California legislature debates surprise medical bills

 Some doctors complain the proposed legislation would empower insurers to keep narrower networks and limit access to crucial health services.

In California, a fierce battle over surprise medical bills pits docs against insurers

For the second time in as many years, California legislators are debating a bill that would protect patients from paying surprise medical bills when they inadvertently get treatment from doctors who are not covered by their insurance.

Under the bill, AB 72, consumers would only pay the equivalent of in-network rates if, for example, during surgery covered by insurance, they are treated by an out-of-network anesthesiologist, or have X-rays read by an out-of-network radiologist. AB 72 is in the California Senate and must be approved before going to the state assembly and governor. The state legislature has until Aug. 31 to act, or the bill effectively dies in committee.

The legislation was sponsored by state Assemblyman Rob Bonta (D-Alameda), who sponsored a similar bill last year that languished over the finer points of what the lower, in-network-style payment would be.

Surprise medical bills occur in a small percentage of overall health care transactions, but they often result in thousands of dollars in unanticipated charges that are difficult for many people to afford. Patients get hit with these extra charges because, in the course of getting treatment, one or more ancillary providers aren’t on their insurance plan, even if the main provider, like a surgeon, is. That ancillary provider maybe someone who routinely works with a particular surgeon or hospital, or just happens to be the only one available that day, said Bonta, so even if patients do all their homework to make sure they are covered, it isn’t enough.

In California, this fight is on full display and the proposal is generating harsh criticism from some doctors because they have to take that lower rate or go to arbitration.  

“We’re supposed to hire an attorney or go off to a dispute resolution process, spend hours getting ready, and then hours at the process?” said Dr. Michael Couris, a San Diego ophthalmologist. “You’re telling me this is a tenable position? This is laughable.”

Some independent physicians argue the current proposal would only empower insurers to keep narrower networks, ignore independent physicians and small practices, and limit access to crucial health services.

Emergency Room surprise bills are common as well.

Mystery Solved: Private-Equity-Backed Firms Are Behind Ad Blitz on ‘Surprise Billing’

Two doctor-staffing companies are pushing back against legislation that could hit their bottom lines.

The emergency department doctor you see in the emergency room does not work for the hospital. He (She) is employed by an outside contract group who negotiated a contract with the hospital for care. This theoretically avoids the issue of hospitals employing physicians directly.  It eliminates the cost of benefits, vacation pay and deductions for taxes and health insurance.  Early this summer, Congress appeared on its way to eradicating the large medical bills that have shocked many patients after emergency care. The legislation to end out-of-network charges was popular and had support from both sides of the aisle. Legislation is also proposed in California and other states regarding surprise emergency medical bills.  The bills were well on their way to becoming law when a curious thing happened.  Private-Equity-Backed Firms launched an ad Blitz on ‘Surprise Billing’. Then, in late July, a mysterious group called Doctor-Patient Unity showed up. It poured vast sums of money (Dark Money) now more than $28 million — into ads opposing the legislation, without disclosing its staff or its funders.Trying to guess who was behind the ads became something of a parlor game in some Beltway circles. Whether this was by design or happenstance is moot, the end result will be the same.Now, the mystery is solved. The two largest financial backers of Doctor-Patient Unity are TeamHealth and Envision Healthcare, private-equity-backed companies that own physician practices and staff emergency rooms around the country, according to Greg Blair, a spokesman for the group.“Doctor-Patient Unity represents tens of thousands of doctors across the country who understand the importance of preserving access to lifesaving medical care and support a solution to surprise medical billing that protects patients,” said Mr. Blair, who issued the statement weeks after the group was first contacted about the campaign. “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.” The two health staffing companies have both previously been accused of shifting the cost of uncompensated care in billing disputes to patients. Both say that's no longer the case and that they support a federal solution to surprise billings. But they don't like the congressional panels' approach, which they call government "rate-setting."Ending surprise bills, a big concern for voters of all stripes, was viewed as one of the only health issues in Congress with bipartisan appeal and the backing of the Trump administration. Everyone agreed that a patient who followed the rules and went to an in-network hospital shouldn't get slammed with enormous bills because he or she ended up with an out-of-network provider, such as an emergency physician or anesthesiologist. But insurers, employers, doctors and hospitals from the beginning have vigorously fought over how to solve the problem and who should pay.Two sources affiliated with Doctor-Patient Unity confirmed that Envision Healthcare and TeamHealth are funding a portion of the $28.6 million campaign that runs from July 30 to Sept. 17 in states including Alabama, California, Colorado, and New Hampshire, according to Advertising Analytics. The sources wouldn't say who else is involved but confirmed the two companies are funders.These two entities provide physicians through an obscure system which purchased multiple physician groups, not just in emergency medicine, but also many other hospital-affiliated physicians, HOSPITALISTS | CRITICAL CARE | RADIOLOGY | ANESTHESIA | WOMEN/CHILDREN | SURGICAL |andn OFFICE MEDICINE. It is a commonly accepted practice and affords ease of recruitment for hospital and physician groups.Greg Blair, a spokesperson for Doctor Patient Unity, also confirmed the two companies are funders, and in a statement said the pair represent tens of thousands of doctors who support an alternate approach to ending surprise medical bills that's been enacted in New York and Texas. Those states both use independent mediators to settle payment disputes — an approach known as arbitration — not a government-set pay scale.“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,” Blair said in the statement.Envision and TeamHealth both confirmed they back Doctor Patient Unity and echoed similar sentiments.TeamHealth Executive Vice President Dan Collard said the group wants to submit billing disputes between health providers and insurers to arbitration instead of using government-set benchmark rates."We will continue to fight an insurance industry proposal to use government rate setting as a vehicle to increase their profits at the expense of potential hospital closures and doctor shortages in underserved communities," Collard said.

California legislature debates surprise medical bills:

Physicians aren't 'burning out.' They're suffering from moral injury - STAT

By SIMON G. TALBOT and WENDY DEAN

Burnout among physicians is a symptom of something larger: the moral injury of being unable to provide high-quality care in today's health care systems.


Physicians on the front lines of health care today are sometimes described as going to battle. It’s an apt metaphor. Physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury.

Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians, it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.

Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work. Even at the Mayo Clinic, which has been tracking, investigating, and addressing burnout for more than a decade, one-third of physicians report its symptoms.

We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience.

Related: Fighting the silent crisis of physician burnout
The term “moral injury” was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges. Each hurdle offers a lesson in endurance in the service of one’s goal which, starting in the third year of medical school, is sharply focused on ensuring the best care for one’s patients. Failing to consistently meet patients’ needs has a profound impact on physician wellbeing — this is the crux of consequent moral injury.

Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already.

In order to ensure that compassionate, engaged, highly skilled physicians are leading patient care, executives in the health care system must recognize and then acknowledge that this is not physician burnout. Physicians are the canaries in the health care coalmine, and they are killing themselves at alarming rates (twice that of active duty military members) signaling something is desperately wrong with the system.



Physicians aren't 'burning out.' They're suffering from a moral injury - STAT

Fraud Alert: Genetic Testing Scam | Office of Inspector General | U.S. Department of Health and Human Services

Senior citizens are often the target of scams. One must be constantly aware of unsolicited offerings which could compromise your personal identity or defraud you or a loved one.

The U.S. Department of Health and Human Services Office of Inspector General is alerting the public about a fraud scheme involving genetic testing.

Genetic testing fraud occurs when Medicare is billed for a test or screening that was not medically necessary and/or was not ordered by a Medicare beneficiary's treating physician.

Scammers are offering Medicare beneficiaries "free" screenings or cheek swabs for genetic testing to obtain their Medicare information for identity theft or fraudulent billing purposes. Fraudsters are targeting beneficiaries through telemarketing calls, booths at public events, health fairs, and door-to-door visits.

Beneficiaries who agree to genetic testing or verify personal or Medicare information may receive a cheek swab, an in-person screening or a testing kit in the mail, even if it is not ordered by a physician or medically necessary.

If Medicare denies the claim, the beneficiary could be responsible for the entire cost of the test, which could be thousands of dollars.

Protect Yourself
If a genetic testing kit is mailed to you, don't accept it unless it was ordered by your physician. Refuse the delivery or return it to the sender. Keep a record of the sender's name and the date you returned the items.
Be suspicious of anyone who offers you "free" genetic testing and then requests your Medicare number. If your personal information is compromised, it may be used in other fraud schemes.
A physician that you know and trust should assess your condition and approve any requests for genetic testing.
Medicare beneficiaries should be cautious of unsolicited requests for their Medicare numbers. If anyone other than your physician's office requests your Medicare information, do not provide it.
If you suspect Medicare fraud, contact the HHS OIG Hotline.

Related Material: Senior Medicare Patrol's Information on Genetic Testing Fraud














Fraud Alert: Genetic Testing Scam | Office of Inspector General | U.S. Department of Health and Human Services:

That Beloved Hospital? It’s Driving Up Health Care Costs - The New York Times

By Elisabeth Rosenthal
Ms. Rosenthal, a journalist, and physician is a contributing opinion writer

It’s easy to criticize pharmaceutical and insurance companies. But we spend much more on hospitals.

As voters fume about the high cost of health care, politicians have been targeting two well-deserved villains: pharmaceutical companies, whose prices have risen more than inflation, and insurers, who pay their executives millions in salaries while raising premiums and deductibles.

But while the Democratic presidential candidates have devoted copious airtime to debating health care, many of the country’s leading health policy experts have wondered why they have given a total pass to arguably a primary culprit behind runaway medical inflation: America’s hospitals.

Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than the gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.

Opening this link will bring you to an interactive map representing reimbursement differentials between private payer insurance companies and Medicare.

A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.

 So why have politicians let hospitals off scot-free? Because a web of ties binds politicians to the health care system.

Every senator, virtually every congressman and every mayor of every large city has a powerful hospital system in his or her district. And those hospitals are as politically untouchable as soybean growers in Iowa or oil producers in Texas.





Opinion | That Beloved Hospital? It’s Driving Up Health Care Costs - The New York Times:

Stop treating medical residents like indentured servants - STAT

The practice of indentured servitude is alive and well in U.S. teaching hospitals. Those laboring under its yoke are known as medical residents.

Hundreds of years ago, poor immigrants were forced to become indentured servants to repay the cost of their passage to the U.S. by performing years of hard labor. This practice lives on for U.S. physicians-in-training, who have no choice but to serve years of indentured servitude to teaching hospitals in order to qualify for a medical license or board certification. We know them as medical residents.

In recent months, the announcement that Hahnemann University Hospital would be closing in September has cast a pall of uncertainty over the future of hundreds of residents who suddenly did not know how or whether they would complete their training. Instead of helping residents find new hospitals that would best support their education, Hahnemann executives, in dealing with Chapter 11 bankruptcy proceedings, simply auctioned its 550 residency slots to the highest bidders, a consortium of regional hospitals, for a sum of $55 million.

The hospital’s recent “sale” of medical residents and their residency slots showcases how some teaching hospitals have subordinated their training mission in favor of the pursuit of profits.

The residents were commoditized and sold as chattels to the highest bidder. Had this occurred to any other group, there would almost certainly have been public outrage. Curiously, there was little protest by entities that oversee the education and well-being of resident physicians. The response from the Association of American Medical Colleges was half-hearted, with a representative telling the Philadelphia Inquirer that the sale “was a big surprise.” Medicare objected to the sale, not because it should be illegal to treat residents as transferable property but because the sale would not allow Medicare to recoup past overpayments to Hahnemann.

To independently practice medicine, students must complete multiyear residencies at accredited hospitals after they graduate from medical school. Once they are matched with a program during the fourth year of medical school, their multiyear funding is tied to the program with which they’ve matched for the duration of their training. Finding a new position mid-way through residency is not trivial, making the instability of a residency program highly stressful for residents.

Teaching hospitals have argued over the years that training physicians comes at a substantial expense. But studies show that graduate medical education programs positively affect hospital finances to the tune of $160,000 to $218,000 per resident physician. In the U.S., Medicare funds a fixed number of residency slots with direct government grants of at least $100,000 per resident — and that does not include the market value of services provided by the resident during his or her training. This amounts to about $15 billion a year in government funding for residencies.

The Hahnemann sale underscores how few strings are attached to this support.

The labor market for residents is controlled by nonprofit teaching hospitals through an intentionally monopolistic entity: the National Resident Matching Program. It is responsible for matching students with residency slots at teaching hospitals during their last year of medical school. These training programs are accredited by the Accreditation Council for Graduate Medical Education. Prospective residents can apply only through a single standardized process called The Match, which allows them to express a preference for where they would like to work, but ultimately locks them into a multiyear employment contract with a single hospital.

The National Resident Matching Program is exempt from antitrust regulation, joining a few other entities such as Major League Baseball and labor unions.

This framework allows a sticky web of private governing bodies in medicine, including the Association of American Medical Colleges, the National Resident Matching Program, the Accreditation Council for Graduate Medical Education, and a consortium of hospitals, to dictate the compensation and training conditions for medical residents.





Stop treating medical residents like indentured servants - STAT:

When Apps Get Your Medical Data, Your Privacy May Go With It - The New York Times

By Natasha Singer


 Medical groups are warning that new federal data-sharing rules, enabling people to get their health records through a smartphone, could lead to invasions of privacy.

Apple’s Health Records app lets people send a subset of their medical data to their iPhones from more than 300 health centers.

Americans may soon be able to get their medical records through smartphone apps as easily as they order takeout food from Seamless or catch a ride from Lyft.

But prominent medical organizations are warning that patient data-sharing with apps could facilitate invasions of privacy — and they are fighting the change.

The battle stems from landmark medical information-sharing rules that the federal government is now working to complete. The rules will for the first time require health providers to send medical information to third-party apps, like Apple’s Health Records after a patient has authorized the data exchange. The regulations, proposed this year by the Department of Health and Human Services, are intended to make it easier for people to see their medical records, manage their illnesses and understand their treatment choices.

Yet groups including the American Medical Association and the American College of Obstetricians and Gynecologists warned regulators in May that people who authorized consumer apps to retrieve their medical records could open themselves up to serious data abuses. Federal privacy protections, which limit how health providers and insurers may use and share medical records, no longer apply once patients transfer their data to consumer apps.

Tech executives are promoting data-sharing in health care. From left, Taha Kass-Hout of Amazon, Aashima Gupta of Google and Peter Lee of Microsoft attended a conference in July for Medicare’s Blue Button system.CreditMicrosoft

Without federal restrictions in place, the groups argued, consumer apps would be free to share or sell sensitive details like a patient’s prescription drug history. And some warned that the spread of such personal medical information could lead to higher insurance rates or job discrimination.

“Patients simply may not realize that their genetic, reproductive health, substance abuse disorder, mental health information can be used in ways that could ultimately limit their access to health insurance, life insurance or even be disclosed to their employers,” said Dr. Jesse M. Ehrenfeld, an anesthesiologist who is the chair of the American Medical Association’s board. “Patient privacy can’t be retrieved once it’s lost.”

There are now many electronic medical records that allow smartphone access, such as Epic (MyChart), DrChrono, Kaiser and countless others.  When retrieving medical records directly via a desktop computer your records are secure. For EHRs that are HIPAA compliant, the vendor must show compliance for desktop retrieval.   If you are using a smartphone and the app provided by the institution it should also be HIPAA compliant.

Dr. Don Rucker, the federal health department’s national coordinator for health information technology, said that allowing people convenient access to their medical data would help them better manage their health, seek second opinions and understand medical costs. He said the idea was to treat medicine as a consumer service, so people can shop for doctors and insurers on their smartphones as easily as they pay bills, check bus schedules or buy plane tickets.

The new rules are emerging just as Amazon, Apple, Google, and Microsoft are racing to capitalize on health data and capture a bigger slice of the health care market. Opening the floodgates on patient records now, Dr. Rucker said, could help tech giants and small app makers alike develop novel consumer health products.

The regulations are part of a government effort to push health providers to use and share electronic health records. Regulators have long hoped that centralizing medical data online would let doctors get a fuller, more accurate picture of patient health and help people make more informed medical choices, with the promise of better health outcomes.

In reality, digital health records have been cumbersome for many physicians to use and difficult for many patients to retrieve.

Americans have had the right to obtain copies of their medical records since 2000 under the federal Health Insurance Portability and Accountability Act, known as HIPAA. But many health providers still send medical records by fax or require patients to pick up a paper or DVD copies of their files.

The new regulations are intended to banish such bureaucratic hurdles.

Dr. Rucker said it was self-serving for physicians and hospitals, which may benefit financially from keeping patients and their data captive, to play up privacy concerns.

“The moment our data goes into a consumer health tech solution, we have no rights,” said Andrea Downing, a data rights advocate for people with hereditary cancers. “Without meaningful protections or transparency on how data is shared, it could be used by a recruiter to deny us jobs,” or by an insurer to deny coverage.

When Apps Get Your Medical Data, Your Privacy May Go With It - The New York Times:

Doctors more likely to prescribe opioids later in the day — or if running late

Author information: Hannah T. Neprash, PhD1; Michael L. Barnett, MD, MS2,3
Author affiliations: 
1Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
2Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
3Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts



Physicians were more likely to prescribe opioids later in the day and when appointments were running behind schedule.

After seeing dozens of patients in a hectic and long day in the clinic, when a doctor is faced with another patient in pain, it may be easiest to prescribe opioids and move on to the next one. New research suggests that doctors who practice with this habit could be contributing to the opioid epidemic.

A study published in JAMA Network Open on Friday reveals that physicians were more likely to prescribe opioids later in the day and when appointments were running behind schedule.

“Physicians play a crucial role in the opioid epidemic and it’s important to find the factors that drive decisions to prescribe opioids,” said Hannah Neprash, an assistant professor of health policy and management at the University of Minnesota and the study’s lead investigator. “Many studies have looked at looked at differences in prescribing patterns between physicians but few have looked at variation within physicians.”

The study utilized claims and electronic health data in 2017 for 678,319 patients with new pain who saw 5,603 physicians at health care clinics. The patients’ complaints ranged from back pain and headaches to muscle and joint aches. The researchers looked at the order of appointments and whether an appointment started at its scheduled time. Opioid prescriptions were compared to prescriptions of non-steroidal anti-inflammatory drugs and physical therapy.

When working with patients in pain who want opioids, offering them alternative therapies such as NSAIDs or physical therapy can require time-consuming discussions, Neprash said. “Prescribing opioids may be the quick fix when they do not have enough time to discuss non-opioid options.”

In 2017 there was six times the number of opioid-related deaths compared to 1999. While much of the opioid epidemic is due to illicit drug use, prescription opioids still play a large role. The authors note that if prescribing practices remained constant throughout the day, 4,459 opioid prescriptions would not have been written in 2017.

The study draws attention to demands placed on doctors who are incentivized to see as many patients as possible. The authors recommend protocols to guard against physician fatigue, arguing that if time pressures are affecting opioid prescriptions, other major medical decisions could also be at risk.
This should come as no surprise to a clinician.  Pain is bad, and immediate relief is wanted by the patient and physician.  Prescribing a pill gratifies both doctor and patient rewarding the encounter clinically, and gratifying a fee for service (pain relief). In today's medical environment satisfaction surveys are supreme. Health insurance companies and plans regularly survey patient's satisfaction quotients based on many subjective metrics.

Dr. Mark Linzer, director of the Office of Professional Worklife at Hennepin Healthcare in Minneapolis, said adding more clinical team members, such as physician assistants and nurse practitioners, could help diffuse the workload of the day and allow clinicians to spend more time with patients. He also proposed making individual visits longer for certain patients in order to provide the time needed to address pain and other sensitive medical problems.

“I suspect this is the tip of the iceberg: that time pressure has numerous adverse consequences, and that these poor outcomes could be attenuated by providing the time that complex patients (including those with acute and chronic pain) need with their clinicians,” said Linzer, who was not involved in the study.

“The conversation that avoids narcotics just takes time,” he said
Was the doctor on time?
Was the staff courteous?
Are you satisfied with the results of your encounter?
How long did you have to wait?
Would you recommend this doctor to a friend or family member?

None of these questions ask for an objective response. None of them are measuring the real quality of care (ie, clinician accuracy).  In most cases, patients are incompetent in assessing their doctor's clinical competence.

Worse than that are newer measures of supposed physician competence, MOC (maintenance of competence) (taken five to ten years after initial board certification). Many insurers now list whether a doctor is maintaining MOCs.  These tests and certifications reveal no correlation of results, patient satisfaction, nor a reduction in medico-legal events.  It may set a totally irrelevant and inaccurate measure of physician quality of care.




Doctors more likely to prescribe opioids later in the day — or if running late: