaccines (inactivated or attenuated) that target a variety of sites on the viral surface. These traditional
vaccines are effective against new variants because all sites would need to mutate simultaneously to escape human immune surveillance.
Polio is a perfect example because it has an enormously high mutation rate - much higher than COVID - but the vaccine works because
it targets a variety of sites that cannot all simultaneously mutate away.
f
COVID will not be defeated until a pharmaceutical company invests the time and expense to develop a live attenuated vaccine
that triggers immunity against several different surface proteins. But they won't because selling "booster" shots every year is
a great business.
The current variant problem began after patients were treated with convalescent plasma, which added selective pressure for
the mutant strains we are struggling with now. The vaccines are simply doing the same.
Jade_Dragon 7 hours ago (Edited)
Well, everything is being run for profit with no regard for the consequences. Corps take on debt to fund share buybacks, eschewing
R & D then need a bailout. Shot that may or may not kill protect you against the CV but reaps billions for the pharma companies
is par for the course. It all reminds me of those shoddy Chinese trinkets you buy on Amazon that break 32 days later
sun tzu 7 hours ago
They will blame it on science instead of greed, corruption, and stupidity
"... There are a lot of things to say about the medication advertising issue and never enough ways to say it. The problem of patients asking their doctors for specific medications is just one problem. In many, if not most, instances, these drugs may not be appropriate or even applicable to specific patients' problems. ..."
"... One of the biggest problems with all of the advertising--and this was supposed to change by law--is that there is no indication of what these drugs cost, especially compared to other similar drugs for the same thing. I have a friend who is a retired nurse and she gets a big kick out of looking up the costs of all the newly advertised drugs so whenever anyone talks about them, she can tell them how expensive they are. ..."
If and when you want to know who you're dealing with, I challenge you to watch the over
the air channels, that's right antenna TV, specifically "ME-TV".
Some background, people who can't or won't afford cable TV, like old, retired, poor people
drop it. Note, most of these folks don't have a DVR and can't pause TV, at best they'll mute
the commercials, eventually they succumb and watch. They are a MARKET.
What you will learn, if you take the antenna challenge, pharmaceutical companies are
predatory, deceptive and, yes, evil. Under their onslaught on the underprivileged it's
causing many to "ask your doctor" about prescription medicines. Wouldn't your doctor know
better about what meds you need? I hate Bill Clinton for authorizing prescription medicines
advertising, again. It was banned and now it's not.
Now, think about it, can you trust such vile people?
chiquita 5 hours ago (Edited)
There are a lot of things to say about the medication advertising issue and never enough
ways to say it. The problem of patients asking their doctors for specific medications is just
one problem. In many, if not most, instances, these drugs may not be appropriate or even
applicable to specific patients' problems. In some cases, patients must take a series of
drugs before being allowed to take certain medications--for example with statins, at one time
(I don't know for sure now, but this was true in the 1990s) some insurance required a patient
to start with one particular statin before they could be moved onto another and so on. Right
now there are a bunch of different type 2 diabetes drugs, but here again without using the
original tried and true medication(s) first, a doctor is unlikely to put a patient directly
on one of the newer medications just because they ask for it if they've never taken any
medication for lowering their blood glucose levels.
One of the biggest problems with all of the advertising--and this was supposed to change
by law--is that there is no indication of what these drugs cost, especially compared to other
similar drugs for the same thing. I have a friend who is a retired nurse and she gets a big
kick out of looking up the costs of all the newly advertised drugs so whenever anyone talks
about them, she can tell them how expensive they are.
Last, even without all the advertising, there has always been the problem with the
pharmaceutical company sales reps soliciting at the doctors' offices (and hospitals). I can't
say what this is like these days because I'm removed from it, but when I was married to a
doctor, I knew exactly what went on. The drug reps came in bearing gifts and boxes and boxes
of samples of all kinds of company products. There was a lot of incentive given to prescribe
their products. My ex was not big on prescribing anything he didn't believe in. However, I
did go to a doctor for years where I got a regular allergy shot (so I was there pretty often)
and I used to sit in the waiting room with the drug reps almost every visit. They're
parasitic.
This Is Why Hospitals Can Charge $6,000 Or $60,000 For The Exact Same Procedure
BY TYLER DURDEN
SATURDAY, FEB 13, 2021 - 17:00
Several months back,
we
pointed out
how new disclosure laws would be forcing hospitals to disclose the cost of services and rates negotiated by
insurers. Now, the numbers are starting to trickle in - and they're ugly.
Roughly 6,000 hospitals across the nation are starting to reveal the rates they negotiate with insurers for a number of
procedures. The figures show how widely prices vary for the same procedure depending on who is paying, as highlighted by a
new
Wall
Street Journal report
.
For example, the report found that a C-section can cost between $6,241 and $60.584 - all depending on which insurer covers
it. Niall Brennan, chief executive of the Health Care Cost Institute said:
"It is
shining a light on the insanity of U.S. healthcare pricing. It's at the center of the affordability crisis in American
healthcare."
The rates are a key driver of the massive healthcare costs in the U.S., some of the highest in the world. It was a Trump
administration rule that shed light on the differences in procedure pricing - some of the widest gaps in pricing of any
U.S. industry. Gerard Anderson, a healthcare economist at Johns Hopkins University, commented: "These price differentials
are unique to the healthcare and hospital industry."
The prices have a direct effect on consumers, as they push up premiums and
deductibles
. And, in a stunning revelation, "total U.S. expenditures on private health insurance have increased
50% in the past decade through 2019, according to federal figures," the
Journal
wrote.
The report found that a Northern California system of 24 hospitals had sometimes "extreme" pricing ranges for procedures.
One cardiac procedure varied between $89,752 to $515,697, depending on insurer. For those paying out of pocket, the
procedure cost $325,703. The system, called Sutter Health, did $13 billion in 2019 revenue is is known for drawing an
antitrust suit from the California state AG in 2018. The system paid $575 million to settle the claims.
Sutter Chief Financial Officer Brian Dean commented: "We enter into negotiations with every health-insurance company or
payer in good faith and with the end goal of providing access to quality, affordable care for patients."
"The variation in the data reflects robust competition in the markets for commercial insurance," he argued.
One former insurance executive told the
Journal
that they could expect the same
types of wide ranges for pricing across the country:
"The California system's pricing spread for the procedures reviewed by the Journal are likely at the upper end, but
similar patterns will be found at many hospitals around the country, said Alan Muney, a former
Cigna
Corp. executive.
"This is probably typical of what you're going to see across big delivery systems," he said.
Prices paid by private insurers in the nation's $1.2 trillion hospital sector are often far higher than the amounts paid
to hospitals by the Medicare program, which are set by the government. Plans offered by insurers under Medicare or
Medicaid often get rates tied to those mandated prices."
Insurers have a better chance of winning better rates if they can drive more
patients to a certain hospital, another former insurance executive said
. Hospitals, meanwhile, sometimes set their
prices with "little bearing on the actual cost or value of a service", the report says. Rather, hospitals set prices based
on their own targets for margins and according to what the market will pay.
Privately insured patients drive margins typically - and hospitals that boosted margins generally didn't cut costs, but
rather raised revenue by increasing rates billed to commercial insurers, one study found. Economists have found that
quality is generally no better at more expensive hospitals. Michael Chernew, the Leonard D. Schaeffer Professor of Health
Care Policy at Harvard Medical School, said: "We have not found evidence that price is a great signal for quality."
The new data will draw the eyes of insurers and hospitals, moreso than consumers. Elizabeth Mitchell, chief executive of
the Purchaser Business Group on Health, which represents major employers, said they will use the data to help choose which
hospitals to use and how to negotiate with insurers.
The Journal examined one cardiac code for cardiac-valve procedures involving catheterization performed on patients with
risk factors. It confirmed that the largest spreads on pricing were in procedures that cost the most:
Seven insurers pay the lowest negotiated rate, $89,752, for their Medicare plans. The lowest price for a
commercial-insurance plan, the type offered to employers, is $197,900. At the top end, the charge is $515,697 for
patients whose health plans don't have the hospital in-network.
For hip- and knee replacements, Medicaid and Medicare plans paid the lowest prices at the Modesto hospital, $3,264 and
$16,349, respectively. The lowest price paid by a commercial insurer totaled $51,895. The highest rate reached $81,617,
again for patients whose insurance didn't include the Modesto hospital in-network.
Recall,
we
first brought up
President Trump's plans to institute these transparency plans back in January.
The $1.2 trillion industry comprising some 6% of the country's economy is now subjected to more transparency than it has
seen in decades. The point of instituting the disclosures, according to the Trump administration, was the hope that good ol'
fashioned market dynamics will kick in, and help lower prices across the board.
Previously, hospital pricing was negotiated confidentially between hospitals and the employer groups and insurance
companies that pay for care.
Many criticized this system for obscuring market rates and helping drive up the cost of health insurance premiums paid by
employers and workers.
Rising hospital prices accounted for about one-fifth of the
nation's health spending growth over the last 50 years.
Now, we will see first hand if a free and open market can help solve some of the industry's problems.
At
least, until President Biden reverses the new rules.
Yves here. Go Katie Porter! While you were busy rubbernecking over Robinhood and GameStop,
some people were staying focused on issues that matter to Americans.
We have written for many years about other elements of bad faith at Big Pharma, like whining
they need more profits to fund drug development, when they spend more on marketing than
R&D, and also spend a lot on buybacks.
From Axios :
The big picture: When billions of dollars became available to the biggest drug companies,
their main priority was to juice earnings, along with the paydays of their executives and
investors -- not investments in new treatments or relief for patients who can't afford their
drugs.
And on top of that, for decades, the overwhelming majority of FDA "new drug applications"
are actually minor reformulations of existing drugs to extend patent life.
By Brett Wilkins, staff writer at CommonDreams. Originally published at
CommonDreams
Rep. Katie Porter on Friday published a damning report revealing the devastating effects of
Big Pharma mergers and acquisitions on U.S. healthcare, and recommending steps Congress should
take to enact "comprehensive, urgent reform" of an integral part of a broken healthcare
system.
While pharmaceutical executives often attempt to portray such consolidation as a means to
increase operational efficiency, the report states that "digging a level deeper 'exposes a
troubling industry-wide trend of billions of dollars of corporate resources going toward
acquiring other pharmaceutical corporations with patent-protected blockbuster drugs instead of
putting those resources toward' discovery of new drugs."
Merger and acquisition (M&A) deals are often executed to "boost stock prices," to "stop
competitors," and to "acquire an innovative blockbuster drug with an enormous prospective
revenue stream."
"Instead of spending on innovation, Big Pharma is hoarding its money for salaries and
dividends," the report says, "all while swallowing smaller companies, thus making the
marketplace far less competitive."
The report calls M&As "just the tip of the iceberg of pharmaceutical companies'
anti-competitive, profit-driven behaviors":
Pharmaceutical companies often claim that lowering the prices of prescription drugs in the
United States would devastate innovation. Yet, as prices have skyrocketed over the last few
decades, these same companies' investment in research and development have failed to match
this same pace. Instead, they've dedicated more and more of their funds to enrich
shareholders or to purchase other companies to eliminate competition.
"In 2018, the year that [former President] Donald Trump's tax giveaway to the wealthy went
into effect, 12 of the biggest pharmaceutical companies spent more money on stock buybacks than
on research and development," the report notes.
Some key findings from the report:
"Competition is central to capitalism," Porter said in a press release
introducing the report. "As our report shows, Big Pharma has little incentive to invest in new,
critically needed drugs. Instead, pharmaceutical giants are free to devote their resources to
acquiring smaller companies that might otherwise force them to compete."
"Lives are on the line; it's clear the federal government needs to reform how it evaluates
healthcare mergers and patent abuses," Porter added.
To that end, Porter's report recommends the following actions:
"It's time we reevaluate the standards for approving these mergers," the report concludes.
"It's time we pass legislation to lower drug prices. And it's time we rethink the structure of
leadership at big pharmaceutical companies. Together, these strategies can help us bring more
innovative, and critically needed, cures and treatments to market."
Okay, this I didn't expect: top recipients of Pharma $ in the senate per Open Secrets:
Bernie Sanders, twice the take of his nearest competitors, Warren and McConnell https://www.opensecrets.org/industries/summary.php
?
Outsized profits has failed to draw competition to itself. Instead, outsized profits is
used to kill competition. Another advantage for the bigs is using the carryforward losses of
the soon to be devoured innovator to offset the big's profits, reducing taxes owed.
Sweet deal for those at the top. Taxpayer funded research -> innovative money losing
company taking a risk -> devour the innovative company and use the generated losses by it
to reduce your own taxes and kill the competition. Circle complete.
How is that circle to be broken when the bigs own congress?
I think this is a wider problem that just the drug industry.
I was invited to a silicon valley party once at the partner of a big law firm. It was kind
of a celebratory party for all the companies that had liquidity events that year.
I went around asking what their companies did. What struck me was how trivial most of the
products these companies were making. Really most were minor upgrades to existing
products.
It turns out that the healthcare industry would rather buy a minor update that do it
themselves, because if they did it themselves it would be a cost. By buying the product it
doesn't show up as cost (at least in the short run).
This makes everything less efficient. A small company starting from scratch takes much
time and money to make this minor update. Once the acquisition occurs, the big healthcare
company now has 2 products, which are similar, but made by different producers, with total
different BOMs.
I covered the health infotech VC startup space (mostly Silicon Valley) for a number of
recent years. I was working in Health IT at the time (electronic medrecs, etc).
Then I watched "Silicon Valley HBO" at the urging of my kids.
The content of this report of Big Pharma corruption should certainly be a national
scandal, resulting in a generation of reform. But the corrupt mass media, corrupt
legislature, corrupt executive, and corrupt judiciary will do nothing at all. They are the
core problem.
The US needs constitutional amendments to restrict funding of mass media, political
parties, and elections to limited individual donations, with very severe penalties for
violations. Congress and the judiciary and most agencies must be purged and restaffed under
strict controls, and monitored for life for corrupt influence. All branches and mass media
corporations must be structured with multiple redundant cross-checking decision committees,
with rotating memberships. Otherwise they sell out.
"The content of this report of Big Pharma corruption should certainly be a national
scandal, ."
You are absolutely right, and it is something that all Americans should know about, so I
searched the major news outlets in this country to see who is carrying this story and guess
what? NOT ONE! Vox is the closest to MSM coverage that I could find.
The 'small government' movement was always a total ruse. It wasn't even libertarian. It
was just 'give me monopolies and tax cuts' populism for the One Percent. Meanwhile the plebes
continue to believe in 'trickle down,' prosperity for themselves. A friend of mine found this
quote. I think it is pertinent: "The Baltimore Evening Sun on July 26, 1920: ""As democracy
is perfected, the office (of the President) represents, more and more closely, the inner soul
of the people. We move toward a lofty ideal. On some great and glorious day, the plain folks
of the land will reach their heart's desire at last, and the White House will be adorned by a
downright moron." The only thing H.L. Mencken didn't consider when he wrote the sentiment was
how many of a like mind and character would be swept into office by the wake." This is not a
criticism of the new President, Joe Biden. He appears sane and maybe even quite progressive.
A true populist, not the fake one we just collectively fired.
A disgraced
Virginia OB/GYN who for years performed unnecessary surgeries on women -- including
hysterectomies -- in an insurance fraud scheme was found guilty on 52 counts for his
crimes.
The former doctor, Javaid Perwaiz, faces more than 400 years in prison when he is sentenced
by a federal judge next spring,
the Washington Post reported .
Perwaiz, who practiced in Hampton Roads, forced women into surgeries by telling them they
had cancer and used broken equipment to perform procedures, according to the report.
At his three-week trial in federal court, victims of the doctor testified how he performed
hysterectomies and other permanent, life-altering surgeries on them.
Perwaiz profited from the scheme by pocketing millions of dollars from Medicaid and private
insurers that paid for the unnecessary medical procedures he performed on the women.
"Doctors are in positions of authority and trust and take an oath to do no harm to their
patients," Karl Schumann, an FBI agent in the Norfolk field office, told the Washington Post in
a statement.
"With unnecessary, invasive medical procedures, Dr. Perwaiz not only caused enduring
complications, pain and anxiety to his patients, but he assaulted the most personal part of
their lives and even robbed some of their future," he added.
At trial, Perwaiz defended himself, arguing he performed the surgeries to help his patients,
not siphon money from their insurers.
From comments: "Article is poorly written by someone who does not know medical science. There
are no viral "cells" so the headline is a put off right away. The comment about "sensitivity" is
misplaced as PCR tests are too sensitive: ergo false positives. I believe "specificity" is the
word the author was searching for. If a test lumps true positives with false positives, then it
lacks specificity."
That's because new research from the University of Oxford's Center for Evidence-Based
Medicine and the University of the West of England has found that the swab-based technique used
for most COVID-19 testing is at risk of returning "false positives" since copies of the virus's
RNA detected by the tests might simply be dead, inactive material from a weeks-old infection.
Although patients infected with COVID-19 are typically only infectious for a week or less,
tests can be triggered by virus genetic material left over from a weeks-old infection.
The team's research involved analyzing 25 studies on the widely used polymerase chain
reaction test. PCR tests use material collected with a swab - the most common type of test
around the world, and especially in the US - then utilize a "genetic photocopying" technique
that allows scientists to magnify the small sample of genetic material collected, which they
can then analyze for signs of viral RNA.
What the researchers here have effectively found is that these PCR tests just aren't
sensitive enough to distinguish if the viral material is active and infectious, or dead and
inert.
For those who desire a more comprehensive understanding of how these tests work, the chart
below can be helpful.
Professor Carl Heneghan, one of the authors of the study, said there was a risk that a surge
in testing across the UK was increasing the risk of this sample contamination occurring and it
may explain why the number of Covid-19 cases is rising but the number of deaths is static.
"Evidence is mounting that a good proportion of 'new' mild cases and people re-testing
positives after quarantine or discharge from hospital are not infectious, but are simply
clearing harmless virus particles which their immune system has efficiently dealt with," he
told the Spectator.
Professor Heneghan added that international scrutiny might be required to avoid "the dangers
of isolating non-infectious people or whole communities." ZKnight 14 minutes ago
Fake science. How about purify the virus first and establish a gold standard for testing
first. No, of course not because the CDC has a patent for Covid-19 and nobody is allowed to try
find it to see if it exists. play_arrow LogicFusion 27 minutes ago
Everybody is a Covid-19 / Coronavirus expert now!
Read about the failed coin dealer and convicted felon's performance. It's hilarious!
Covid -19 has been so politicized that I don't believe a word of any publication for or
against testing, existence of the Virus, or anything that provokes testing or issues opinions
about locking down communities. Just like the riots, Covid news is just plain boring.
play_arrow ominous 3 hours ago
"Give me control of a nation's money, and I care not who makes the laws" - Mayer Amschel
Rothschild. play_arrow play_arrow tangent 4 hours ago remove link
People who recommend a vaccine for an entirely cured virus should lose their license to
practice medicine. 99.9% cure rate applying to people who take it before being hospitalized is
one of the biggest success stories in the history of medicine for HCQ. Not only that, but there
are multiple other likely cures that simply have not been studied well. You'd think people
would appreciate the fact that the common cold has been cured, but instead they just whine that
big pharma isn't getting those bucko bucks.
I honestly expected a ticker tape parade like in the movies when that first cure study came
out. But instead they took a massive **** on the study and on the doctor... ****ty world we
live in. ay_arrow Pair Of Dimes Shift 2 hours ago
An exec (55+) at my company is gung ho about the vaccine.
Unfortunately, I just had to give him a "wait and see" response although I know vaccines for
coronaviruses are impossible. play_arrow 2 play_arrow ThanksIwillHaveAnother 4 hours ago
(Edited)
Viruses are not full cells. They are DNA/RNA wrapped with a protein the clings to a cell
then the cell imports the DNA/RNA to start making its proteins. So what is inactive? If that
person sneezes on another person depending on immune system status that other person could get
a bad infection. y_arrow 4 CrabbyR 3 hours ago
viruses utilizes CELL structures and host DNA to replicate dna or rna according to the
viruses genetic code, the protein jacket is the final product to
disguise the virus from detection and to bind on another cell after the compromised cell
RUPTURES, there's more to it but if it cannot copy itself effectively it can become nonviable
and unable to infect another cell. It replicates DNA inside a host cell, It is not a complete
organism and cannot replicate unless it can inject its DNA into a host cell. Antibodies cling
to viruses and destroy this ability to bind to a target cell. A non viable virus has a damaged
coat or DNA RNA that has to many Dimers (damage or code breaks) Bacteria is more in line with
what you think a virus is y_arrow onewayticket2 4 hours ago (Edited) remove link
they lost me when they changed the definition of "death" to include "presumed, untested"
cases (while bI@#$% ing at me that we needed to "follow the science")....and even got busted
for the laughable motorcycle accident being classified as a covid death and the Labs that were
sending in 100% positive results. (until they were caught) play_arrow OutaTime43 4 hours ago
remove link
The test detects RNA. Not necessarily viable virus. Also, it will detect RNA presence in an
individual who may already have antibodies and may be immune. We are bombarded daily by viruses
of which we already have immunity. play_arrow sun tzu 10 hours ago
Shocking news that the South Koreans already discovered and published back in May. Western
big pharma driven medicine is garbage 😂😂😂
Interesting play_arrow play_arrow Jack Mehoff 1 more time 9 hours ago
Business as usual play_arrow play_arrow Argon1 7 hours ago
Preparation for agenda 2021 in 2017. play_arrow 1 play_arrow CrabbyR 4 hours ago
WOW.......ties a few strands from other sources together into a real ugly picture play_arrow
play_arrow Welsh Bard 10 hours ago
The professor who won the Nobel prize for work in this field, said that the way this test is
being operated with over forty cycles, means that any results are entirely meaningless.
In Britain, having spent over £15 billion setting up PCR testing systems and a shaky
test and trace apparatus on top of that, it appears that 90% of positive results now appear to
be false. This is compounded by the fact that when a hot spot develops, more testing is done to
show a rapid increase in more false positive results, meaning further new lockdowns and even
more testing to prove yet more false positive results ad infinitum.
Now whether this is by design or ineptitude, people must decide for themselves but the
outcome is utter chaos.
For those countries who have not followed the Swedish model especially countries like
Australia and New Zealand who have set up complete isolation, now face a future perpetually cut
off from the rest of the world.
Okay, new techniques will and are coming along to treat the disease like HCQ when used
correctly maybe as a prophylactic and a vaccine that will need to be constantly upgraded like
the Flu vaccine, means that the whole world has painted itself into a corner unless drastic
revision is now made to the whole sorry mess.
In the meantime, we will now be stuck with digital currency and the introduction of ID
Health Cards that will limit people in how they travel where they work and access to a whole
heap of things like government services.
Welcome to the new world order! play_arrow 1 KuriousKat 11 hours ago (Edited) remove
link
Don't tell the Shameless Aussie gov that after arresting hundreds for simply voicing doubt
on need to lockdown entire city...Next time it will be thousands and not a damn thing they can
do to stop it..These people are trickling us the truth how worthless the tests are when pretty
much everyone knows. play_arrow espirit 12 hours ago remove link
Lessee.
WHO
Imperial College
John Hopkins
CDC
Line all those peeps up against the wall, and the first one to rat gets to live.
I'll provide my own ammo... ay_arrow Sick Monkey 6 hours ago
Not everyone working in these agencies are dishonest but like you and I we have to work and
eat.
Most of them are trapped in this mess with bills to pay threatened by NDA.
play_arrow 1 Urban Roman 12 hours ago
Not particularly new news. Been talked about since April at least -- it's an RNA virus, it
has its own polymerase, and it leaves lots of RNA fragments in its wake.
The Corona family of viruses make 5 or 6 strands with partial copies of their RNA molecule.
negative copies are made first, and then copied again into positive copies. Finally the one big
RNA is made with the entire genome on it.
So about a dozen RNA molecules are made for each finished virus particle that is produced.
And finally, a variety of different primers are used for the PCR tests, some are matched to the
small partial RNA copies and others are matched to various features on the large whole-virus
RNA. They can give different results for the same sample.
So, someone who registers on a PCR test has probably been exposed to the virus, but the test
gives no clue as to whether it is an active infection, or the person is contagious, or they are
just coming down with it, or they got over it six months ago. play_arrow 4 play_arrow 1
10 play_arrow gordo 12 hours ago remove link
Sweden, no masks, no lock downs, ALL SCHOOLS OPEN, herd immunity, no second wave.
Still think your masks and lock downs are working muppets?
1 play_arrow The 3rd Dimentia 13 hours ago
https://youtu.be/sjYvitCeMPc
SARS-CoV2 and the Rise of Medical Technocracy. Lee Merritt, M.D. play_arrow 3 play_arrow
hugin-o-munin 13 hours ago
I'm glad to see that many are starting to counter the official narrative.
We've been asleep for too long and allowed these agendas to fester to the point we're at now
where a college dropout software salesman and a former 3rd world communist terrorist (neither
of whom have any medical degree) are dictating to the world how everyone needs to get a DNA
altering vaccine and a medical ID. It's completely nuts and bonkers yet more or less the entire
planet's governments follow in 'lockstep' with ever more draconian laws and regulations
incarcerating people in their own homes, making them wear masks causing oxygen deprivation and
shutting down the entire world economy.
lay_arrow Warthog777 , 13 hours ago
Article is poorly written by someone who does not know medical science. There are no viral
"cells" so the headline is a put off right away. The comment about "sensitivity" is misplaced
as PCR tests are too sensitive: ergo false positives. I believe "specificity" is the word the
author was searching for. If a test lumps true positives with false positives, then it lacks
specificity.
Anyone who would use the term "virus cells", has no clue what they're talking about and
should be completely disregarded. Viruses are not cells. PCR tests are searching for
something your body produces in response to a virus as well. They are not produced
specifically for a singular virus either. The entire concept of PCR testing is garbage. This
**** was a scam from the get-go.
hugin-o-munin , 13 hours ago
Yes it is evident now that this entire pandemic is false and political. The goal seems to
be to vaccinate entire populations and the question people need to ask is - why? what for?
Aside from the obvious economic motives there are some more sinister plans that most people
will have a hard time accepting but these need to be looked at. Several years ago there were
a group of doctors and researchers that died of suspicious suicides who were collaborating
and studying vaccines and the link to autism.
The effort was led by Dr.Jeffrey Bradstreet who was researching the natural substance
GcMAF and how this could boost the immune system. What he discovered was that many vaccines
had a compound/substance called Nagalase in them that is unnatural and has a detrimental
effect on the immune system and function of GcMAF (which is produced by our own bodies) and
has no business at all being in vaccines. Just before he was able to blow the whistle on this
he also died of a suspicious 'suicide' and today most of the clinics and research groups
working on GcMAF have been destroyed and ruined. Draw your own conclusions.
snblitz , 14 hours ago
Dr. Kary Mullis invented the PCR test. He said it was ineffective for this purpose.
Though he was addressing its use in a prior virus hoax unleashed upon the world.
I bet you didn't know this scam has been used before.
That is why I was able to call out the scam right from the start. The second I saw them
using the PCR again, I knew it was from the same playbook.
snblitz , 14 hours ago
So many lies.
Viruses are not alive. They have no metabolic functions. They cannot move.
Don't believe me? Get a degree is virology or microbiology or just a read a book on the
subject. Or capture a wuhan-virus yourself and watch it under a microscope. It won't move. It
won't consume anything. It will just sit there inert.
The problem is that you are being lied to at a scale you cannot imagine.
I know, off to the fema re-education camp for me for spreading false information about the
wuhan-virus.
Though I am not the one spreading fear and hysteria.
aldousd , 13 hours ago
There article is confused, but the work of the doctor is not. Viruses use your cells to
reproduce. When your immune system targets the virus it actually kills your own cell which
has become host to the virus. The virus particles and markers, and the DNA of the virus can
be detected in these dead cells, but dead cells cannot serve as a factory for more viruses.
So it's effectively a dead virus infected cell. Not a dead virus cell.
So while the transcription of the idea here was done by an idiot, it's not an idiotic
idea. The tests cannot tell if the virus came in a living cell that is actively producing
more viruses or a dead host cell that has been assassinated by your immune system. That's
what they're talking about here.
mstyle , 11 hours ago
what about the chromosome 8 stuff that has been mentioned lately?
(since you appear to be rather intelligent)
hugin-o-munin , 11 hours ago
Thanks. Well the chromosome 8 discovery in the PCR test specifications/details is strange
and worrying because it makes you wonder why it's part of this at all. Some believe it's to
get more false positive results while others believe it is what the mRNA vaccines are
intended to target and if that's right then it's really sinister. What exactly is the plan?
To make all of us get Downs Syndrome? I don't know but judging by all their other lies and
schemes it wouldn't surprise me.
IRC162 , 14 hours ago
Fuggin progressives and their pandemic political prop. But really this reaction is the
same as their reaction to 'racial injustice'. They focus on feelings before the facts are
known in order to achieve their end, and then do their best to bury/ignore the facts when
they are gathered later.
94% COVID deaths with multiple comorbidities.
10 unarmed blacks killed by police in 2019 (6 were in self-defense).
adr , 15 hours ago
Why didn't you mention that nearly all labs are running 35-40 cycles which guarantees a
positive test, simply from noise.
The inventor of the test said if you don't find anything after 15 cycles, it probably
isn't there. After 20 cycles the noise starts to be greater than any real information. By 30,
the test is mostly noise. More than 35, the test is completely worthless.
Of course I've been saying this for five months, but most people didn't listen. After the
NYT article came out, people I know started saying, "How did you know?"
I said, "Because I have critical thinking skills. Why didn't you believe me? Name a time
I've steered you wrong."
Antiduck , 14 hours ago
333 labs in florida had 100% positivity. (stupid word.)
ZenStick , 12 hours ago
Exactly correct.
Nobody will touch this line of reasoning in public or on media.
Bastages.
Identify as Ferengi , 15 hours ago
See above, Born2Bwired.
The PCR test is not useful for what they are using it for apparently. This has been
known since the beginning. Here is quote regarding AIDS:
"Kary Mullis, who won the Nobel Prize in Science for inventing the PCR, is thoroughly
convinced that HIV is not the cause of "AIDS". With regard to the viral load tests, which
attempt to use PCR for counting viruses, Mullis has stated: "Quantitative PCR is an
oxymoron." PCR is intended to identify substances qualitatively, but by its very nature is
unsuited for estimating numbers. Although there is a common misimpression that the viral
load tests actually count the number of viruses in the blood, these tests cannot detect
free, infectious viruses at all; they can only detect proteins that are believed, in some
cases wrongly, to be unique to HIV. The tests can detect genetic sequences of viruses, but
not viruses themselves.
What PCR does is to select a genetic sequence and then amplify it enormously. It can
accomplish the equivalent of finding a needle in a haystack; it can amplify that needle
into a haystack. Like an electronically amplified antenna, PCR greatly amplifies the
signal, but it also greatly amplifies the noise. Since the amplification is exponential,
the slightest error in measurement, the slightest contamination, can result in errors of
many orders of magnitude."
esident Trump recently introduced
four executive orders aimed at reducing drug prices for all Americans. Affordability
in health care is consistently a leading issue on the minds of the people, and the price of
prescription drugs is a key component of that. Every president, regardless of party, wants to
make medication more affordable. But more times than not, they fail to make much of a
difference. President Trump's orders, however, should.
Insulin, a drug that has been in existence for nearly a century, continues to be cost
prohibitive for many diabetics. We've all seen story after story of people having to choose
between groceries and lifesaving drugs -- even at a time when the Affordable Care Act is the
law of the land. Over the last 10 years, the price of
Humalog, a commonly prescribed insulin, has increased from $75 to $250, with no changes to
formula, packaging, or designs.
Over the same time frame, the list prices established by pharmaceutical companies have
skyrocketed, although their profits have remained relatively flat . The middlemen and insurers, however, have
seen record growth and
rampant consolidation due to the large rebates they command from the manufacturers that benefit
from being on the insurers' drug lists. This is a broken system; it sounds like a business
model straight out of The Godfather movies.
The next EO, the International Pricing Index (also known as the "most favored nation"
order), seeks to compel pharmaceutical manufacturers to charge the U.S. no more than the lowest
price available among economically advanced countries for Medicare Part B drugs. Clearly, this
is rate-setting and not a sustainable solution, but the order is the only one that comes with a
trigger mechanism. President Trump has given Big Pharma until noon August 24 to negotiate a
substantive plan to lower the cost of drugs for the American people.
If the manufacturers are unsuccessful in producing a viable plan, it will pull the trigger
that initiates most favored nation status. This tactic has given the president necessary
leverage to push for a deal that makes sense.
The importation order achieves the same end, but it will ultimately be up to the states to
implement, should they wish to import drugs from nations with which they negotiate. Governor
Ron DeSantis of Florida has been a long-time proponent of this policy and has been leading the
charge for his state.
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Another order that focuses on bringing down the cost of insulin and epinephrine was issued
within the network of clinics known as Federally Qualified Health Centers (FQHC). Patients that
are seen in these clinics will now be able to take advantage of newly extended purchasing
discounts that will allow them to get these life-saving drugs for pennies on the dollar.
The fourth and perhaps most substantive order makes rebates
for Medicare patients available at the pharmacy. Insurers and other middlemen have often kept
these rebates and counted them as revenue rather than passing them on to patients. This order
makes Medicare patients the beneficiaries of these rebates, which will result in much greater
affordability for our seniors who are often on fixed incomes.
Are the orders perfect? Perhaps not. But the absence of leadership from Congress to get this
done has resulted in needed action from President Trump. The physicians and patients who
attended the signing applauded this effort and encouraged the administration to press on to
make health care even more affordable. We are all patients, and efforts like this are
opportunities for us to unite in our effort to fix our broken health care system.
David Balat is the policy director of the Right on Healthcare initiative at the Texas
Public Policy Foundation.
I work for a Pharma company. I haven't heard anyone concerned about these EOs. If they
were actually going to impact pricing, I would have heard the concern as I deal directly with
upper level management.
Also, insulin and epinephrine are made by only a handful of companies. There are a ton
more drugs around than these generic drugs. It's the on patent drugs which drive the extreme
cost of healthcare. Focusing on genetics isn't remotely where the big dollars are for the
industry. Yea, there is gouging going in for insulin, it's certainly not the biggest thing
going on right now in pricing.
In early 2013 I was given a 3 PBC rating for my 2012 performance, the main reason cited by my
manager being that my team lead thought I "seemed distracted". Five months later I was
included in a "resource action", and was gone by July. I was 20 months shy of 55. Younger
coworkers were retained. That was about two years after the product I worked on for over a
decade was off-shored.
Through a fluke of someone from the old, disbanded team remembering me, I was rehired two
years later - ironically in a customer support position for the very product I helped
develop.
While I appreciated my years of service, previous salary, and previous benefits being
reinstated, a couple years into it I realized I just wasn't cut out for the demands of the
job - especially the significant 24x7 pager duty. Last June I received email describing a
"Transition to Retirement" plan I was eligible for, took it, and my last day will be June 30.
I still dislike the job, but that plan reclassified me as part time, thus ending pager duty
for me. The job still sucks, but at least I no longer have to despair over numerous week long
24x7 stints throughout the year.
A significant disappointment occurred a couple weeks ago. I was discussing healthcare
options with another person leaving the company who hadn't been resource-actioned as I had,
and learned the hard way I lost over $30,000 in some sort of future medical benefit account
the company had established and funded at some point. I'm not sure I was ever even aware of
it. That would have funded several years of healthcare insurance during the 8 years until I'm
eligible for Medicare. I wouldn't be surprised if their not having to give me that had
something to do with my seeming "distracted" to them. <rolls eyes="">
What's really painful is the history of that former account can still be viewed at
Fidelity, where it associates my departure date in 2013 with my having "forfeited" that
money. Um, no. I did not forfeit that money, nor would I have. I had absolutely no choice in
the matter. I find the use of the word 'forfeited' to describe what happened as both
disingenuous and offensive. That said, I don't know whether's that's IBM's or Fidelity's
terminology, though.
Super happy to see you bring up care ethics and how the existence of relationships of care
undermine the individualist focus of (neo)liberalism. Have you done a video on care
ethics?
If so I'll be watching it shortly. I wish you'd gone even farther and looked at the
importance of un-paid or underpaid care labour in the foundation of capitalism, but I suppose
that's tangential.
lass="comment-renderer-text-content expanded"> Neoliberalism is pretty much what caused
me to have to leave the UK when they simply made it too difficult to survive as someone with
a disability. I can consider myself unreasonably lucky in holding dual citizenship, and in
the other country I have citizenship of not (yet) resorting to quite the same level of
sadistic behaviour... But it certainly wasn't something that was reassuring... And I feel
sorry for all the people in similar circumstances who had to somehow find a way to cope with
it anyway...
"They assume that free markets mean competition. And competition means that quality is kept high, prices are kept low, and it drives innovation, distributes resources efficiently to the people that want them the most."
That's... not specifically a neoliberal thing. That's capitalism in general. But OK... I'm inclined to mostly agree with this stated premise (might pick some different semantics but eh... close enough). You're going to tell me why I shouldn't. So let's see what you've got:
"Have free markets resulted in a lot of competition everywhere? Or have some markets become dominated by a very small number of companies?"
Yep... oligarchies happen. Ever notice that it tends to be in the most heavily regulated markets? Big companies with fat profit margins can survive regulations, small businesses and startups can't. The more you free the market, the easier it is for literally anyone with money, charisma, and/or a brilliant idea to spring up and carve off a big piece of the big guy's market share with a better product/service/resource for everyone.
"Are resources as efficiently distributed as they could be?"
Never. There's always room for improvement. But if we're to compare against existing examples capitalism does it faster, cheaper & overall better than the alternatives.
"Do they always go to the people who want them the most?"
They go to people able and willing to provide something of value in exchange. There's a lot of overlap between the two groups. But no. Some people don't get the resources they want because wanting something doesn't automatically mean you get it. Although even in a ruthless capitalist society of individualism people actually do still give a shit about their fellow man. Private charities are still perfectly functional capitalist entities (for profit or otherwise).
"Is the innovation that is happening always useful?"
No. People chase bad ideas all the time. But generally, people quickly lose interest and stop supporting bad ideas (or run out of money). At least in a capitalist setting bad ideas can die on their own merit of providing nothing in exchange for what you give them. Instead of being propped up by tax dollars people don't want to spend on a completely unsustainable pet project of some ego-centric politician and the slight majority he's convinced is not a bad enough reason to kick him out of office.
"Is it allowed to benefit all of human kind when it is?"
Who decides what is and isn't beneficial to all of human kind? Or are you simply referring to the fact that when someone creates something useful and new, it isn't immediately somehow provided to everyone who may want it?
I can't help but notice there was weasel wording in every single one of these questions. As presented, you have to answer "no" to all of them because the question requires absolute total success in all cases in order to answer "yes" to any of them.
"individualism ignores systemic privilege"
Yea... so what? In what way does someone else being rich, good looking, charismatic, smart or skilled negatively affect you? Especially someone you never interact with?
What it does not ignore is systemic discrimination. Stuff that actually negatively affects people in a quantifiable way.
"individualism ignores or misvalues the role of care" Individuals still
care about people. They still have friends and family. The only difference is that they
are encouraged to take it upon themselves to see to the well being of themselves and
the people they care about. Sure, you can be a shithead who burns every social bridge
but you end up fucking yourself when hard times fall upon you. An individualist still
has vested personal interest in maintaining good relationships with those around them
for this very reason. Even when their motives are completely selfish. As individuals we
are encouraged to make these connections ourselves as opposed to expecting some
authority to forcibly extract our needs from strangers. Individuals care about other
people, collectivists care about the idea of other people.
In the warped world of prescription drug pricing, generic drugs can cost more than branded
ones, old drugs can be relaunched at astronomical prices, and low-cost options are shut out of
the market. In Drugs, Money and Secret Handshakes, Robin Feldman shines a light into the dark
corners of the pharmaceutical industry to expose a web of shadowy deals in which higher-priced
drugs receive favorable treatment and patients are channeled toward the most expensive
medicines. At the center of this web are the highly secretive middle players who establish
coverage levels for patients and negotiate with drug companies. By offering lucrative payments
to these middle players (as well as to doctors and hospitals), drug companies ensure that
inexpensive drugs never gain traction. This system of perverse incentives has delivered the
kind of exorbitant drug prices - and profits - that everyone loves except for those who pay the
bills.
A measure of just how perverse US pharmaceutical markets have become is the "reverse
payment" in which the original manufacturer sues the maker of the new generic version for
patent infringement, then settles by paying the generic maker to go away for several months
before launching its version. If that is intriguing instead of revolting, Drug Wars is for
you.
Feldman and Frondorf have researched all the Food and Drug Administration's generics files
going back to the turn of the century, and found a treasure trove of manipulation, waste and
greed that prove why we need an FDA in the first place. That the FDA is being crippled by all
these shenanigans is criminal. To the tune of billions of dollars a year.
The name of the game is delay. Every month of delay can mean tens of millions of dollars
from consumers and insurers overpaying. A year's delay can easily mean a billion dollars'
profit. The frightening total is that 45% of Pharma revenues worldwide come from American
patients. Because no other country lets them get away with this.
Some of the tactics Big Pharma uses:
-claiming its drug is so dangerous it can only be handled in and by a single named
drugstore, making it unavailable generally, and specifically not to a generics firm wishing
to examine it
-delaying selling a sample to a generics firm for years, until they go away
-changing one tiny aspect of the drug so the generic no longer copies it (could be the
packaging or the directions). Business process patents have nothing to do with drug
efficacy, but count in patent law
-filing a citizen petition questioning the methodology to measure the generic's
performance. The FDA routinely rejects them (some years 100% of them), but Big Pharma keeps
filing to keep delaying
-when a drug firm removes a drug completely, the remaining generic is disqualified from
most formularies because there is no alternative to it. It (ironically) defaults to brand
status itself, and goes unfilled. Pharma then releases a new version, free of generic
competition.
Big Pharma fills the courts with frivolous suits, loads down the FDA with nonsenses
complaints (demanding tests that are already required, for example) and applications, and
stalls. A finding that a drug might be dangerous may not be filed for years – until a
generic appears on the scene. Bogus applications that slow down generic approvals are
routinely rejected – but they serve the purpose by taking up valuable time, at taxpayer
and patient expense. While Drug Wars has a worthy conclusion packed with sensible
recommendations, it is clear Congress will not act on them, and that lifesaving drugs should
not be left to the "free" market.
David Wineberg
Rebecca
L. Elson , Reviewed in the United States on June 28, 2017
This article originally appeared on The Magical Buffet's website on 06/28/2017.
When you read that I'm about to discuss a book called "Drug Wars" your mind probably goes
straight to America's "war" on illegal drugs, but you would be mistaken. There is a war
involving prescription drugs going on right now that many of us had no idea existed. It's one
where pharmaceutical companies always win and the public always loses.
A long time ago, before the mid-80's (I can't believe I called that a long time ago!)
people realized that very few generic drugs were coming onto the market. Wait, let me back up
for those of you who aren't constantly on meds like myself. So in the fashion world designer
label Louis Vuitton sells its "Saint Michel" purse for $1,700. It's a bag, it holds stuff.
You can also find on your better handbag websites what are subtly referred to as "knock off"
versions for a couple hundred dollars. It's also a bag. It also holds stuff. That's
essentially prescription drugs and their generic versions, except in this case the FDA makes
sure that the bags are made of the same primary material. A prescription drug can be hundreds
of dollars, but a generic drug is nearly identical at a fraction of the price. With the state
of health insurance then, and now, there is an interest in generics for public
consumption.
Thus in 1984 The Drug Price Competition and Patent Term Restoration Act, often called the
Hatch-Waxman Act, went into effect to stimulate a generic drug market. The Hatch-Waxman Act
is a great idea. It attempts to strike a balance between capitalism and the common good. When
a pharmaceutical company goes to market with a new chemical that company is given 5 years of
exclusivity. It also streamlined the process for companies looking to bring a generic version
to the market. Thus the originator gets 5 years of market dominance to recoup research costs,
etc. while providing the eventual competition of a generic to make things easier on the
consumer's pocketbook and encourage pharmaceutical companies to get back to the drawing board
to innovate and bring another new drug to market that again gets 5 years of competition free
existence. Pretty elegant, right?
What no one saw coming, but let's face it, those in the know probably did, was that
pharmaceutical companies found ways to extend their periods of exclusivity, which of course
makes things harder on us sickos of America. The use of lawsuits to stall generics going to
market is common, and not surprising once you're reading "Drug Wars". What was shocking was
the collusion between the manufacturers of the original drug and the companies making the
generics. When these companies are in litigation they can fight it out, or settle. Oddly the
settlement involves the manufacturer of the original drug paying obscene sums of money to the
generic, and the generic agreeing to hold off going to market for several more years. There
many ways safe and effect generic drugs are delayed from becoming available, and "Drug Wars"
does an amazing job highlighting them. The authors, Robin Feldman and Even Frondorf, also
make recommendations on how to fix these issues.
If you're into intricate bureaucracies, healthcare in America, and a few laugh out loud
absurdities then you need to read "Drug Wars: How Big Pharma Raises Prices and Keeps Generics
Off the Market" by Robin Feldman and Even Frondorf.
"... corporate health insurance has far higher administrative costs than single-payer programs like Medicare , and even the much-vaunted Affordable Care Act allows insurers to siphon up to 20% of customers' premiums to corporate profits rather than actual medical care. ..."
"... That's probably why insurance companies have been lobbying for it . They know that such a program would boost their short-term profits, and they know that once such a program is in place, it would be politically difficult to get it repealed and replaced by progressives' far better Medicare for All program. In other words: Democrats' Cobra plan may secure insurance companies' profit-skimming position between Americans and their healthcare providers for decades to come. ..."
Democrats in
Washington are not just passively failing to mount an opposition to Trump. They are actively
helping Republicans. 'This corporate counterrevolution is easiest to see in Democrats' enthusiastic support for Republicans'
legislative response to the coronavirus crisis.'
These are bleak days for America's progressive movement. The
Democratic primary process handed the party's nomination to the candidate with the most
conservative record. Corporate-friendly politicians like the New York governor, Andrew Cuomo,
are using the pandemic to brandish their images and
install billionaires to run things . Progressive lawmakers in Congress are being
steamrolled,
even by their own party's leadership . And a recession is battering the state and local
budgets that fund progressive priorities like education and the social safety net.
Perhaps this is a temporary stall-out – a fleeting moment of retreat in a
two-steps-forward-one-step-back trajectory. After all, polls continue to show that from
workers'
rights to
universal healthcare , a majority of Americans support a progressive policy agenda.
The problem, though, is that Democrats in Washington are not just passively failing to mount
a strong opposition to Donald Trump – they are actively
helping Republicans try to fortify the obstacles to long-term progressive change well after
this emergency subsides.
This corporate counter-revolution is easiest to see in Democrats' enthusiastic support for
Republicans' legislative response to the coronavirus crisis. Democrats' entire 2018 electoral
campaign told America that the opposition party needed to win back Congress in order to block
Trump's regressive agenda. And yet, when the Republicans proposed a bill to let Trump's
appointees dole out government cash to their corporate allies with
no strings attached , this same opposition party mustered not a single
recorded vote against the package. Not one.
Thanks to that, Trump appointees and the Federal Reserve can now hand out $4tn to
politically connected corporations as they lay waste to our economy and steamroll progressive
reforms.
Private equity firms and
fossil fuel companies get new tax breaks as they buy elections and try to lock in permanent
climate change.
These bailouts were part of a larger legislative package that included good things like
expanded unemployment benefits – and so you could argue that Democrats simply had to swallow a bitter
pill and vote yes. Except, they subsequently proposed their own standalone legislation that
would further strengthen the corporate opponents of progressive reform.
For example, there is the Democrats' push to alter the so-called paycheck protection program
(PPP). Those loans were designed to help employees of mom-and-pop enterprises throughout the
country. House Democrats' new stimulus legislation would open up the small business lending
program to what they call "small nonprofits", but their language was crafted to provide the
forgivable loans to industry trade associations. Those lobby groups represent the planet's
biggest corporations – and their political action committees have delivered more than
$191m of
campaign cash to lawmakers in the last two decades.
Democrats have pitched their legislation as a "message" bill that declares their values
– and in this case, they are reassuring Washington power-players that money meant for
workers at neighborhood restaurants, local shops and other mom-and-pop concerns can be raided
by the front groups representing giant drug companies, health insurers and Wall Street firms.
If the legislation passes, it would not merely be an epic tale of greed – the new funding
stream for corporate lobbying groups would bolster the very forces that make sure federal
policy disempowers workers, maximizes private profit and generally protects the ruling
class.
The tragedy is we're already moving in that wrong direction, and chances to change the
dynamic don't come around often
It's an even worse story on healthcare. As 43
million Americans face the prospect of losing private health insurance, Democrats had a
huge opportunity. After Trump himself suggested he wanted the government to
pay healthcare providers directly for treating uninsured Covid-19 patients, they could have
called his bluff and passed
existing legislation to expand a Medicare program that provides actual medical care.
Instead, House Democrats passed a bill to support lightly regulated private insurance
marketplaces and to subsidize existing private insurance plans through a Rube Goldberg machine
known as Cobra – and they passed this giveaway just after receiving an infusion
of campaign cash collected by insurance lobbyists.
Taken together, these initiatives would route yet more public money through a corporate
insurance bureaucracy in hopes that medical care eventually trickles down to Americans who
desperately need it. Such a system is totally inadequate during a pandemic: it doesn't
guarantee healthcare – it only only guarantees insurance coverage, which is so often
denied or restricted when a medical claim is actually filed. Moreover, corporate health
insurance has far
higher administrative costs than single-payer programs like Medicare , and even
the much-vaunted Affordable Care Act allows insurers to siphon up to 20% of
customers' premiums to corporate profits rather than actual medical care.
But then, Democrats' Cobra plan is not merely a financial bailout for insurers – it is
also a political bailout when the industry needs it most. At a time when popular support for
Medicare for All is surging
– when even a Republican president feels the need to make rhetorical (if empty)
gestures toward the concept of government-funded healthcare – the Cobra plan would
use public money to firm up the private health insurance industry's dominance over the
healthcare system, just in time to short circuit a Medicare expansion.
That's probably why insurance companies have been lobbying
for it . They know that such a program would boost their short-term profits, and they know
that once such a program is in place, it would be politically difficult to get it repealed and
replaced by progressives' far better Medicare for All program. In other words: Democrats' Cobra
plan may secure insurance companies' profit-skimming position between Americans and their
healthcare providers for decades to come.
If you get the sense that the fix is in and this is all deliberate, you're not wrong. Many
of the self-styled progressive
advocacy groups in Washington that posture as #resistance leaders turned a blind eye to the
bill's problems and endorsed the legislation shortly after it was introduced, undercutting
progressive lawmakers off the bat.
Making matters worse was the theater on the House floor. During the debate over the
Democratic bill, nine progressive lawmakers made a
public show of voting against the procedural measure to
advance the bill, along with a tiny group of moderates. When it came to the real vote on
actually passing the bill, a larger group of moderates ended up voting against it, but only one
progressive lawmaker, Representative Pramila Jayapal, voted no . Had the progressives and moderates
combined forces on either of the votes, they would have forced the bill back to the drawing
board. Instead, their shenanigans ultimately helped secure the legislation's passage.
Taken together, the spectacle was more confirmation that whatever resistance exists in the
nation's capital, it is so often performance art, rather than anything real.
"Outside groups and House lawmakers need to work together to build a populist bloc –
probably inclusive of moderate Democrats and perhaps even an occasional Republican – who
will stand united to force votes to ensure that our economy does right by ordinary people,"
said David Segal of Demand Progress, pointing to news of a
potential Democratic coalition to buck the party's leadership and support a plan to float
businesses' payrolls through the crisis. "We must make sure that America does not go in the
wrong direction and become even more inequitable because we let unemployment soar, compel
cities and states to implement austerity, force small businesses to shutter and let large
corporations backstopped by the Fed roll them up."
The tragedy is that we're already moving in that wrong direction, and chances to change the
political dynamic do not come around often. As Barack Obama's former chief of staff Rahm
Emanuel (now an investment
banker and TV talking head)
said more than a decade ago during the financial crisis: "Never allow a good crisis to go
to waste – it's an opportunity to do the things you once thought were impossible."
Billionaires and corporations are clearly following that advice, aiming to use the pandemic
to grow their wealth and political power in previously unfathomable ways. It would be better if
the opposition party put up a real fight – or at least refused to be complicit in
postponing progress for yet another generation.
David Sirota is a Guardian US columnist and
Jacobin editor at large who served as Bernie Sanders' presidential campaign speechwriter. He
also publishes Too Much Information
newsletter.
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. ..."
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.
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.
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.
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.
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.
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:
States not expanding Medicaid : While
Medicaid will not pay as much as commercial healthcare insurance or Medicare; without
Medicaid, a hospital may be left with a larger debt. Hospitals located in communities with
high numbers of uninsured residents are more susceptible to closures. According to the
University of North Carolina's
Rural
Health Research Program , the 17 states that did not expand Medicaid under the Affordable
Care Act had the highest number of hospital closures. Texas lost the most hospitals (15),
followed by Tennessee, Georgia, Alabama, Mississippi and North Carolina. Over half of the
remaining rural hospitals in Texas and Tennessee and more than a third of hospitals in
Oklahoma and Georgia are at risk of closing due to their weak financial position. These
states are Republican led states and it is solely politics.
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.
High Deductible Commercial Healthcare Plans :
Plans with annual deductibles of $3,000, $5,000 or even $10,000 have become commonplace
since the implementation of the Affordable Care Act as companies and insurers look for ways
to keep monthly premiums to a minimum. In rural areas where high-deductible plans are
prevalent and incomes lower than in urban areas, patients can struggle to pay those
deductibles."Bad debt for rural hospitals has gone up ~50% since the passage of the
Affordable Care Act in 2010."
Patient Transferred to A Larger Hospital : Smaller hospitals and in particular rural
hospitals may lack the needs of a patient. The patient admitted to a smaller hospital are
stabilized and then transferred to a larger hospital which has the resource to care for the
patient. When the insurance finally processes the bill, the first facility ends up with the
deductible portion while the larger hospital has most of its bill paid.
Consolidations: The
National Rural
Health Association , a nonprofit, estimated that 673 rural facilities (with a variety of
ownership structures) were at risk of closure, out of over 2,000. And with the new tax
legislation, and events like the merger of the drugstore chain CVS and the insurer Aetna, the
turmoil looks to get worse. In response, stand-alone nonprofit hospitals have been auctioning
off their real estate to investors, selling themselves to for-profit chains or private-equity
firms, or, like Berger hospital in Ohio have been folding themselves into regional health
systems. Mergers and closing are not only happening in rural areas.
Paladin Healthcare ,
an entity owned by private equity baron Joel Freedman, bought Hahnemann (Center City,
Philadelphia) as part of small hospital portfolio. He made no improvements for 18 months, and
then closed the facility with the intention of selling the real estate, which is set in a
"gateway location" for gentrification.
Political Interests: Back in 2014 the Crominbus Appropriations bill was passed less than
three hours before a midnight deadline that threatened a federal shutdown. It was a
compromise between Repubs and Dems. Inserted within the bill (just before it was passed) was
Section 227 by Representative Jack Kingston of Colorado at the behest of Representative Fred
Upton. It said:
Sec. 227. None of the funds made available by this Act from the Federal Hospital
Insurance Trust Fund or the Federal Supplemental Medical Insurance Trust Fund, or
transferred from other accounts funded by this Act to the "Centers for Medicare and
Medicaid Services–Program Management" account, may be used for payments under
section 1342(b)(1) of Public Law 111-148 (relating to risk corridors).
The
Risk Corridor Program which compensated Insurance Companies in the initial three years
for taking on risky people with pre-existing conditions could not be funded by moving funds
from other programs. Initially, it was passed without a Congressional appropriation and was
blocked by the GAO who had received a letter from Senator Jeff Sessions who asked if the
Administration could appropriate funds for a program. The Administration can not do so;
but, it can move funding around.
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.
Staffing: I do not know Steve, a commenter on one of my
Posts . His comment makes sense. 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.
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.
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.
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.
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.
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.
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.
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'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.
"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.
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.
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.
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-
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
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."
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.
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.
>. . . 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.
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.
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.
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".
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!
"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.
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.
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.
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.
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 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.
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!!!
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.
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.
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.
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?
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.
"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."
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.
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.
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.
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.
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.
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.
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.
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.
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
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:
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.
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.
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.
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.
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.
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).
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.
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.
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?
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.
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."
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.
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.
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 .
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/
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.
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.
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
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.
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.
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.
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...
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. ..."
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."
@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)
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.
"... 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. ..."
"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?
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
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
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."
Our work is licensed under a Creative Commons Attribution-Share Alike 3.0 License. Feel free to republish and share widely.
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
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.
fernSmerl 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. Atlasoldie 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.
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.
Another example of "American Exceptionalism." China doesn't charge its coronavirus patients, neither does South Korea. I guess
they are simply backward countries.
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).
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.
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.
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-Lepore10h 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.
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
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.
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...".
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.
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.
"... 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. ..."
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:
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/
"... 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. ..."
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 .
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.
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.
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.
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.
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!
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.)
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?
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!
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.
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?
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?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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. " ..."
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.
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.
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.
"Plans with annual deductibles of $3,000, $5,000 or even $10,000 have become commonplace
since the implementation of the Affordable Care Act as insurers look for ways to keep monthly
premiums to a minimum.
But in rural areas, where high-deductible plans are even more prevalent and incomes tend to
be lower than in urban areas, patients often struggle to pay those deductibles.
That has hit patients like Flowers hard as they grapple with medical debt when emergencies
happen -- but small rural hospitals like Lincoln Community are suffering, too. These facilities
often stabilize critically ill patients and then transfer them to larger regional or urban
hospitals for more definitive care. But when the hospitals submit their claims, bills from the
first site of care generally get applied to a patient's deductible.
And if patients can't afford to cover that amount, those hospitals often don't get paid,
even as the larger urban hospitals where patients were transferred get close to full payment
from the health plan. 'As soon as we send them to the city, those things start being paid by
the insurance company,' said Kevin Stansbury, CEO of Lincoln Community, 'while we're still
chasing the patient around for collections.'"
"... 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. ..."
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.
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..
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.
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.
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?
"... 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? ..."
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. ;) )
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.
..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."
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?
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.
Part A has no premiums,
Part B has a premium (paid to the Gov),
and Part D (prescriptions) has a premium which is paid to commercial healthcare insurance.
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.
" 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
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
That dramatic growth culminates Tuesday with the grand opening in the Cayman Islands of
the first phase of a $2 billion "health city" complex -- a project that seems far removed
from the nonprofit health system's humble origins and its Catholic mission to serve the
poor and vulnerable.
Ascension executives say they hope through this joint venture with a for-profit, India
hospital chain to learn ways to reduce medical costs.
But the Caribbean investment also illustrates how dramatically U.S. health care is
changing. In its rapid-fire evolution, Ascension has become a leading example of a
nonprofit health system that often acts like a for-profit, blurring the line between
businesses and charities. Its health ministry has drawn criticism for risk-taking and its
ties to Wall Street. And some critics have raised questions about its tax-exempt
status.
perceived influence over US health care of chief executives of health systems is
increasing. To the extent that the ranking validly reflects influence, the sharp rise in the
influence of chief executive officers at the expense of representatives of patients or health
professionals may underscore the increasing industrialization of health care. It is not
possible to find patients, patient advocates, clinicians, or clinician advocates at the top
of this list . This trend placing health care influencers within C-suites, accountable to
boards mostly comprising other corporate leaders, may explain the rise of business
language and thinking
They suggested that it is possible that there is a
causal association between the concentration of executive influence and problems of
patient care derived from efforts to optimize operational efficiency and financial
performance, for example, clinician burnout , the heavy burden of treatment afflicting
patients with chronic conditions, and the erection of barriers to care to optimize
'payer mix.'
Dr Montori also said in the interview
Americans increasingly find themselves in a corporate-centric healthcare
echo-chamber , one in which the public will increasingly approach tough policy decisions
having heard only the viewpoint from the top.
'The primary goals of CEOs are to advance the mission of their organization,' Montori
says. 'If all that influences healthcare are the ideas of people who advocate for the success
of their organizations, people who are not served by them will not have their voices
heard.'
Furthermore, he suggested that the public may be befuddled by the current health policy
debates, including those about universal health care and the possibility of reducing the power
of commercial health insurance companies because
in the rest of the narrative all that they hear is about are the successes of biotech, the
successes of tech companies, and the successes of healthcare corporations who achieve high
levels of innovation thanks to the bold leadership of their executives. It's why we have been
calling for greater awareness of the industrialization of healthcare for some time now
Summary
The new study by Longman, Ponce, Alvarez-Villalobos and Montori adds to the evidence that
health care has been taken over by business-trained managers, and in the US, especially by
large commercial health care organizations run by such managers.
Since we started Health Care
Renewal , we have frequently discussed the rise of generic managers, which later we
realized has been called managerialism. Managerialism is the belief
that trained managers are better leaders of health care, and every other sort of organization,
than are than people familiar with the particulars of the organizations' work. Managerialism
has become an ascendant value in health care over the last 30 years. The majority of hospital
CEOs are now management trained, but lacking in experience and training in medicine, direct
health care, biomedical science, or public health. And managerialism is now ascendant in the US
government. Our president, and many of his top-level appointees, are former business managers
without political experience or government experience.
We noted an
important article in the June, 2015 issue of the Medical Journal of Australia(1) that made
these points:
– businesses of all types are now largely run by generic managers, trained in
management but not necessarily knowledgeable about the details of the particular firm's
business
– this change was motivated by neoliberalism (also known as
economism
or market
fundamentalism )
– managerialism now affects all kinds of organizations, including health care,
educational and scientific organizations
– managerialism makes short-term revenue the first priority of all organizations
– managerialism undermines the health care mission and the values of health care
professionals
Generic or managerialist
managers by definition do not know much about health care, or about biomedical science,
medicine, or public health. They are prototypical ill-informed
leadership , and hence may blunder into actual incompetence. They are trained that they
have a right to lead any sort of organization, which breeds arrogance. These managers are not
taught about the values of health care professionals. Worse, they are taught in their business
style training about the shareholder value dogma, which states that the main objective of any
organization is to increase revenue. Thus, they often end up hostile to the
fundamental mission of health care, to put care of the patient and the health of the
population ahead of all other concerns, which we have called mission-hostile management.
(Furthermore, it appears that the shareholder value dogma is just smokescreen to cover the real
goal of managers, increasing their own wealth, e.g., look
here .) Finally, arrogance and worship of revenue allows self-interested and conflicted,
and even sometimes corrupt leadership.
Managerialists may be convinced that they are working for the greater good. However, I am
convinced that our health care system would be a lot less dysfunctional if it were led by
people who actually know something about biomedical science, health care, and public health,
and who understand and uphold the values of health care and public health professionals –
even if that would cost a lot of very well paid managerialists their jobs.
Maybe someday the top "influencers" in health care will actually be people who know
something about health care and actually care about patients' and the public's health.
John Raulston Saul, in "Voltaire's Bastards", has produced an intellectual fireworks
display that deals directly with the problem Dr.Poses sees pretty clearly. Endhoven proposes
an attack on what he sees as a regressive medieval remnant, a Guild, an attack that has been
pretty successful in a broad swath of our neoliberal world. Saul would recognize that attack
immediately, and despise it. It's what he wrote about with such fiery contempt.. And in my
opinion, he's right.
Managerialists, purveyors of "reason", are leaving a trail of disaster in pretty much every
area where their influence is powerful. Their ivy league, MBA-dominated education seemingly
has failed to provide any sense of the human feelings and needs that must be an essential
part of successful planning or policy. The bottom line trumps all else, and generates
disaster as well as shareholder value. Treat yourself, as well as tantalize your wits. Read
it.
Thanks for this post.
Two quotes that sum up much of the overpriced disfunction, imo.
Managerialism is the belief that trained managers are better leaders of health care,
and every other sort of organization, than are than people familiar with the particulars of
the organizations' work.
Better leaders toward what goal?
– managerialism makes short-term revenue the first priority of all
organizations
managerialism makes short-term revenue the first priority of all organizations
Except when it comes to manufacturing ideologies. There, they are quite capable of taking
the long view with think tanks, generational influence (stacking) of the judical system,
education, politics and policy and so on.* It's not as if they are unaware of the concept of
laying foundations. But short term revenue seems to be tightly coupled in their view to what
they get to put in their pockets which in turn (perhaps ironically by the foundation
builders: self worth by comparative metrics) has been tightly coupled to their perceived
worth as human beings.
(Ultimately, I believe, the phenomenon of comparative metrics
literally projects the homeless -or in this case the paucity of care for whole segments of
society- into existence and maintains their numbers in relation to those of the "managers.")
Interestingly, the mix of origins, whether such seminal ideas ( "eat your vegetables,
think of the starving Chineese" ) are vernacular and borrowed and repurposed or canonical
and disseminated helps in no small part to obscure the process.
*Even if the managers are not always the drivers, they are aware of the value.
"The Urban Institute's Single Payer Cost Estimate: False Assumptions False Conclusions"
[David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H.,
PNHP ]. The Urban Institute study was instantly signal-boosted by CNN ,
the Hill , and
The Atlantic , among others, and seems to have led to the "pay for" questions in the last
debate, and Warren taking on the task -- not planned already? -- of writing a tax proposal for
whatever she determines Medicare for All to actually be. "Administrative savings, Part 1: The
UI report assumes that single-payer reform would reduce insurance overhead to 6% of claims
($234 billion) from the current level of about 10.6%. In contrast, overhead in Canada's
single-payer system is only 1.8%, and overhead in the fee-for-service Medicare program is 2%.
The UI group justifies its 6% estimate by claiming that a single payer system " would require a
host of administrative functions to effectively operate, such as rate setting for many
different providers and services of different types; quality control over care provision;
development, review, and revision of regulations; provider oversight and standards enforcement;
claims payments to providers; and other functions." UI's claim ignores the fact that all of
these functions are currently carried out by both Canada's program and the fee-for-service
Medicare program." • This is a brutal takedown of the Urban Institute study, which you
should read in full.
"What the Health Care Debate Still Gets Wrong" [Adam Gaffney,
The Boston Review ]. "[T]his entire edifice of reform [ObamaCare ACOs] was built on sand.
Quite simply, as a nation, we actually do not use too much health care; if anything, we use
fewer services than people in other high-income countries. While 'overutilization' may indeed
be a major problem in some areas (and who wants an unnecessary slice from a scalpel?), it
cannot, simply as a matter of basic accounting, explain our total off-the-charts spending. In
particular, it cannot account for the fact that we spend more than $10,000 per capita on health
care -- approximately double that of Canada -- nor for the nearly six-fold rise in
inflation-adjusted healthcare spending from 1970 to 2017, according to estimates from the
Kaiser Family Foundation. The real cost problem, all along, has been the other half of the
spending equation: not the quantity of medical services rendered, but the prices paid by
insurers for each unit of care provided. So what can? It turns out that the real cost problem,
all along, has been the other half of the spending equation: not the quantity of medical
services rendered, but the prices paid by insurers for each unit of care provided. This simple
but crucial insight is most frequently attributed to the legendary health economist Uwe
Reinhardt."
"A New Generation of Activist Doctors Is Fighting for Medicare for All" [ Time ]. "[Travis
Singleton, executive vice president of Merritt-Hawkins], whose firm conducts a biennial survey
of doctors' opinions, says that while there are myriad reasons for an uptick in political
involvement, one of the most compelling is simple: doctors see the dysfunction of the health
care system on a daily basis. As health care costs ballooned and the private insurance industry
expanded, the job of being a doctor changed. Instead of just treating patients, doctors today
must battle with insurance requirements, manage arcane reimbursement systems and juggle
enormous administrative costs, Singleton's firm found. Much of this is a direct consequence of
physicians' early opposition to health care reform, explains Beatrix Hoffman, a history
professor at Northern Illinois University. By pushing back against government involvement, she
says physicians created the system that is now dominated by private insurance. 'We've heard so
many horror stories from doctors who have come before us about spending hours on the phone
negotiating with insurance companies,' says Scott Swartz, a 28-year-old medical student in San
Francisco. 'That's not how we want to spend our time.' All of these factors have combined to
shift doctors' politics to the left." • But patients love their insurance
companies. Right?
"We Found Over 700 Doctors Who Were Paid More Than a Million Dollars by Drug and Medical
Device Companies" [
Pro Publica ]. "Back in 2013, ProPublica detailed what seemed a stunning development in the
pharmaceutical industry's drive to win the prescription pads of the nation's doctors: In just
four years, one doctor had earned $1 million giving promotional talks and consulting for drug
companies; 21 others had made more than $500,000. Six years later -- despite often damning
scrutiny from prosecutors and academics -- such high earnings have become commonplace. More
than 2,500 physicians have received at least half a million dollars apiece from drugmakers and
medical device companies in the past five years alone, a new ProPublica analysis of payment
data shows. And that doesn't include money for research or royalties from inventions."
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."
"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."
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."
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
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.
We'll tell you what's true. You can form your own view.
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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 (Ł6,000) 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.
Is America's Health Care System a Fixer-Upper
or a Teardown? https://nyti.ms/34RCADP
NYT - Margot Sanger-Katz - Updated September 20
Illustrations by Tim Enthoven (at the link)
To understand the competing Democratic health care plans, consider an elaborate home
construction metaphor.
Imagine the United States health care system as a sort of weird old house. There are
various wings, added at different points in history, featuring different architectural
styles.
Maybe you pass through a wardrobe and there's a surprise bedroom on the other side, if not
Narnia. Some parts are really run down. In some places, the roof is leaking or there are some
other minor structural flaws. It's also too small for everyone to live in. But even if
architecturally incoherent and a bit leaky, it still works. No one would rather be homeless
than live in the house.
In Democratic politics, there is agreement that the old house isn't good enough, but
disagreement about just how possible -- or affordable -- fixing it will be. The biggest fault
line in the debate is between candidates who think our current system can be salvaged with
repairs and those who think it should be torn down and built anew. Building a dream house
eases the way to simplification, but it increases potential disruption and cost.
The Pelosi plan
The most limited Democratic plan, championed by House Speaker Nancy Pelosi, for example,
would deal with the house's biggest structural issues. It would lower the cost of health
insurance for more people and fix some glitches in Obamacare's design -- the home
construction equivalent of patching the roof, fixing a saggy porch and repainting. Residents
could remain in the house while such minor repairs take place. These changes would not cost a
ton of money. The house would still be weird. There would still be some people without a
place to live.
The Biden plan
The next tier of health care plans, like the one from Joe Biden, would go further. Mr.
Biden, too, would patch the roof and upgrade the windows. But he'd also put on a big new
wing: an expansion of the Medicare program that would allow more people to join, sometimes
called a public option. Everyone living in the house can stay while the renovations take
place, though there might be disruptions. It would cost more, more homeless people would now
fit in, and some living in the weirder wings might move into the new addition. People would
pay for housing through a mixture of taxes and rent.
There are a bunch of plans in this general category, including proposals from Michael
Bennet, Steve Bullock, Pete Buttigieg, John Delaney, Julian Castro, Amy Klobuchar, Beto
O'Rourke and Marianne Williamson. They differ, mainly, in how many people in existing wings
are allowed to move into the new wing, and how large that wing will be.
The Sanders plan
Bernie Sanders wants to tear down the weird old house entirely and build his dream home.
It would be enormous and feature many wonderful amenities. When done, there would be no
homeless people at all, and everyone's bedrooms would look exactly the same. The weirdness
would be gone. But the entire old house would be gone, too, which some people might miss, and
there could be unanticipated cost overruns in the construction. Some people might not enjoy
the aesthetics of a modernist villa. While no one would have to pay rent in exchange for
housing there, most people would have to pay more in taxes so the government could maintain
the property.
Several candidates have signed on, in whole or part, to the single-payer dream house
approach, including Cory Booker, Tulsi Gabbard, Elizabeth Warren and Andrew Yang.
The Harris plan
Kamala Harris also wants to tear down the old weird house. But she doesn't want to make
everyone live in identical bedrooms. Her dream arrangement involves more choices, but most of
the basic architectural features would be very similar. She would eliminate nearly every part
of the existing health insurance system, and set up a new universal Medicare program that
includes options from private insurers. It's like a housing development with several slightly
different model homes. The basic architecture and amenities would all be the same, but
families would be able to choose some custom options, like paint color, countertops and bed
linens. It would also be expensive, and everyone would still need to move.
The debate
At the debate last week, you heard arguments between the teardown candidates and the
fixer-upper candidates about cost -- and about change. Tearing down your current house comes
with risks that many candidates don't want to take on.
Although big changes to the health care system often garner strong support in surveys,
Americans frequently also tell pollsters that they like their current insurance arrangements,
and would dislike giving them up. The authors of some fixer-upper plans assume that only some
people are looking for a change, while other candidates assume that, over time, nearly
everyone will want to opt into a form
of government-run insurance.
You also heard a debate about fairness and choice. Giving all Americans access to the same
housing arrangements means that no one will have to live in a cramped attic. But it also
means that some family members will have to part with some of their favorite furniture. "Of
the 160 million people who like their health care now, they can keep it," said Mr. Biden, of
the virtues of his fixer-upper proposal. "If they don't like it, they can leave." By
contrast, Ms. Warren emphasized the universal nature of a teardown approach: "We're going to
do this by saying, everyone is covered by Medicare for all; every health care provider is
covered."
The "Medicare for all" system envisioned by Mr. Sanders would cover more benefits than
nearly any system in the world, but it would require everyone to have the same type of
insurance, with no easy workarounds for patients who aren't satisfied. Ms. Harris's plan
would allow more choice, allowing private plans to operate alongside the government system.
But those tightly regulated products would not be allowed to differ nearly as much as plans
that exist in today's system, and would also amount to a brand-new system.
The candidates also disagree on how people should finance their ambitions. The fixer-upper
candidates, for the most part, favor a system in which most Americans would still need to pay
some form of rent to live in the house. The teardown candidates think everyone's housing
costs should be financed by taxes instead of direct payments.
A tax-financed system would mean big changes in who pays what for health care, and how. A
system that preserves a mix of taxes, premiums and direct payments like deductibles would
mean less rearranging of the financing of health care, and would probably require more modest
tax increases.
This is only a metaphor, of course. There are many ways the health care system is not like
a residence. But if you've ever renovated or built a home, you know the emotional and
budgetary stakes. The health care system is personal to many Americans, just like their home.
It's no surprise the debate has been so heated.
"Is America's Health Care System a Fixer-Upper
or a Teardown?"
Do you recognize the 'assumption' in the title, the fallacy?
Does America have a "Health Care System" or a Medical Delivery System that does a lousy
job of delivering Health?
If the DEMS just fix what we have then we will get more of the same, i.e., a massive
transfer of money from the people either out of their wallets or from taxation to the
MEDICAL-INDUSTRIAL-COMPLEX that puts its profit above all patient welfare.
Go ahead and ignore my comment, after all I am just a D.C.
I agree with im1dc, we dare not recognize the US' 'health care system' for what it is.
It is a sacred market, where Milton Friedman told us markets make efficiency and also make
its participants "free to choose".
PPACA did nothing but keep the profits in the "free to choose" edict.
However, the worth value, price....) of efficiency and "free to choose" is only measured
from the perspective of those profiting.
Lately, some observers have been observing!
One is Binyamin Appelbaum.
David Warsh has read hos recent book.
It is somewhat critical of "free to choose" and market efficiency idolatry.
Appelbaum has observed that markets for such things and saving your life or warriors are
such that the participants with demand really cannot go anywhere else.
"Free to choose" to work for the demanders must assure the choosers can leave the market
and not die or work at Burger King.
That is b/c our 'Health Care System' prioritizes profit to providers over OUTCOMES, which
includes FDA oversight and rule making.
The Federal Government does not protect patients it protects Corporations, especially Big
Pharma, Big Device Makers, Big Medical Groups, and Big Hospitals.
States are no better either.
The CDC imo today is chiefly operating in the public's interest most of the time,
but...there are cracks forming there too.
FTR, we have superb medical scientists and superb world class Physicians that are forced
to live and work in a system that denigrates and punishes them if they prioritize patients
and people over profits and power.
IOW, since this is an Economics Blog, the American Health Care System practiced today
prioritizes Capital over the Welfare or Commonweal of The People.
For example the Cost-Benefit Analysis in a For Profit system that pays Health Care CEO's,
et. al., millions a year decays, diverts, and disrupts Health Outcomes Analysis due to a
built in Profit benefit that feeds Executives that do not provide actual health care patient
benefits.
Remember Pharma Bro Shkreli's 5000% price increase on Daraprim from $13.50 to $750 per
tablet and the insane price increase of the epinephrine autoinjector EpiPen the Corporate CEO
of that Big Pharma is the daughter of a Congressman and a DEM.
Are you aware some scientists of the FDA and CDC said they could manufacture off patent
medicines cheaply and make them available to the public through the FedGovt if allowed to do
so, but were turned down b/c it was thought unseemly for the FedGovt to compete with Big
Pharma's Big Profits?
IOW, we are capable of drastic changes to the American Health Care System, lower costs and
better outcomes for more people, but are stymied at every turn b/c Congress won't allow it
due to the myth that pure Capitalism is the better way.
You should think about it instead of slavishly following the past and its built-in
fallacies, tendencies, deficiencies, and errors.
And when you do you will ultimately come to the conclusion that prioritizing People over
Capital in actual Health Care is the way it ought to be in the USA. We could catch up with
the rest of the world in delivering Outcomes that increase our Health and longevity.
It *is* semantics when you insist
that there is No System when clearly
there is a system, but one that you
don't like.
Extraordinary difficulty of starting
from scratch on a new one, or making
drastic mods to the one we've got
is why it's so difficult to get
where you want to be. Which
is why we have to do the
latter, not the former.
And not too satisfying.
Not quite as tough as repealing
the 2nd amendment, but right up there.
"... 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] ..."
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-ŕ-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.
[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)
[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."
[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.
[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.
[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)
[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)
"... 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." ..."
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.
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."
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.
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.
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.
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.
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.
"... 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. ..."
"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.
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.
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.
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.
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.
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.
HealthcareHot 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.
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.
"... 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. ..."
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."
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.
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.
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.
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.
"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.
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.
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.
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!
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???
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)
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.
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
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.
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.
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.
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.
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
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.
"... 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." ..."
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.)
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 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.
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.
""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.
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.
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.
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.
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.
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.
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.
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).
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.
"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.
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.
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.
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.
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.
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 ."
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.
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.
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.
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.
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.
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.
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 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.
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.
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.
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.
"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.
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.
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)
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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..."
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.
I
n the early 2000s
Terry Mitchell's dentist retired. For a while,
Mitchell, an electrician in his 50s, stopped seeking dental care altogether. But when one of his wisdom teeth began to
ache, he started looking for someone new. An acquaintance recommended John Roger Lund, whose practice was a convenient
10-minute walk from Mitchell's home, in San Jose, California. Lund's practice was situated in a one-story building with
clay roof tiles that housed several dental offices. The interior was a little dated, but not dingy. The waiting room was
small and the decor minimal: some plants and photos, no fish. Lund was a good-looking middle-aged guy with arched eyebrows,
round glasses, and graying hair that framed a youthful face. He was charming, chatty, and upbeat. At the time, Mitchell and
Lund both owned Chevrolet Chevelles, and they bonded over their mutual love of classic cars.
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Lund extracted the wisdom tooth with no complications, and Mitchell began seeing him regularly. He never had any pain or
new complaints, but Lund encouraged many additional treatments nonetheless. A typical person might get one or two root
canals in a lifetime. In the space of seven years, Lund gave Mitchell nine root canals and just as many crowns. Mitchell's
insurance covered only a small portion of each procedure, so he paid a total of about $50,000 out of pocket. The number and
cost of the treatments did not trouble him. He had no idea that it was
unusual to undergo so many root canals
-- he thought they were just as common as fillings. The payments were spread out
over a relatively long period of time. And he trusted Lund completely. He figured that if he needed the treatments, then he
might as well get them before things grew worse.
Meanwhile, another of Lund's patients was going through a similar experience. Joyce Cordi, a businesswoman in her 50s,
had learned of Lund through 1-800-DENTIST. She remembers the service giving him an excellent rating. When she visited Lund
for the first time, in 1999, she had never had so much as a cavity. To the best of her knowledge her teeth were perfectly
healthy, although she'd had a small dental bridge installed to fix a rare congenital anomaly (she was born with one tooth
trapped inside another and had had them extracted). Within a year, Lund was questioning the resilience of her bridge and
telling her she needed root canals and crowns.
Cordi was somewhat perplexed. Why the sudden need for so many procedures after decades of good dental health? When she
expressed uncertainty, she says, Lund always had an answer ready. The cavity on this tooth was in the wrong position to
treat with a typical filling, he told her on one occasion. Her gums were receding, which had resulted in tooth decay, he
explained during another visit. Clearly she had been grinding her teeth. And, after all, she was getting older. As a
doctor's daughter, Cordi had been raised with an especially respectful view of medical professionals. Lund was insistent,
so she agreed to the procedures. Over the course of a decade, Lund gave Cordi 10 root canals and 10 crowns. He also
chiseled out her bridge, replacing it with two new ones that left a conspicuous gap in her front teeth. Altogether, the
work cost her about $70,000.
In early 2012, Lund retired. Brendon Zeidler, a
young dentist looking to expand his business, bought Lund's practice and assumed responsibility for his patients. Within a
few months, Zeidler began to suspect that something was amiss. Financial records indicated that Lund had been spectacularly
successful, but Zeidler was making only 10 to 25 percent of Lund's reported earnings each month. As Zeidler met more of
Lund's former patients, he noticed a disquieting trend: Many of them had undergone extensive dental work -- a much larger
proportion than he would have expected. When Zeidler told them, after routine exams or cleanings, that they didn't need any
additional procedures at that time, they tended to react with surprise and concern: Was he sure? Nothing at all? Had he
checked thoroughly?
In the summer, Zeidler decided to take a closer look at Lund's career. He gathered years' worth of dental records and
bills for Lund's patients and began to scrutinize them, one by one. The process took him months to complete. What he
uncovered was appalling.
W
e have a fraught relationship
with dentists as
authority figures. In casual conversation we often dismiss them as "not real doctors," regarding them more as mechanics for
the mouth. But that disdain is tempered by fear. For more than a century, dentistry has been half-jokingly compared to
torture. Surveys suggest that up to 61 percent of people are apprehensive about seeing the dentist, perhaps 15 percent are
so anxious that they avoid the dentist almost entirely, and a smaller percentage have
a genuine phobia
requiring psychiatric intervention.
When you're in the dentist's chair, the power imbalance between practitioner and patient becomes palpable. A masked
figure looms over your recumbent body, wielding power tools and sharp metal instruments, doing things to your mouth you
cannot see, asking you questions you cannot properly answer, and judging you all the while. The experience simultaneously
invokes physical danger, emotional vulnerability, and mental limpness. A cavity or receding gum line can suddenly feel like
a personal failure. When a dentist declares that there is a problem, that something must be done before it's too late, who
has the courage or expertise to disagree? When he points at spectral smudges on an X-ray, how are we to know what's true?
In other medical contexts, such as a visit to a general practitioner or a cardiologist, we are fairly accustomed to seeking
a second opinion before agreeing to surgery or an expensive regimen of pills with harsh side effects. But in the dentist's
office -- perhaps because we both dread dental procedures and belittle their medical significance -- the impulse is to comply
without much consideration, to get the whole thing over with as quickly as possible.
The uneasy relationship between dentist and patient is further complicated by an unfortunate reality: Common dental
procedures are not always as safe, effective, or durable as we are meant to believe. As a profession, dentistry has not yet
applied the same level of self-scrutiny as medicine, or embraced as sweeping an emphasis on scientific evidence. "We are
isolated from the larger health-care system. So when evidence-based policies are being made, dentistry is often left out of
the equation," says Jane Gillette, a dentist in Bozeman, Montana, who works closely with the
American Dental Association's Center for Evidence-Based Dentistry
, which was established in 2007. "We're kind of behind
the times, but increasingly we are trying to move the needle forward."
Consider the maxim that everyone should visit the dentist twice a year for cleanings. We hear it so often, and from such
a young age, that we've internalized it as truth. But this supposed commandment of oral health has no scientific grounding.
Scholars have traced its origins to a few potential sources, including a toothpaste advertisement from the 1930s and an
illustrated pamphlet from 1849 that follows the travails of a man with a severe toothache. Today, an increasing number of
dentists acknowledge that adults with good oral hygiene need to see a dentist only once every 12 to 16 months.
Many standard dental treatments -- to say nothing of all the recent innovations and cosmetic extravagances -- are likewise not
well substantiated by research. Many have never been tested in meticulous clinical trials. And the data that are available
are not always reassuring.
The Cochrane organization
, a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of
oral-health studies since 1999. In these reviews, researchers analyze the scientific literature on a particular dental
intervention, focusing on the most rigorous and well-designed studies. In some cases, the findings clearly justify a given
procedure. For example, dental sealants -- liquid plastics painted onto the pits and grooves of teeth like nail polish -- reduce
tooth decay in children and have no known risks. (Despite this, they are not widely used, possibly because they are too
simple and inexpensive to earn dentists much money.) But most of the Cochrane reviews reach one of two disheartening
conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there
is simply not enough research to say anything substantive one way or another.
Fluoridation of drinking water seems to help reduce tooth decay in children, but there is insufficient evidence that it
does the same for adults. Some data suggest that regular flossing, in addition to brushing, mitigates gum disease, but
there is only "weak, very unreliable" evidence that it combats plaque. As for common but invasive dental procedures, an
increasing number of dentists question the tradition of prophylactic wisdom-teeth removal; often, the safer choice is to
monitor unproblematic teeth for any worrying developments. Little medical evidence justifies the substitution of
tooth-colored resins for typical metal amalgams to fill cavities. And what limited data we have don't clearly indicate
whether it's better to repair a root-canaled tooth with a crown or a filling. When Cochrane researchers tried to determine
whether faulty metal fillings should be repaired or replaced, they could not find a single study that met their standards.
"The body of evidence for dentistry is disappointing," says
Derek Richards
, the director of the Centre for Evidence-Based Dentistry at the University of Dundee, in Scotland.
"Dentists tend to want to treat or intervene. They are more akin to surgeons than they are to physicians. We suffer a
little from that. Everybody keeps fiddling with stuff, trying out the newest thing, but they don't test them properly in a
good-quality trial."
The general dearth of rigorous research on dental interventions gives dentists even more leverage over their patients.
Should a patient somehow muster the gumption to question an initial diagnosis and consult the scientific literature, she
would probably not find much to help her. When we submit to a dentist's examination, we are putting a great deal of trust
in that dentist's experience and intuition -- and, of course, integrity.
When Zeidler purchased Lund's
practice,
in February 2012, he inherited a massive collection of patients' dental histories and bills, a
mix of electronic documents, handwritten charts, and X‑rays. By August, Zeidler had decided that if anything could explain
the alarmingly abundant dental work in the mouths of Lund's patients, he would find it in those records. He spent every
weekend for the next nine months examining the charts of hundreds of patients treated in the preceding five years. In a
giant Excel spreadsheet, he logged every single procedure Lund had performed, so he could carry out some basic statistical
analyses.
The numbers spoke for themselves. Year after year, Lund had performed certain procedures at extraordinarily high rates.
Whereas a typical dentist might perform root canals on previously crowned teeth in only 3 to 7 percent of cases, Lund was
performing them in 90 percent of cases. As Zeidler later alleged in court documents, Lund had performed invasive, costly,
and seemingly unnecessary procedures on dozens and dozens of patients, some of whom he had been seeing for decades. Terry
Mitchell and Joyce Cordi were far from alone. In fact, they had not even endured the worst of it.
Dental crowns were one of Lund's most frequent treatments.
A crown is a metal or ceramic cap that completely encases an injured or decayed tooth, which is first shaved to a peg so
its new shell will fit.
Crowns
typically last 10 to 15 years. Lund not only gave his patients superfluous crowns; he also tended to replace
them every five years -- the minimum interval of time before insurance companies will cover the procedure again.
More than 50 of Lund's patients also had ludicrously high numbers of root canals: 15, 20, 24. (A typical adult mouth has
32 teeth.) According to one lawsuit that has since been settled, a woman in her late 50s came to Lund with only 10 natural
teeth; from 2003 to 2010, he gave her nine root canals and 12 crowns. The American Association of Endodontists claims that
a root canal is a "quick, comfortable procedure" that is "very similar to a routine filling." In truth, a root canal is a
much more radical operation than a filling. It takes longer, can cause significant discomfort, and may require multiple
trips to a dentist or specialist. It's also much more costly.
Root canals are typically used to treat infections of the pulp -- the soft living core of a tooth. A dentist drills a hole
through a tooth in order to access the root canals: long, narrow channels containing nerves, blood vessels, and connective
tissue. The dentist then repeatedly twists skinny metal files in and out of the canals to scrape away all the living
tissue, irrigates the canals with disinfectant, and packs them with a rubberlike material. The whole process usually takes
one to two hours. Afterward, sometimes at a second visit, the dentist will strengthen the tooth with a filling or crown. In
the rare case that infection returns, the patient must go through the whole ordeal again or consider more advanced surgery.
Zeidler noticed that nearly every time Lund gave someone a root canal, he also charged for an incision and drainage,
known as an I&D. During an I&D, a dentist lances an abscess in the mouth and drains the exudate, all while the patient is
awake. In some cases the dentist slips a small rubber tube into the wound, which continues to drain fluids and remains in
place for a few days. I&Ds are not routine adjuncts to root canals. They should be used only to treat severe infections,
which occur in a minority of cases. Yet they were extremely common in Lund's practice. In 2009, for example, Lund billed
his patients for 109 I&Ds. Zeidler asked many of those patients about the treatments, but none of them recalled what would
almost certainly have been a memorable experience.
In addition to performing scores of seemingly unnecessary procedures that could result in chronic pain, medical
complications, and further operations, Lund had apparently billed patients for treatments he had never administered.
Zeidler was alarmed and distressed. "We go into this profession to care for patients," he told me. "That is why we become
doctors. To find, I felt, someone was doing the exact opposite of that -- it was very hard, very hard to accept that someone
was willing to do that."
Zeidler knew what he had to do next. As a dental professional, he had certain ethical obligations. He needed to confront
Lund directly and give him the chance to account for all the anomalies. Even more daunting, in the absence of a credible
explanation, he would have to divulge his discoveries to the patients Lund had bequeathed to him. He would have to tell
them that the man to whom they had entrusted their care -- some of them for two decades -- had apparently deceived them for his
own profit.
Arsh
Raziuddin
The idea of the dentist as potential
charlatan
has a long and rich history. In medieval Europe, barbers didn't just trim hair and
shave beards; they were also surgeons, performing a range of minor operations including bloodletting, the administration of
enemas, and tooth extraction.
Barber surgeons
, and the more specialized "tooth drawers," would wrench, smash, and knock teeth out of people's mouths
with an intimidating metal instrument called a
dental key
: Imagine a chimera of a hook, a hammer, and forceps. Sometimes the results were disastrous. In the 1700s,
Thomas Berdmore, King George III's "Operator for the Teeth,"
described one woman
who lost "a piece of jawbone as big as a walnut and three neighbouring molars" at the hands of a
local barber.
Barber surgeons came to America as early as 1636. By the 18th century, dentistry was firmly established in the colonies
as a trade akin to blacksmithing (
Paul
Revere
was an early American craftsman of artisanal dentures). Itinerant dentists moved from town to town by carriage
with carts of dreaded tools in tow, temporarily setting up shop in a tavern or town square. They yanked teeth or bored into
them with hand drills, filling cavities with mercury, tin, gold, or molten lead. For anesthetic, they used arsenic,
nutgalls, mustard seed, leeches. Mixed in with the honest tradesmen -- who genuinely believed in the therapeutic power of
bloodsucking worms -- were swindlers who urged their customers to have numerous teeth removed in a single sitting or charged
them extra to stuff their pitted molars with homemade gunk of dubious benefit.
In the mid-19th century, a pair of American dentists began to elevate their trade to the level of a profession. From
1839 to 1840,
Horace Hayden and Chapin Harris
established dentistry's first college, scientific journal, and national association.
Some historical accounts claim that Hayden and Harris approached the University of Maryland's School of Medicine about
adding dental instruction to the curriculum, only to be rebuffed by the resident physicians, who declared that dentistry
was of little consequence. But no definitive proof of this encounter has ever surfaced.
Whatever happened, from that point on, "the professions of dentistry and medicine would develop along separate paths,"
writes Mary Otto, a health journalist, in her recent book,
Teeth
. Becoming a practicing physician requires four
years of medical school followed by a three-to-seven-year residency program, depending on the specialty. Dentists earn a
degree in four years and, in most states, can immediately take the national board exams, get a license, and begin treating
patients. (Some choose to continue training in a specialty, such as orthodontics or oral and maxillofacial surgery.) When
physicians complete their residency, they typically work for a hospital, university, or large health-care organization with
substantial oversight, strict ethical codes, and standardized treatment regimens. By contrast, about 80 percent of the
nation's 200,000 active dentists have individual practices, and although they are bound by a code of ethics, they typically
don't have the same level of oversight.
Throughout history, many physicians have lamented the segregation of dentistry and medicine. Acting as though oral
health is somehow divorced from one's overall well-being is absurd; the two are inextricably linked. Oral bacteria and the
toxins they produce can migrate through the bloodstream and airways, potentially damaging the heart and lungs. Poor oral
health is associated with narrowing arteries, cardiovascular disease, stroke, and respiratory disease, possibly due to a
complex interplay of oral microbes and the immune system. And some research suggests that gum disease can be an early sign
of diabetes, indicating a relationship between sugar, oral bacteria, and chronic inflammation.
Dentistry's academic and professional isolation has been especially detrimental to its own scientific inquiry. Most
major medical associations around the world have long endorsed evidence-based medicine. The idea is to shift focus away
from intuition, anecdote, and received wisdom, and toward the conclusions of rigorous clinical research. Although the
phrase
evidence-based medicine
was coined in 1991, the concept began taking shape in the 1960s, if not earlier (some
scholars trace its origins all the way back to the 17th century). In contrast, the dental community did not begin having
similar conversations until the mid-1990s. There are dozens of journals and organizations devoted to evidence-based
medicine, but only a handful devoted to evidence-based dentistry.
In the past decade, a small cohort of dentists has worked diligently to promote evidence-based dentistry, hosting
workshops, publishing clinical-practice guidelines based on systematic reviews of research, and creating websites that
curate useful resources. But its adoption "has been a relatively slow process," as a
2016 commentary
in the
Contemporary Clinical Dentistry
journal put it. Part of the problem is funding: Because
dentistry is often sidelined from medicine at large, it simply does not receive as much money from the government and
industry to tackle these issues. "At a recent conference, very few practitioners were even aware of the existence of
evidence-based clinical guidelines," says Elliot Abt, a professor of oral medicine at the University of Illinois. "You can
publish a guideline in a journal, but passive dissemination of information is clearly not adequate for real change."
Among other problems, dentistry's struggle to embrace scientific inquiry has left dentists with considerable latitude to
advise unnecessary procedures -- whether intentionally or not. The standard euphemism for this proclivity is
overtreatment
.
Favored procedures, many of which are elaborate and steeply priced, include root canals, the application of crowns and
veneers, teeth whitening and filing, deep cleaning, gum grafts, fillings for "microcavities" -- incipient lesions that do not
require immediate treatment -- and superfluous restorations and replacements, such as swapping old metal fillings for modern
resin ones. Whereas medicine has made progress in reckoning with at least some of its own tendencies toward excessive and
misguided treatment, dentistry is lagging behind. It remains "largely focused upon surgical procedures to treat the
symptoms of disease," Mary Otto writes. "America's dental care system continues to reward those surgical procedures far
more than it does prevention."
"Excessive diagnosis and treatment are endemic," says Jeffrey H. Camm, a dentist of more than 35 years who wryly
described his peers' penchant for "
creative
diagnosis
" in a 2013 commentary published by the American Dental Association. "I don't want to be damning. I think the
majority of dentists are pretty good." But many have "this attitude of 'Oh, here's a spot, I've got to do something.' I've
been contacted by all kinds of practitioners who are upset because patients come in and they already have three crowns, or
12 fillings, or another dentist told them that their 2-year-old child has several cavities and needs to be sedated for the
procedure."
Trish Walraven, who worked as a dental hygienist for 25 years and now manages a dental-software company with her husband
in Texas, recalls many troubling cases: "We would see patients seeking a second opinion, and they had treatment plans
telling them they need eight fillings in virgin teeth. We would look at X-rays and say, 'You've got to be kidding me.' It
was blatantly overtreatment -- drilling into teeth that did not need it whatsoever."
Studies that explicitly focus on overtreatment in dentistry
are rare, but a recent field experiment provides some clues about its pervasiveness. A team of researchers at ETH Zurich, a
Swiss university, asked a volunteer patient with three tiny, shallow cavities to visit 180 randomly selected dentists in
Zurich. The Swiss Dental Guidelines state that such minor cavities do not require fillings; rather, the dentist should
monitor the decay and encourage the patient to brush regularly, which can reverse the damage. Despite this, 50 of the 180
dentists suggested unnecessary treatment. Their recommendations were incongruous: Collectively, the overzealous dentists
singled out 13 different teeth for drilling; each advised one to six fillings. Similarly,
in
an investigation for
Reader's Digest
, the writer William Ecenbarger visited 50 dentists in 28 states in the U.S.
and received prescriptions ranging from a single crown to a full-mouth reconstruction, with the price tag starting at about
$500 and going up to nearly $30,000.
A multitude of factors has conspired to create both the opportunity and the motive for widespread overtreatment in
dentistry. In addition to dentistry's seclusion from the greater medical community, its traditional emphasis on procedure
rather than prevention, and its lack of rigorous self-evaluation, there are economic explanations. The financial burden of
entering the profession is high and rising. In the U.S., the average debt of a dental-school graduate is more than
$200,000. And then there's the expense of finding an office, buying new equipment, and hiring staff to set up a private
practice. A dentist's income is entirely dependent on the number and type of procedures he or she performs; a routine
cleaning and examination earns only a baseline fee of about $200.
In parallel with the rising cost of dental school, the amount of tooth decay in many countries' populations has declined
dramatically over the past four decades, mostly thanks to the introduction of mass-produced fluoridated toothpaste in the
1950s and '60s. In the 1980s, with fewer genuine problems to treat, some practitioners turned to the newly flourishing
industry of cosmetic dentistry, promoting elective procedures such as bleaching, teeth filing and straightening, gum lifts,
and veneers. It's easy to see how dentists, hoping to buoy their income, would be tempted to recommend frequent exams and
proactive treatments -- a small filling here, a new crown there -- even when waiting and watching would be better. It's equally
easy to imagine how that behavior might escalate.
"If I were to sum it up, I really think the majority of dentists are great. But for some reason we seem to drift toward
this attitude of 'I've got tools so I've got to fix something' much too often," says Jeffrey Camm. "Maybe it's greed, or
paying off debt, or maybe it's someone's training. It's easy to lose sight of the fact that even something that seems
minor, like a filling, involves removal of a human body part. It just adds to the whole idea that you go to a physician
feeling bad and you walk out feeling better, but you go to a dentist feeling good and you walk out feeling bad."
Arsh
Raziuddin
In the summer of 2013,
Zeidler
asked several other
dentists to review Lund's records. They all agreed with his conclusions. The likelihood that Lund's patients genuinely
needed that many treatments was extremely low. And there was no medical evidence to justify many of Lund's decisions or to
explain the phantom procedures. Zeidler confronted Lund about his discoveries in several face-to-face meetings. When I
asked Zeidler how those meetings went, he offered a single sentence -- "I decided shortly thereafter to take legal action" -- and
declined to comment further. (Repeated attempts were made to contact Lund and his lawyer for this story, but neither
responded.)
One by one, Zeidler began to write, call, or sit down with patients who had previously been in Lund's care, explaining
what he had uncovered. They were shocked and angry. Lund had been charismatic and professional. They had assumed that his
diagnoses and treatments were meant to keep them healthy. Isn't that what doctors do? "It makes you feel like you have been
violated," Terry Mitchell says -- "somebody performing stuff on your body that doesn't need to be done." Joyce Cordi recalls a
"moment of absolute fury" when she first learned of Lund's deceit. On top of all the needless operations, "there were all
kinds of drains and things that I paid for and the insurance company paid for that never happened," she says. "But you
can't read the dentalese."
"A lot of them felt,
How can I be so stupid?
Or
Why didn't I go elsewhere?
" Zeidler says. "But this is not
about intellect. It's about betrayal of trust."
In October 2013, Zeidler sued Lund for misrepresenting his practice and breaching their contract. In the lawsuit,
Zeidler and his lawyers argued that Lund's reported practice income of $729,000 to $988,000 a year was "a result of
fraudulent billing activity, billing for treatment that was unnecessary and billing for treatment which was never
performed." The suit was settled for a confidential amount. From 2014 to 2017, 10 of Lund's former patients, including
Mitchell and Cordi, sued him for a mix of fraud, deceit, battery, financial elder abuse, and dental malpractice. They
collectively reached a nearly $3 million settlement, paid out by Lund's insurance company. (Lund did not admit to any
wrongdoing.)
Lund was arrested in May 2016 and released on $250,000 bail. The Santa Clara County district attorney's office is
prosecuting a criminal case against him
based on 26 counts of insurance fraud. At the time of his arraignment, he said
he was innocent of all charges. The Dental Board of California is seeking to revoke or suspend Lund's license, which is
currently inactive.
Many of Lund's former patients worry about their future health. A root canal is not a permanent fix. It requires
maintenance and, in the long run, may need to be replaced with a dental implant. One of Mitchell's root canals has already
failed: The tooth fractured, and an infection developed. He said that in order to treat the infection, the tooth was
extracted and he underwent a multistage procedure involving a bone graft and months of healing before an implant and a
crown were fixed in place. "I don't know how much these root canals are going to cost me down the line," Mitchell says.
"Six thousand dollars a pop for an implant -- it adds up pretty quick."
Joyce Cordi's new dentist says her X‑rays resemble those of someone who had reconstructive facial surgery following a
car crash. Because Lund installed her new dental bridges improperly, one of her teeth is continually damaged by everyday
chewing. "It hurts like hell," she says. She has to wear a mouth guard every night.
What some of Lund's former patients regret most are the psychological repercussions of his alleged duplicity: the
erosion of the covenant between practitioner and patient, the germ of doubt that infects the mind. "You lose your trust,"
Mitchell says. "You become cynical. I have become more that way, and I don't like it."
"He damaged the trust I need to have in the people who take care of me," Cordi says. "He damaged my trust in mankind.
That's an unforgivable crime."
described
as "probably the most dishonest argument in the entire Medicare for All debate."
"People who love their employer-based insurance do not get to hold on to it in our current
system. Instead, they lose that insurance constantly, all the time. It is a complete
nightmare."
-- Matt Bruenig, People's Policy Project
In an
interview with the Washington Post , the Democratic leader said she is "agnostic" on
Medicare for All and claimed, "A lot of people love having their employer-based insurance and
the Affordable Care Act gave them better benefits."
Matt Bruenig, founder of the left-wing think tank People's Policy Project, argued in a
blog post that Pelosi's statement "implies that, under our current health insurance system,
people who like their employer-based insurance can hold on to it."
"This then is contrasted with a Medicare for All transition where people will lose their
employer-based insurance as part of being shifted over to an excellent government plan,"
Bruenig wrote. "But the truth is that people who love their employer-based insurance do not get
to hold on to it in our current system. Instead, they lose that insurance constantly, all the
time, over and over again. It is a complete nightmare."
To illustrate his point, Bruenig highlighted a University of Michigan study showing that
among Michiganders "who had employer-sponsored insurance in 2014, only 72 percent were
continuously enrolled in that insurance for the next 12 months.
"This means that 28 percent of people on an employer plan were not on that same plan one
year later," Bruenig noted.
"Critics of Medicare for All are right to point out that losing your insurance sucks,"
Bruenig concluded. "But the only way to stop that from happening to people is to create a
seamless system where people do not constantly churn on and off of insurance. Medicare for All
offers that. Our current system offers the exact opposite. If you like losing your insurance
all the time, then our current healthcare system is the right one for you."
All On Medicare -- a pro-Medicare for All Twitter account -- slammed Pelosi's remarks,
accusing the Democratic leader of parroting insurance industry talking points:
The Speaker's alternative to the Medicare for All legislation co-sponsored by
over 100 members of her caucus is a bill to strengthen the Affordable Care Act (ACA), which
she
introduced last week .
"We all share the value of healthcare for all Americans -- quality, affordable healthcare
for all Americans," Pelosi told the Post . "What is the path to that? I think it's the
Affordable Care Act, and if that leads to Medicare for All, that may be the path."
The nation's largest nurses union was among those who expressed disagreement with the
Speaker's incrementalist approach.
In a
statement last week, National Nurses United president Zenei Cortez, RN, said Pelosi's plan
would "only put a Band-Aid on a broken healthcare system."
"National Nurses United, along with our allies, will continue to build the grassroots
movement for genuine healthcare justice and push to pass Medicare for All," Cortez concluded.
This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License
Here is a 5 day old article on Trump deregulating Big Pharma that directly impacts the skyrocketing costs of American Health Care
to go with the above posts re the Republican Party's AHCA cutting of coverage and transfer of wealth to the wealthiest in America
Trump is the #1 problem with American Health Care today, he works for the interests of the corporations not the people's
"Draft Order on Drug Prices Proposes Easing Regulations"
By SHEILA KAPLAN and KATIE THOMAS...JUNE 20, 2017
"In the early days of his administration, President Trump did not hesitate to bash the drug industry. But a draft of an executive
order on drug prices appears to give the pharmaceutical industry much of what it has asked for - and no guarantee that costs to
consumers will drop.
The draft, which The New York Times obtained on Tuesday, is light on specifics but clear on philosophy: Easing regulatory hurdles
for the drug industry is the best way to get prices down.
The proposals identify some issues that have stoked public outrage - such as the high out-of-pocket costs for medicines - but
it largely leaves the drug industry unscathed. In fact, the four-page document contains several proposals that have long been
championed by the industry, including strengthening drugmakers' monopoly power overseas and scaling back a federal program that
requires pharmaceutical companies to give discounts to hospitals and clinics that serve low-income patients.
Mr. Trump has often excoriated the drug industry for high prices, seizing on an issue that stirs the anger of Republicans and
Democrats alike. He has accused the industry of "getting away with murder," and said that he wanted to allow the federal government
to negotiate directly with drug companies over the price of drugs covered by Medicare.
But the proposed order does little to specifically call out the drug industry and instead focuses on rolling back regulations,
a favorite target of the administration..."
I don't know the reason for persistence at attempts to understand the Economics of Trump's and the Republican various remake of
the American Economy from an academic Economics perspective by this blog.
It is not possible to do any such rational analysis, b/c as Paul Krugman has pointed out recently and pointedly, there is no
rhythm or reason to what they are doing except to obtain the sole single outcome of a major transfer of wealth to the wealthiest
Americans in the form of a huge tax cut for most of America's Billionaires and Mega-Millionaires by eliminating as much as possible
of the American Safety Net and other protections from the 99%.
We can spend endless amounts of money on the NSA, wars overseas, political campaigns and bailing out banks, but PGL and the weak
tea centrists demand "how are we going to pay for it???" now that single-payer is becoming a real possibility. Every other advanced
nation does it better with massive savings for their taxpayers.
Op-Ed Single-payer healthcare for California is, in fact, very doable
by Robert Pollin
June 21, 2017
The California Senate recently voted to pass a bill that would establish a single-payer healthcare system for the entire state.
The proposal, called the Healthy California Act, will now be taken up by the state Assembly. [not]
The plan enjoys widespread support - a recent poll commissioned by the California Nurses Assn. found that 70% of all Californians
are in favor of a single-payer plan - and with good reason. Under Healthy California, all residents would be entitled to decent
healthcare without having to pay premiums, deductibles or copays.
But as critics of the bill have pointed out, a crucial question remains: Is Healthy California economically viable? According
to research I conducted with three colleagues at the University of Massachusetts, Amherst, the answer is yes.
Enacting Healthy California would entail an overhaul of the state's existing healthcare system, which now constitutes about
14% of California's GDP. In particular, it would mean replacing the state's private health insurance industry with government-managed
insurance. Our study - which was also commissioned by the California Nurses Assn. - concludes not only that the proposal is financially
sound, but that it will produce greater equity in the healthcare sector for families and businesses of all sizes.
California will spend about $370 billion on healthcare in 2017. Assuming the state's existing system stayed intact, the cost
of extending coverage to all California residents, including the nearly 15 million people who are currently uninsured or underinsured,
would increase healthcare spending by about 10%, to roughly $400 billion.
That's not the full story, though. Enacting a single-payer system would yield considerable savings overall by lowering administrative
costs, controlling the prices of pharmaceuticals and fees for physicians and hospitals, reducing unnecessary treatments and expanding
preventive care. We found that Healthy California could ultimately result in savings of about 18%, bringing healthcare spending
to about $331 billion, or 8% less than the current $370 billion.
How would California cover this $331-billion bill? For the most part, much the same way it covers healthcare spending right
now. Roughly 70% of the state's current spending is paid for through public programs, including Medicare and MediCal. This funding
- totaling about $225 billion - would continue, as is required by law. It would simply flow through Healthy California rather
than existing programs.
The state would still need to raise about $106 billion a year to cover the cost of replacing private insurance. This could
be done with two new taxes.
First, California could impose a gross receipts tax of 2.3% on businesses, but with an exemption for the first $2 million of
revenue. Through such an exemption, about 80% of all businesses in California - small firms - would pay nothing in gross receipts
tax, and medium-sized businesses would pay an effective tax rate of less than 1%.
Second, the state could institute a sales tax increase of 2.3%. The tax would not apply to housing, utilities, food purchased
for the home or a range of services, and it could be offset for low-income families with a 2% income tax credit.
Relative to their current healthcare costs, most Californian families will end up spending less, even with these new taxes,
and some will even enjoy large gains. Net healthcare spending for middle-income families would fall by between 2.6% and 9.1% of
income. Most businesses would also see a drop in spending. Small firms that have been providing health insurance for their workers
will see costs fall by 22% as a share of payroll. For medium-sized firms, costs will fall by an average of between 6.8% and 13.4%
as a share of payroll. Even most large firms will see costs fall, by an average of between 0.6% and 5% of payroll.
At the moment, about 2.7 million of California's residents, or about 8% of the population, have no health insurance. Another
12 million residents, or about 33% of the population, are underinsured. A large proportion of the remaining 60% of the population
who are adequately insured still face high costs, as well as anxiety over President Trump's proposal to repeal and replace Obamacare.
Healthy California is capable of generating substantial savings for families at most income levels and businesses of most sizes.
These savings are in addition to the benefits that the residents of California will gain through universal access to healthcare.
"There ain't no such thing as a free lunch" (alternatively, "There is no such thing as a free lunch" or other variants)
is a popular adage communicating the idea that it is impossible to get something for nothing.
The acronyms TANSTAAFL, TINSTAAFL, and TNSTAAFL, are also used. Uses of the phrase dating back to the 1930s and 1940s have
been found, but the phrase's first appearance is unknown.[1]
The "free lunch" in the saying refers to the nineteenth-century practice in American bars of offering a "free lunch" in
order to entice drinking customers.
The phrase and the acronym are central to Robert Heinlein's 1966 science-fiction novel The Moon Is a Harsh Mistress, which
helped popularize it.[2][3]
The free-market economist Milton Friedman also popularized the phrase[1] by using it as the title of a 1975 book,[4] and
it is used in economics literature to describe opportunity cost.[5]
Campbell McConnell writes that the idea is "at the core of economics".
[I was a bigger fan of Robert Heinlein's than I was of Milton Friedman and even then it was "Stranger in a Strange Land" and
"The Unpleasant Profession of Jonathan Hoag" rather than later works that appealed to me.]
@animalogic I don't
know if you live in the US, sounds like you don't, but one could argue that the healthcare
system has already been nationalized. Consumers must shop for policies that meet
Obamacare standards which include coverage for gender reassignment and other things
that 10 years ago no private insurer would dream of paying for. This is a direct result of
government's boot on the market's throat. (And the market likes it, based on HMO stock
prices)
It is illegal for any insurer to offer a bare bones catastrophic plan that doesn't
cover Obama's hopey-changey list of progressive surgical procedures. 15 years ago, those
catastrophic plans were everywhere, and very affordable.
And to your point about providing healthcare to people who can't afford it. We already
have that, it's called Medicaid. When those receiving it die, the government comes in and
grabs all of their estate's assets, because they used a government program that was
forced on them. Like I said, it's been taken over.
"... I've lived in the US and the UK for extended periods so can compare and contrast. I actually think that due to the structure of the US system that the US medical system builds a dependency on subscribing more and more drugs to people because MDs and pharmas get the money (not a shocking statement). ..."
"... Exactly. The phrase "providing access" is nauseating. It really means "preventing access" unless you pay. ..."
In the early 21st century, the debate about health care reform in the US ramped up. The
result ultimately was the Patient Protection and Affordable Care
Act (PPACA, ACA, "Obamacare"), which arguably improved access to health care, made some
reforms in the regulation of health care insurance, but did not affect the fundamental reliance
of the US on employer-paid, for-profit health care insurance to finance health care for many
patients. Nor did it really affect the issues we discuss on Health Care Renewal (look
here
for details).
After the tumultuous election of President Donald Trump, the debate started up again with
his and his party's attempt to "repeal and replace" Obamacare. Arguably, Obamacare ended up
damaged but not repealed. Once again, the issues we discuss on Health Care Renewal were
ignored, including threats ot the integrity of the clinical evidence base, deceptive marketing,
distortion of health care regulation and policy making, bad leadership and governance,
concentration of power, abandonment of health care as a calling, perverse incentives, the cult
of leadership, managerialism, impunity enabling corrupt leadership, and taboos, or the anechoic
effect. (Look here
for a detailed discussion. )
It is time once again to discuss health care reform in the US. Now the push is from the
Democrats and the left, with the stated goals of making care more universal, and perhaps
decreasing or even ending the role of for-profit commercial health care insurance
companies.
It is no surprise that those who benefit the most from the current system (even as modified
by Obamacare) are rushing to its defense.
Dark Money to Defend Commercial Health Insurance
We already discussed
how large health care corporations, including pharmaceutical and biotechnology companies, have
been using dark money to funnel money for distinctly partisan purposes, to defeat whom they
perceive as too left-leaning politicians, almost all Democrats. They seem to fear such
politicians might promote health care reform efforts that would be based on "anti-free-market,
anti-business ideology," that is efforts to decrease the role of commercial, for-profit health
insurance in financing health care.
More recently, the focus has shifted to Democratic proposals for government run
single-payer, or "Medicare for all" health insurance. In early January, 2019,
the Hill reported
Thomas Donohue, the president and CEO of the Chamber of Commerce, on Thursday vowed to use
all of the Chamber's resources to fight single-payer health care proposals.
'We also have to respond to calls for government-run, single-payer health care, because it
just doesn't work,' Donohue said during his annual 'State of American Business' address.
The US Chamber of Commerce historically has had many executives of big health care
corporations on its board. We
listed 10 such members in 2015. It also historically has received financial support from
some corporations. We
listed 17 in 2018.
Then later in January,
The Hill reported that a group called Partnership for America's Health Future started
digital ads attacking "Medicare for All." The Hill stated its
members include major industry players such as America's Health Insurance Plans and the
Pharmaceutical Research and Manufacturers of America
So here we have the leaders of big health care corporations funneling corporate money into
propaganda campaigns to defeat government run single payer health insurance, an old policy idea
that suddenly is looking politically credible. Current US regulation and practice allows them
to hide the exact amounts spent on such campaigns by processing them through dark money
organizations.
Such stealth health policy advocacy is now not new. What is surprising now is how some top
leaders are willing to jump into the debate themselves, rather than just trying to manipulate
public opinion through public relations/ propaganda proxies. Here are some telling examples. in
chronological order.
Quest Diagnostics CEO Attacks "Medicare-for-All" Using an Appeal to Authority, an
Argument by Gibberish, the Non Sequitur Fallacy, (and an Incomplete Comparison)
A top health care CEO is sounding the alarm on 'Medicare for All,' an idea gaining steam
in political circles, including from newly-elected Rep. Alexandria Ocasio-Cortez (D-NY).
' Most people don't understand the basics of health-care economics in the United
States ,' said Steve Rusckowski, chairman & CEO Quest Diagnostics (DGX), in an
interview with Yahoo Finance editor-in-chief Andy Serwer at the World Economic Forum in
Davos, Switzerland .
Mr Rusckowski implied that he knows a lot more about health care economics than most people,
so most people should listen to him. Thus, he began with an implied logical fallacy, the
appeal
to authority .
He then presented the justification for his argument.
'The majority of people get their health care from their employers, and the majority of
healthcare costs are paid by employers and employees,' he said. 'If you look at the $3.5
trillion spent on healthcare costs, that portion is actually funding the Medicare and
Medicaid programs throughout this country.'
.
