Price gouging is a pejorative term referring to when a seller spikes the prices
of goods,
services or commodities to a level much higher than is considered reasonable or fair, and
is considered exploitative, potentially to an unethical extent. Usually this event occurs
after a demand or supply shock: common examples include price increases of basic
necessities after
hurricanes or other
natural disasters. In precise, legal usage, it is the name of a crime that applies in
some jurisdictions of the
United States
during civil emergencies. In less precise usage, it can refer either to prices obtained by
practices inconsistent with a competitive
free market, or
to
windfall profits. In the former
Soviet Union,
it was simply included under the single definition of
speculation.
The term is similar to
profiteering but can be distinguished by being short-term and localized, and by a
restriction to essentials such as food, clothing, shelter, medicine and equipment needed to
preserve life, limb and property. In jurisdictions where there is no such crime, the term
may still be used to pressure firms to refrain from such behavior.
Balance Billing is a scam that it is still legal in many
states. And medical providers use and abuse it, especially for ambulance and IR services.
Even if the bill is correct, you should still set up a time to speak with someone in the billing
office — someone with the authority to negotiate on your balance. Go into the conversation equipped with
the knowledge that Medicare and insurance companies rarely pay the hefty price tags that consumers see.
Standard practice for insurers is to negotiate with providers to pay merely a fraction of the cost.
In the case of inpatient hospital bills, for example, a NerdWallet
study found Medicare negotiates, on average, a 73% discount. While the ambulance service may not
agree to such a large discount for you, coming to any negotiation equipped with such knowledge will
put the company on notice that you aren’t going to lay down and take its bullying or an inflated bill.
Consider how much you are able to pay. If the ambulance service isn’t willing to deduct a good portion
of the original bill, think about how much is fair and reasonable for the service your husband received
and your budget. Negotiating a lower balance, even if you can’t pay it off in a lump sum, will remove
a considerable burden from your shoulders. It may even benefit the ambulance company, which might fear
receiving no payment from you at all, since the majority of bills in collections are never paid off.
If you do set up a formal payment agreement, make sure to get it in writing.
Negotiating with an ambulance service or any medical provider is not easy, but it is possible. Be
persistent. If your efforts prove fruitless, you can always consider hiring a professional. A
medical billing advocate is able to represent clients’ interests much in the way an attorney would
advocate for you in a courtroom. Their experience and expertise in the field can sometimes prove more
effective (and less stressful) than taking on a stubborn provider alone.
How much do patient and medical billing advocates cost?
Patient advocates are often members of your family, nonprofit organizations or clergy, and may not
charge you for their services. In most cases, however, there will be a fee associated with patient advocates,
and it usually depends on the amount of time they spend with you and your doctor. Advocates on the hospital
staff may have their charges built into your bill. For this reason, costs may vary from as little as
$75 for a single doctor’s visit to a few thousand dollars for an extended hospital stay.
Medical billing advocates usually have more concrete charges. Some charge hourly, at a rate of $100-$200.
Others charge as a percentage of savings—usually 25%-35% of the price they got your total charges reduced
by, but some charge as little as 15% of savings.
Where can I find a patient or medical billing advocate?
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.
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."
"... 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.
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 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.
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.
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.
"... 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.
"... 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?
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
"... 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-à-vis
hospitals and insurance companies. They have also bought up other emergency providers, such as ambulance and medical transport services.
They grow by buying up many small specialty practices and 'rolling them up' into umbrella organizations that serve healthcare systems
across the United States. Mergers of large physician staffing firms to create national powerhouses have also occurred. As these companies
grow in scale and scope and become the major providers of outsourced services, they have gained greater market power in their negotiations
with both hospitals and insurance companies: hospitals with whom they contract to provide services and insurance companies who are
responsible for paying the doctors' bills. Hospitals have consolidated in order to gain market share and negotiate higher insurance
payments for procedures.
Healthcare costs have been driven up further by the dynamics associated with payments for out-of-network services. As physicians'
practices merge or are bought out and rolled up by private equity firms, their ability to raise prices that patients or their insurance
companies pay for these doctors' services increases. The larger the share of the market these physician staffing firms control, the
greater their ability to charge high out-of-network fees. The likelihood of surprise medical bills goes up, and this is especially
true when Insurance companies find few doctors with these specialties in a given region with whom they can negotiate reasonable charges
for their services. The design of the private equity business model is geared to driving up the costs of patient care. Private equity
funds rely on the classic leveraged buyout model (LBO) in which they use substantial debt to buyout companies (in this case specialty
physician practices as well as ambulance services) because debt multiplies returns if the investment is successful. They target companies
that have a steady and high cash flow so they can manage the cash in order to service the debt and make high enough returns to pay
their investors 'outsized returns' that exceed the stock market.
[xi]
Emergency medical practices are a perfect buyout target because demand is inelastic, that is, it does not decline when prices
go up. Moreover, demand for these services is large – almost 50 percent of medical care comes from emergency room visits, according
to a 2017 national study by the University of Maryland School of Medicine, and demand has steadily increased.
[xii]
PE firms believe they face little or no downside market risk in these buyouts. Private-equity owned companies differ from publicly
traded for-profit chains not only in their greater use of debt, but also because the private equity firm, via the general partner
of the investment fund it sponsors, makes all investment decisions on behalf of the investor shareholders. Investors commit capital
to a PE-sponsored fund, typically for 10 years, and have no say in investment decisions. Thus, the PE general partner's power is
concentrated and largely unaccountable, as investors cannot 'exit' or sell their shares if they are dissatisfied – unlike shareholders
in publicly traded corporations.
[xiii]
In addition, PE firms charge their portfolio companies additional 'advisory fees' and 'transactions fees' that can amount to millions
of dollars over time. And because PE owned companies are not publicly traded on the stock exchange, they are not required to file
a detailed report to the Securities and Exchange Commission (SEC) the way that publicly traded companies must do. Their activities
and their financial transactions are largely hidden from the public eye, despite the fact that they receive substantial taxpayer
funding from Medicare and Medicaid for their services, though not for surprise charges. Two private-equity owned physician-staffing
firms dominate the market for outsourced doctors' practices -- Envision Healthcare, owned by KKR with 69,300 employees, and TeamHealth
owned by Blackstone Group with 20,000 employees. KKR also is a major owner (along with other private equity firms) of AirMedicalGroup
Holdings -- one of the nation's three largest ambulance and air transport companies.
We also showcase private equity owned Air Methods medical transport company. These examples help illuminate how and why private
equity firms have become national powerhouses in the provision of professional healthcare services and why their activities and those
of other private equity firms in this sector are leading to higher healthcare costs for patients and the industry as a whole.
Envision Healthcare
Envision Healthcare today is the result of fifteen years of private equity transactions in buying up and consolidating emergency
ambulance and specialty physicians' practices. It was formed in 2005 when private equity firm Onex took over two companies -- American
Medical Response (AMR) and EmCare -- and merged them. In and out of private equity ownership since 2005, Envision most recently was
acquired by KKR in October, 2018 in a public to private leveraged buyout worth $9.9 billion. Its sprawling organization employs tens
of thousands of healthcare professionals; and it supplies doctors in 774 physician practices to hospitals and ambulatory surgical
centers throughout the United States. It provides ER doctors, anesthesiologists, radiologists, hospitalists, and other specialists
covering intensive care, medical, neo-natal, pediatrics, psychiatric, skilled nursing, rehabilitation, and other inpatient units.
Its outpatient ambulatory surgical arm (AMSURG) provides trauma and acute care general surgery in 260 facilities in 35 states.
[xiv]
Between 2005 and 2018, Envision provided two types of emergency medical services: an ambulance and medical transport business
through American Medical Response (AMR) and emergency physician staffing through EmCare Holdings.
Today, Envision focuses on physician staffing services as it sold the ambulance and transport business in a $2.4 billion leveraged
buyout in 2018 to another private equity consortium that still includes KKR (as we detail below). The prior ownership patterns of
AMR and EmCare were similar. American Medical Response was listed as a publicly traded company as of August 1992; and in February,
1997, it was acquired by ambulance company MedTrans, a subsidiary of Laidlaw International. At an undisclosed date between 1997 and
2005, PE firm Peak Capital invested an undisclosed amount in the company. Like AMR, EmCare Holdings was acquired by Laidlaw International
in the summer of 1997 and subsequently received an undisclosed amount of investment from PE firm Peak Capital.
Emergency physician practices figured prominently among EmCare's 10 acquisitions and 17 sister physician staffing and management
firms.
[xv]
In December 2005, just months after acquiring and merging AMR and EmCare, Onex brought Envision Healthcare to the public market
via an IPO in which it retained a majority of the shares. Subsequent sales of shares left Onex with 31 percent of the company's equity
at the time it was again taken private, this time by Clayton Dubilier & Rice with participation of PE firm Ardian through a $3.2
billion LBO in May 2011. An IPO in 2013 returned Envision Healthcare to the public market. The PE owners retained about two-thirds
of the shares of the now-publicly traded company. The PE companies subsequently sold some of the stock. And in September 2017, two
hedge funds – Starboard Value and Comex Management – took minority stakes in Envision Healthcare.
Between July 2006 and October 2018, Envision Healthcare acquired 39 companies.
[xvi]
Envision Healthcare bought out AMSURG in December 2016 after AMSURG failed in an attempt to acquire TeamHealth (described below).
The deal brought together two seemingly complementary healthcare companies to form a single organization with pro forma market capitalization
of $10 billion and an enterprise value including debt of approximately $15 billion. A little over $8 billion of this was new debt.
However, KKR contributed $5.57 billion to the deal, using $4.43 billion to retire Envision's prior liabilities and the remainder
mainly as equity in the LBO.
Adding AMSURG's large chain of ambulatory surgical centers was supposed to make Envision Healthcare a dominant player across the
outsourced medical services landscape – emergency room doctors, hospitalists, outpatient surgery, and ground and air ambulance. But
integrating the two health care companies – with a combined 69,300 employees as of December 2017 – proved difficult for publicly
traded Envision Healthcare.
[xvii]
Envision Healthcare appears to be extremely profitable, but its financials are murky, with no publicly available accounting of
its transactions with each round of private equity buyouts. And under private equity ownership, when companies are taken private
or pass from one private equity fund to another, there is no transparency.
Each private equity buyout, however, is typically accompanied by levering substantial debt on the target company, which must be
serviced by managing for cash. Emergency medical services are attractive to private equity firms and are very lucrative because they
throw off a lot of cash, and as noted earlier, demand is inelastic and the fees are not subject to competitive market pricing. The
contracts negotiated between these physician staffing companies and hospitals also are not publicly available. Depending on how they
are crafted, they may provide incentives to outsource even more ER departments, and in turn increase out-of-network billing. One
Wall Street investor analysis, for example, highlights Envision's 'joint venture' model that raises serious questions.
A 2013 analysis by Deutsche Bank Securities described a 2012 joint venture between EmCare and the HCA Healthcare chain – with
a history of private equity ownership between 2006 and 2011 and substantial PE ownership of shares following its 2011 IPO. HCA apparently
agreed to give up directly charging for physicians' services and outsourced these services to EmCare in exchange for a 50-50 profit
split once EmCare achieved a 13% margin threshold, according to the Deutsche Bank calculation. This allowed EmCare to " penetrate
HCA's 160+ hospital portfolio more deeply with its physician offerings." As of 2014, EmCare valued its HCA joint venture at a net
revenue of $124 million, with assets of $155 million and liabilities of $31 million, according to the company's SEC filing. The filing
identified similar joint ventures with hospitals involving Evolution Health (also owned by Envision).
[xviii]
Commenting on EmCare's relations with hospitals, Benedic Ippolito, a research fellow in public finance and health economics
at the American Enterprise Institute, noted, "Right now, EmCare surprise bills patients and hospitals effectively turn a blind eye."
[xix]
Envision has come under heavy scrutiny for the huge out-of-network surprise medical bills it sends to ER patients.
A team of Yale University health economists examined the billing practices of EmCare, Envision's physician staffing arm.
[xx]
They found that when EmCare took over the management of emergency departments, it nearly doubled its charges for caring for patients
compared to the charges billed by previous physician groups. These egregious practices have resulted in a Congressional investigation
headed by Missouri Senator Claire McCaskill, lawsuits from shareholders, and court actions involving Envision and UnitedHealth Group,
the largest U.S. insurer.
[xxi]
TeamHealth
TeamHealth has also grown into a powerful national healthcare professional staffing company with 20,000 employees. It contracts
with hospitals to provide doctors and other healthcare professionals as ER staff, anesthesiologists, hospitalists, and hospital specialists
(OB/GYN, orthopedics, general surgery, pediatric services); and in post-acute care, ambulatory care, and behavioral health.
[xxii]
The company experienced successive rounds of private equity leveraged buyouts punctuated by IPOs that returned it to the public
markets – only to be taken private again through another LBO. In 1999, private equity firms Cornerstone Equity Investors and Madison
Dearborn Partners, with minority participation of Becken Petry O'Keefe and Company, acquired TeamHealth as a platform for a physician
staffing company. According to PitchBook (an industry research and data firm), TeamHealth acquired an anesthesiology practice, a
hospitalist company, and a health management business in its first two years. It made no further acquisitions until after it was
acquired by the Blackstone Group in 2005 in a leveraged secondary buyout (in which one PE fund sells a company to another PE fund).
TeamHealth made two more acquisitions between 2005 and 2009 – an emergency physician's group and a hospitalist company.
In 2009, Blackstone Group returned TeamHealth to the public market via an IPO, but retained possession of a majority of shares
in the newly public company. Passage of the Affordable Care Act in 2010, with its promise of cost containment via capitated and bundled
payments, spurred TeamHealth to go on a buying spree. Between 2010 and 2016, TeamHealth acquired 51 companies, mainly practices of
emergency doctors and anesthesiologists and a few hospital management companies. One very large exception to this pattern was TeamHealth's
2015 acquisition of IPC Healthcare.
[xxiii]
IPC Healthcare was a major hospitalist company. In its early years, it attracted four rounds of venture capital investments between
1998, when it was launched as IPC The Health Company, and 2002. In June 2002, IPC had an IPO and began its life as a publicly traded
company. Between 2002 and 2009, IPC acquired 20 physician practices. Between 2010 and 2015, following passage of the ACA, it acquired
78 more. The companies acquired by IPC were overwhelmingly hospitalist companies with a smattering of doctor's practices in specialties
such as geriatrics.
[xxiv]
TeamHealth's acquisition of IPC in 2015 raised questions. There was no evident fit between TeamHealth's specialty physician practices
and IPC's hospitalist companies. IPC was also in trouble with the Department of Justice, which in June 2014, had filed a civil lawsuit
against the company for "knowingly engaging in systematic overbilling" for services billed to Medicare and Medicaid and other government
health programs. Ultimately, TeamHealth paid $60 million plus interest to resolve these allegations.
[xxv]
This fueled speculation that TeamHealth, which had rebuffed AMSURG's attempt to acquire it, wanted this very large acquisition
in order to protect itself from being taken over. TeamHealth's explanation was that it wanted IPC's expertise in participating in
Medicare and Medicaid bundled payments programs.
[xxvi]
In February 2017, Blackstone Group once again took TeamHealth private in a $6.1 billion leveraged buyout. Similar to Envision
Healthcare, the financials of TeamHealth are murky. After many LBOs, its revenues, debt load, and financial stability remain unknown,
as do the contracts it negotiates with the phyisician groups it has acquired and the hospitals it contracts with for services.
And like Envision, its billing practices are being scrutinized. The Yale researchers who investigated EmCare and found excessive
use of surprise medical billing also examined TeamHealth's billing practices. They found that Blackstone owned TeamHealth has taken
a somewhat different tack. It uses the threat of sending high out-of-network surprise bills for ER doctors' services to an insurance
company's covered patients to gain high fees from the company as in-network doctors. In most cases, the researchers noted, TeamHealth
emergency physicians would go out-of-network for a few months, then rejoin the network after bargaining for in-network payment rates
that were 68 percent higher than in-network rates received by the previous ER doctors.
[xxvii]
While this avoids the situation of a patient getting a large, surprise medical bill for the services of ER doctors, it raises
healthcare costs and premiums for everyone.
Emergency Ambulance and Air Transport Services
Emergency ambulance and air transport is also a lucrative target for private equity investment, which has fueled consolidation
in this industry segment. Demand is inelastic – there is no competitive market pricing. And demand for air transport has grown considerably
because many rural hospitals have closed or consolidated, leading to far longer distances for access to emergency care. Two of the
three air transport companies that together control two-thirds of this US market are private equity owned – AirMedicalGroup Holdings
and Air Methods. The third, PHI Air Medical, is privately owned.
[xxviii]
Returning to the Envision story, recall that American Medical Response (AMR) was the ambulance service division that Envision
spun off in 2018. Before the divestiture, however, AMR grew to a national powerhouse in the decade from 2007 to2017 through 12 acquisitions
of ambulance and medical transport businesses and one air ambulance company7. In addition to these acquisitions, AMR has seven sister
companies – mainly ambulance companies, including several air ambulance businesses. It was acquired in 2017 by air ambulance company,
AirMedicalGroup Holdings (AMGH) -- owned by PE firms Ardian, Koch Equity Development, and KKR -- in a $2.4 billion leveraged buyout.
With this acquisition, AirMedicalGroup now holds a leading position in emergency and medical transport across a range of transport
modalities.
[xxix] The acquisition merged the largest provider of ground ambulance services in the U.S. with a leading operator
of medical helicopters, with over 320 locations in 38 states.
[xxx]
The combined entity creates the opportunity for KKR to substitute its more expensive medical helicopters for short trips previously
done by AMR's ambulances.
[xxxi]
Air Methods became private equity owned in 2017, when it was acquired by American Securities and Alpinvest Partners through a
$2.5 billion public-to-private LBO. The company's air medical transport services operate out of over 300 bases in 48 states.
[xxxii]
The buyout came in response to pressure from activist hedge fund investor, J. Daniel Plants, founder of Voce Capital Management.
Concerned about the bad publicity surrounding predatory charges by air ambulance companies, Plants wanted Air Methods to agree to
be taken private by a PE firm in order to keep information about its billing practices out of public view. According to the hedge
fund, Air Methods big price hikes created economic and political risks for the company. Going private would shield its financial
documents from patients and insurers. The hedge fund was right to be concerned about Air Methods predatory billing practices. The
average bill for being transported in one of its medical helicopters was $17,262 in 2009 and had risen to $40,766 in 2014. Air Methods
calculates that it accounts for nearly 30 percent of total air ambulance revenue in the U.S. Its profit increased sevenfold from
2004 to 2014.
[xxxiii]
In general, charges for out-of-network ambulance services are likely to be high. In the case of air ambulances, they are exceedingly
high – not only due to the high costs of air travel, but especially because an estimated 69 percent of charges are out-of-network
-- according to a 2017 US General Accountability Office (GAO) study of private insurance records for 2012-2017. That is, insured
patients in these cases ended up being billed for most of the charge. The GAO study also found that the median price for helicopter
service doubled between 2010 and 2014 – from roughly $15,000 to $30,000 per tri;p it also found that the average cost of an air ambulance
trip is over $36,000. .
[xxxiv]
Another study by researchers at Johns Hopkins University found charges were likely to be – as they put it – sky high. The study
found that air ambulance charges had risen substantially from 2012 to 2016, and in 2016 these charges ranged from 4 to 9 times higher
than what Medicare paid for this service. Some of the largest providers had among the highest charges. Between 2012 and 2016, the
median charge ratios (the charge divided by the Medicare rate) for the services increased by 46-61 percent.
[xxxv]
Legislative Solutions
Some hospitals have attempted to solve the problem of surprise billing on their own by simply requiring all attending physicians
in their hospitals to remain in-network – receiving payment from the insurance companies with whom the hospital has contracted. This
has been the traditional approach used by hospitals in managed care networks. According to John Cascell, Senior Vice President of
Managed Care at MemorialCare Health System in Fountain Valley, California, "Such stipulations were commonplace decades ago, but some
experts say the practice slipped out of favor around 2000 as major physician staffing companies -- which tend to make more money
when they're out of network -- gained market power."
[xxxvi]
MemorialCare, however, has retained this long-standing policy, which Cascell supports. The downside of this approach, however,
is that it may shift bargaining power to insurance companies who will seek to set lower in-network payments for specialty services.
In these cases, according to Cascell, MemorialCare takes a strong role in negotiating with insurance companies to maintain reasonable
payments.
[xxxvii]
More generally, the public, healthcare providers, insurers, and state and federal legislators recognize that individual solutions
are only stop-gap measures and that no individual hospital can solve the pervasive problem of surprise medical billing on its own.
Twenty-five states have passed legislation that aims to protect patients from surprise billing, but these laws do not fully cover
all types of situations. Over seventy-five percent of Americans believe that the federal government should step in and protect
them from surprise bills, according to a Kaufman Family Foundation April, 2019 national survey. The same survey found that 90 percent
of Democrats, three-quarters of Independents, and 60 percent of Republicans favored federal legislation to protect patients.
[xxxviii]
Americans differ, however, in who they think should bear the costs of care. According to the Kaufman survey, about half say insurance
companies alone should cover the costs of care (43 percent) while about half favor joint responsibility between providers and insurance
companies (47 percent).
[xxxix]
Two approaches to 'fixing' surprise medical bills have been put forward. One would benchmark the fees paid to out-of-network doctors
to the negotiated fees received by in-network doctors in that region for the procedure performed or the service provided. This would
have the effect of holding down health care costs by setting limits to what out-of-network physicians can charge. In the second approach,
out-of-network doctors would immediately be paid a given amount by the patient's insurance company – possibly 125 percent of the
Medicare payment or, alternatively, the median payment for that procedure or service in the geographic region – and could then take
the insurance company to arbitration in an effort to collect the balance of the patient's bill.
The second approach has the potential to raise health care costs if arbitration panels award out-of-network doctors all or a major
part of the fees they charge. This approach, which is favored by investor-owned physician staffing firms and by large physician practice
groups, would further raise health care costs for consumers. Even if many of these physician practices became in-network doctors,
as Envision now claims to be doing
[xl]
, the threat of going out-of-network remains. As the TeamHealth example illustrates, this allows physician staffing firms to
negotiate high in-network rates that drive up premium costs for consumers.
In sum, there is growing concern over the pricing practices of companies like Envision, TeamHealth, AirMedicalGroup, and Air Methods
-- leading emergency healthcare companies owned and operated by private equity firms. There is little oversight of the prices they
charge, and evidence suggests that these companies are among those responsible for driving up health costs by taking advantage of
the possibilities for surprise medical billing. But they are not alone, as private equity firms buy out medical services in specialties
other than trauma and radiology and as large physician practices take a page from the PE playbook when setting fees. Reining in these
charges is critical to efforts to slow the growth or even reduce health care costs.
[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)
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.
"... 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.
Three Bernie Sanders Bills to Arrest the Highway Robbery in the Prescription Drug
Market
Allowing foreign imports, authorizing Medicare bargaining, or setting prices at what other
nations pay -- all good options
By DEAN BAKER
The prescription drug market in the United States is an incredible mess. From an economic
standpoint, everything is wrong. Drugs that would sell for a few hundred dollars in a free
market often sell for tens or even hundreds of thousands of dollars because we give their
manufacturers patent monopolies. This leads to the sort of distortions and inefficiency that
would be expected from tariffs as high as many thousands percent.
From a heath perspective the situation is no better. The huge markups give drug companies
enormous incentive to misrepresent the safety and effectiveness of their drugs and to push
them for uses where they may not be appropriate. This is a big part of the story of the
opioid epidemic.
Cumulatively, it is a huge deal in both economics and health. We spent more than $430
billion (2.2 percent of GDP) on prescription drugs last year. These drugs likely would have
cost less than $80 billion in a free market. The difference of $350 billion is almost five
times the annual federal budget for food stamps. This is real money.
This is the backdrop for three bills proposed last week by Senator Bernie Sanders, along
with Representatives Elijah Cummings and Ro Khanna, to address the high and rapidly rising
cost of prescription drugs. The three measures provide alternative paths for reducing drug
prices.
The first one, "The Prescription Drug Price Relief Act," would end the patent monopoly for
any drug that sold for a price exceeding the median price in five other major countries:
Canada, the United Kingdom, France, Germany, and Japan. This would allow large savings since
drug prices in these countries are roughly half as much as in the United States. Drug
companies would have a choice of either lowering their prices or losing their patent
monopoly.
In the latter case, the competition is likely to push the price well below the levels in
the five countries. While these nations do regulate drug prices, patent monopolies still let
the companies charge a price that is far higher than the price that would exist in a
competitive market with generic competition.
The second bill is "The Medicare Drug Price Negotiation Act." This bill would allow
Medicare to negotiate collectively for the drugs purchased through Medicare prescription drug
insurance. Since this program spends roughly $100 billion annually on drugs, it should have
serious bargaining power.
Anyone designing a rational drug insurance program would have required negotiation when
the program was created, but rational design was not necessarily the top priority at the time
this program was enacted.
Anyone designing a rational drug insurance program would have required negotiation when
the program was created, but rational design was not necessarily the top priority at the time
this program was enacted. Representative Billy Tauzin, who headed the Energy and Commerce
Committee, which structured the Medicare prescription drug legislation, resigned immediately
after the bill was signed into law to become head of the pharmaceutical industry's trade
association.
The third bill, "The Affordable and Safe Prescription Drug Importation Act," is also an
effort to take advantage of the fact that drugs are so much cheaper in other countries than
in the United States. This bill would allow people to freely import drugs from other wealthy
countries that have safety standards that are comparable to those in the United States.
This bill both highlights the sharp differences in prices between the United States and
other countries and calls out one of the big lies used to justify these differences. Allies
of the drug industry often claim that we cannot count on getting safe drugs from other
countries, implying that countries like Canada and Germany do not protect their populations
from unsafe drugs.
This is, of course, absurd. The standards in these countries are every bit as high as in
the United States. And, if we think the quality of imported drugs is a problem, we all should
already be very worried because many of the drugs and ingredients in drugs sold in the United
States are already imported, largely from China. So the idea that we can't be assured of the
safety of imported drugs is simply an industry talking point, not a real concern.
Which of these paths for reducing drug costs is best? Importation is probably the most
far-reaching, since it should quickly bring our prices down to the level of other wealthy
countries. As a practical matter, however, progressives should back anything that moves the
debate forward.
We really need to turn the industry on its head, paying for research upfront and then
having drugs sold in a free market, like paper plates and shovels. It is absurd to pay for
research that has already been done, at the point when people are suffering from serious
conditions jeopardizing their health or their life.
No one thinks it makes sense to pay firefighters based on the value of their work when
they come to our burning house with our families inside, yet this is essentially how we pay
for drug research under the patent monopoly system. In fact, the story is even worse with
drugs, since typically we have a third party payer (either an insurance company or the
government) who we are trying to get pick up most of the tab.
These bills would not fully solve the problem, but each would be a big step in the right
direction. Sanders, Cummings, and Khanna have done a great service in pushing them
forward.
"No one thinks it makes sense to pay firefighters based on the value of their work ..."
We value fire fighters as worthless, by not paying most fire fighters in the US.
After all, requiring the people saving your life to be paid kills jobs, so we end up with
unpaid life savvers.
We should appply the same principle to people providing life saving food, the people
building the roads needed to deliver life savings, the people making the vehicles used by
those providing life saving services.
In fact, no one should be paid to work! Thats free lunch economics!
Sarcastic, yes.
Dean Baker meantioned nothing about costs, which are always labor costs.
Look, Keynes argued that when there were unemployed workers, and capital is scarce,
government should tax and spend to pay workers to build capital.
For drugs, paying unemployed researchers to build capital, eg, life saving drugs, then
taxing the drugs produced to repay the cost of developing the drugs, with so many new drugs
developed, the private capital in drug factories, etc will produce so many drugs that drug
prices fall to total labor costs per unit, plus the drug tax.
We know there are unemployed drugresearchers because NIH always runs out of money to pay
all thre recent collage grads seeking grants to fund their hoped for job as a researcher.
"On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders -- on the pavement with a
broken arm.
A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic
questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital,
where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain
medication, and with a recommendation to follow up with an orthopedist.
A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79
of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the
hospital threatened to send to collections in mid-December..."
"Monopolies hurt the public and the republic alike; the job of policing that power must be taken seriously."
Elizabeth Warren
Within so many of the corporate dominant monopolies like Healthcare, Banking, Pharmaceuticals, some companies seem to be
free to do just about whatever they wish in billing consumers.
Healthcare in the US is bordering on insane when it comes to billing practises and lack of practical recourse or common
sense, with Big Pharma running a close second. But the Banks are not all that far behind.
I have met many, many dedicated professionals in the healthcare industry, but like most participants they are just being
swept along because they have little practical recourse or power. To speak up is to be punished, and severely.
A simple law that states that when a patient is brought into a hospital emergency room for treatment, their private
insurance and the treatments must be provided at the network rates in their insurance policy, or at the prevailing rate for
a Medicare patient, whichever is lower. And any uncollectible services to be written off or compensated by government will
be done at the Medicare rate and not at some ficitonal billing statement.
I believe that New York State has a law requiring ER and Hospital doctors to accept private insurance for patients as if
they are in-network. This includes those 'consultations' which happen during a hospital stay by doctors who accept no
insurance and who charge whatever they feel like charging for some service, of which provider or price the patient is never
informed beforehand.
The real solution is of course universal healthcare, which has been implemented for years by every major developed nation
but the US. This will not happen for the same reason that we are seeing no movement towards meaningful reform in Pharma
or Banking. And you know exactly why, unless you have been living in a bubble or are willfully blind.
Stocks managed to extend their rally today despite some setbacks.
We will see what Trumpolini has to say about our 'crisis' at the southern border this evening, and the trade war, and
probably whatever else crosses his mind. My only certainly is that it will not involve any meaningful reform in healthcare,
finance, insurance, or pharmaceuticals.
"... Bottom line, experts say, medical professionals should make the patient aware if they prescribe a high-priced medicine and explain why it's beneficial. Patients should play defense and ask their physicians about the cost of every new prescription. ..."
"... " experts say " ..."
"... medicine is less expensive if you pay the cash price and we don't run it through your health plan ..."
Shame is a 20th century concept ill-suited to this modern post-tobacco settlement world.
Where some saw a consumer victory after decades of warnings on packs by getting big tobacco
to acknowledge risks, others saw methodology victory for the neo-liberal machine, and an
instruction manual .
Like the Big C, cancer, that machine keeps rolling along. Now it is mainstream, to be
emulated instead of castigated. At least that is what appears to have happened among those
shame-free star pupils of Big Pharma and their fellow travelers in FIRE, aided and abetted on
the Big Screen where deviancy got defined down so far it got erased. Political and economic
trends ebb and flow, with some elements of populism appearing on the horizon. Greater
awareness of the plight of one's fellow humans may help focus the mind.
Bottom line, experts say, medical professionals should make the patient aware if
they prescribe a high-priced medicine and explain why it's beneficial. Patients should play
defense and ask their physicians about the cost of every new prescription.
Bottom line, it's doctors and patients fault for not defending themselves against the
ludicrously corrupt health insurance industry. Bottom line, medical professionals and
patients have to spend their time and effort (increasingly dwindling, because markets) to try
to avoid being charged a month's pay for a tube of ointment. Because, bottom line, changing
the system is not an option, so keep banging your head against that wall!
Yeah, try getting a straight answer on what this stuff will cost BEFORE you take
possession, er , are treated. "$200" has turned into $1000 bills from a third party device
company that magically turns to $0 after 3 months of emails and phone calls. I've walked out
of hospitals after getting full disclosure of costs minutes before a procedure that was
scheduled weeks in advance.
The neolib corruption numbness has to seep through the cartilage into the bones to call
these practices anything but criminal.
There is really no excuse for the crooks in the medical (health care? nah!) industrial
complex not to provide costs of any procedure or service ahead of time. I admire you for
walking out minutes before the procedure and more people should do the same. I would do the
same and have.
If there's no "Price Discovery", is it really a "Marketplace"?
towards the end of my six and a half year slog through the disability process(sic), I
learned about Cuba. I got a price for a new hip pretty easily from them (around 10 grand,
including a "bungalo on the beach with a private nurse for recovery")
so I called the nearest hospital, and asked what a new hip would cost me, cash money,
walking in the door.
The person obviously didn't understand the question, and after some time of me waving my
arms and trying to word the question in a form she would understand she said" oh insurance
takes care of that and it depends on many factors"
"such as?" sez I
Her:" like what kind of replacement they use which is up to the surgeon and many
things"
This went on and on, and I finally got her not nailed down at around 300 grand.
Then I asked her what medicare would pay for the same thing and she hung up on me. It
ain't a "Market", it's a Racket.
(and, about the toenail fungus my grandmother would tell her to just pee on it .)
By the "logic" of the guest post, bottom line is it's that baby's fault for not being
strong enough to defend itself against the big kid who took its candy. It's the woman's fault
for dressing that way before she was raped.
The victims should be blamed because they didn't play defence well enough against the
criminals who write the rules of the system. I presume your comment is to flesh out the BS
justification from the article, Gandhi, not to endorse it. Excuses like the one capping the
guest post, instead of rabid outrage, are part of what allows the crimes to continue. I can
see why so many Merkins want to burn the (family blog)er down, even though they wind up
voting for Trump as a means of expressing that feeling.
Seriously, who are these 'experts'!?!? Between the 'experts' , who blame the victims, kick
cans down the road and pass the bucks to the lay-people (no one is an expert in everything,
i.e. everyone is ignorant about something at some point in their lives) they're suppose to be
advising whenever 'expertise' is required, and the 'journalists' who give them a venue to
spew their apocryphal twaddle in an attempt to portray themselves as 'experts' when their
true intentions are to gaslight, obfuscate and divide common sense and decency. Throw in the
politicians, crony capitalists and all the other puppet masters and you have the perfect
storm so many Americans, like myself, finds themselves drowning in. Once upon a time
expertise inferred wisdom. Those days are history.
I don't know if it works but I've been told that petroleum jelly will cure toenail fungus.
it seems salves or topical medicines are usually expensive. I use a salve that I apply to the
rash from my. Eczema. I have used it for years and the price is constantly increasing. When I
started using it the cost was $50 per tube. The last tube I got cost $480. I was prescribed
an inhaler for Bronchitis. It cost almost $500 and didn't seem to do much to relieve the
symptoms. Fortunately my insurance payed for the medicine. It still makes me mad when I think
about what was charged for these prescriptions.
There are much cheaper alternatives to inhalers for asthma or bronchitis. Buy a
"Nebulizer" (we just bought a portable one for $50), which is a vaporiser, and get your
doctor to prescribe "nebules" of albuterol sulphate and/or sodium chromalyn to load into the
nebulizer. We get a prescription refill of nebules for $3.49 v. over $50 for a ventolin
inhaler . And there is no propellant in the nebulizer which there is on an inhaler.
The greed and parasitism of the pharmaceutical cartel is criminal.
My gp told me to use Vick's VapoRub for my toenail fungus. I asked the pharmacist and she
said it has about a 10% success rate, same as the petroleum jelly from which Vick's is made.
There was some branded treatment, $40 for a 2ml bottle that she said worked maybe 15% of the
time. Only been a few weeks, but so far I haven't seen much of a change.
I did (after trying other topical but non-prescription products) and it didn't
initially.
But then I used it in conjunction with a lotion with a lot of hyaluronic acid in it.
Hyaluronic acid is widely used in cosmetic products to increase penetration of the active
ingredients into the skin.
Worked great.
Just by sure to apply any treatment to the cuticle, particularly at the root of the nail.
That is where the fungus lives.
I am not recommending websites replace physicians, but apparently it is necessary to
always second guess the physicians.
My treatment cost less than $10.
I'm amazed this simple idea never gets traction. Car mechanics, e.g., are required by law
to provide a written estimate before work begins; if something is found that will change the
estimate, they have to get your OK. Car repairs are usually much cheaper than medical bills
and are often equally or more opaque to diagnose.
Having doctors and medical offices provide you with an estimate after diagnosis but before
treatment does not seem like it would be terribly hard. They (uniquely) have visibility into
your insurance arrangements, their reimbursement rates, their costs, overhead, profit rates,
and so on. Software for this purpose would make pretty short work of boiling this down to the
out-of-pocket for the patient. The patient could then either OK it, negotiate other options,
or decide to shop around. If the provider later tries to charge more, the patient would have
something on paper to justify refusing it.
There's no reason patients should be treated like a bottomless bank account by the medical
industry.
Many doctors have no clue what things cost. I received a single shot of cortisone for an
arthritic shoulder and was charged $200. When I complained to the health care system, I was
told that, had I been insured, the cost to me would be $100 less. When I complained to my
doctor, he had no idea about any of this.
P.S. I knew the owner of an herb farm who had foot fungus. She visited a podiatrist and
was prescribed some expensive salve which didn't work. The woman then went out on her farm,
gathered some herbs according to an old remedy, made her own salve and was cured.
I was told to get the shot for shoulder pain (was a bad idea from this quacK). The
"doctor" had no idea what it would cost!! At any rate it cost me over a $100 even with Kaiser
coverage and it did NOT help. It hurt a lot for a few days (in more ways than one). What a
fraud this industry is.
I dread the day I'd have to go to the hospital where I it was such an emergency that I'd
be at the mercy of this robber baron system
Had any car or truck repair work done lately? Or speaking of things automotive, have any
of us had experiences with the sales machinery of car and truck dealers, new or used?
Speaking of transparency in pricing, firm quotes and all that? As just one example of how The
Machine actually works? Catch-22: "They can do anything to us they want that we can't keep
them from doing." http://www.slate.com/articles/life/the_spectator/2011/08/seeing_catch22_twice.html
Big ones twice in the past four years on the RAV4. 2 different shops, in different states.
They both gave me firm, up front price quotes. One was wrong on the low side, and the owner
called me with the real price and an apology before doing the work. Just like the law
requires.
This kind of fair dealing and respect for the customer never happens in medical practices.
The doctors rarely soil their highly educated minds with matters of cost; everyone else in
the office has little authority, and the chubby young women who sit up front in scrubs do as
little as possible for the captives they call patients.
"This kind of fair dealing and respect for the customer never happens in medical
practices. "
This! And stress over billing affects health!
it is stressful and aggravating that doctors can't/won't address cost at the point of
service. This destroys patient's trust in the physician as well.
Therapeutic relationship is wrecked as well as health and personal finances.
This NYS law applies to services, not drugs. It's a start:
Emergency Medical Services and Surprise Bills Law – New York State https://www.health.ny.gov/regulations/ bill
/ems_and_surprise_bills_law_faq.htm
If they do not participate in a patient's health care plan, they must upon request from a
patient inform the patient of the estimated amount they will bill absent unforeseen medical
circumstances that may arise. Under subdivisions (3) and (4), physicians in private practice
also must provide information regarding any other ..
We're talking about mild toenail fungus. The price tag is difficult to rationalize,
experts said.
What kind of "expert" tries to rationalize cost of prescription on severity, rather than,
say, cost of making the product?
16,500 for the course of an eleven month treatment with 6 percent chance of working. Seems
like a medical RX vacation almost anywhere else in the world would be prudent.
Today's fast-paced, stimulating world in pharmaceutical revenue management and marketing
needs H1-B visa assistance to hire the kind of expert that is not available in sufficient
quantity or quality to allow efficient pursuit of medical excellence. In past years, such
personnel were to be found only in select industries such as tobacco and other personal care
products. Building the right team, with applicable key performance indicators and
mission-critical elements, is too important to be left to chance so every avenue must be
explored, every base touched. Consumer options are opened up in the free market of healthy
competition for products rather than stifled under excess regulatory and legal layers.
"The results of our laboratory studies confirm that pure lavender and tea tree oils can
mimic the actions of estrogens and inhibit the effects of androgens ," said Korach. "This
combinatorial activity makes them somewhat unique as endocrine disruptors."
It should have been "Bill Of The Month: For Toenail Fungus, A $16,500 Prescription and
less than 10% effective".
. . . She began swabbing it on the two toenails, as directed, having been told it would
take about 11 months to treat the fungus .
– – – – Unbeknownst to her, Kerydin, which it turned out costs nearly $1,500 per monthly refill .
. .
– – – – In its application for Food and Drug Administration approval granted in 2014, Anacor
Pharmaceuticals highlighted that a yearlong treatment of Kerydin completely cured toe fungus
in 6.5 percent of patients for one trial, and 9.1 percent of patients in another.
The post's title diminishes the scale of the scam by a factor of at least 100.
That last bit blew my mind. Why in the hell is the FDA approving anything as a treatment
that can only be shown to cure what it's supposed to less than 10% of the time!?!? And we
know how the approval process scam works – the companies only submit the best results
in the first place and leave out the data the shows treatments to be less successful.
That being said, who would like to try out my new wonder drug? It cures absolutely
everything that ails you at least 5% ot the time. I call it Plaisibeaux – the
ingredients are French and they're a trade secret. Any FDA employess around who can fast
track this one for me?
My simple stupid solution just avoid them entirely, the docs the tests the meds the
hospitals. Advil is cheap and works for most of the pain. A couple of other basic meds for
occasional random stuff that I buy when I travel outside the US. Try to work out a bit and
eat more or less right. Except for easy obvious stuff I never met anyone that actually got
better by going to a doctor. When its time to die I guess I will die.
It's really worse than the article suggests. Kerydin (tavaborole) isn't even all that
effective. In one trial, "cure" was achieved in about 7% of cases and in other trials
"completely or almost clear nail rates" were achieved in 15 – 30% of cases:
In clinical trials, tavaborole was more effective than the vehicle (ethyl acetate and
propylene glycol) alone in curing onychomycosis. In two studies, fungal infection was
eliminated using tavaborole in 6.5% of the cases vs. 0.5% using the vehicle alone, and 27.5%
vs. 14.6% using the vehicle alone.
Last visit was a snake bite. Antivenom was about 60k. Pretty sure same can be had in
Mexico for less than $1,000, maybe much less. That was 5 years ago. I refuse to participate
any longer, & I have good insurance. I hope eating better, exercise, & homeopathic
treatments can work for me. Have not seen a doctor since & won't unless taken
unconscious.
Agree with you. Eat healthy foods, exercise, homeopathic or ayurvedic treatment when
absolutely necessary. No need to go for their "free" physicals. Listen to your body.
So a physicians assistant diagnosed a fungus strictly on observation, calls in a
prescription for an ineffective and more difficult to use but massively expensive
prescription and it is the patient's fault.
Don't know about the rest of you, but I see at least three problems in that that have
nothing to do with the patient OR even the obscene greed of the pharmaceutical industry but a
whole lot with the Braun Dermotological Center.
I have no proof, but my guess is that these medical centers have sweetheart deals with
mail-order pharmacies for various overpriced drugs. We took my son to a dermatology place
several times for acne treatment; they would commonly propose something I had never heard of
and urge us to order from a particular mail-order pharmacy, often providing coupons. I saw no
reason not to get it from our local pharmacy but they were strangely insistent on us doing it
by mail.
One obvious problem with mail-order pharmacies is made clear in this piece: by the time
you find out how much things cost, it's already a done deal. At a retail pharmacy, you can
walk away without paying. This is obviously a feature of mail-order pharmacies, not a
bug.
The proliferation of specialty medical centers around the western Chicago suburbs has been
amazing to witness – similar to the proliferation in the number of bank outlets prior
to the crash
No kidding. How is prescribing a drug, even a cheap one, that's "effective" only 7% of the
time even considered medical "treatment?"
And what in the world is that "statement" pictured above? It's flat out false. Is it
somehow supposed to be official? Where did it come from?
"Total Rx cost" in January: $56.52???? No, it was $1,496.09–same as in February.
"You paid" (Patient paid?) in January: $56.52? No, the patient paid $1,439.57, "funded"
through her HRA and shown with an asterisk at the bottom. $56.52 was apparently a drug
company rebate / coupon.
About the only true thing in January was that the insurance paid $0.
The "You paid" in February was not, in fact paid by the patient, but by another drug
company rebate / coupon. She was not even asked to write a check for the copay, an expense
she would have expected.
The "Your Cost" of $620.43 at the top appears to be the sum of the two drug company
coupons for January and February, although no time frame is specified. At this point, the
patient had written NO checks, even for the copays.
As an aside, where is the $60 "Copay/Co-insurance for January?
The patient's actual "cost" over the two months would most accurately be
represented as the sum of the two months' Rxs–about $3000–plus two $60 copays.
"You Paid" should be what she actually paid, either out of pocket or through the
HRA, and any fees or copays that were covered by drug company rebates should be clearly noted
as CHARGED but ABROGATED.
I'd suggest that deliberately confusing and understating seemingly obvious terms such as
"cost" and "paid"
deliberately obfuscates the situation in order to sell expensive drugs that people would balk
at purchasing if they knew the true "cost."
And all of this is before figuring out, for a Medicare recipient, how all these worthless,
expensive drugs, coupons and rebates propel the patient toward the "donut hole," an entirely
different kettle of fish in which nobody pays for nuthin' except the patient.
This reminds me of the time I was billed $300 for a foot splint by a podiatrist that my
insurance refused to pay for. I could have bought a foot splint off Amazon for $30.
Always ask for prices for any treatments or medicines. I trust my dentist way more than
any doctor I've been too.
I'm sure he meant "medicine that fixes toe fungi" is free in France, not Kerydin. And of
course Kerydin isn't approved in Europe, with a 7% efficacy rate, it's doesn't really have
medicinal value. It would only be prescribed in the US.
I went to a Podiatrist a couple years ago for a different problem but mentioned I thought
I had a toenail fungus, too.
The Dr confirmed that but instead of prescribing something he recommended coconut oil. He
said it worked much better & faster than any pills he could prescribe & he was
right.
I had a large jar of solid coconut oil (around $6) & applied it with a Q tip.
In very short time the fungus was gone.
A girlfriend had gone to her Dr who prescribed pills.
Her fungus returned within a few months.
Mine hasn't.
This is not surprising – before I read your post I was thinking, there is probably a
simple home remedy for that condition. There are a lot of useful drugs out there, but there
are probably just as many that are useless, ineffective, or that have dangerous side effects
and unintended consequences. I took over-the-counter anti-allergy meds for my hay fever for
years, only recently reading that they (Claritin, etc) are now implicated in the onset of
Alzheimer's. Thanks a lot
I was written a script for a tube of cream that supposedly cost nearly $3k. It's hard to
know what the pharmacy benefit manager actually paid because they are pretty secretive about
that sort of thing. Per a friend she estimated it at probably $50 which is still idiotic. It
was an anti-itch cream and wasn't any better than a $2.50 tube of cortisone cream.
For the love of Pete. Isopropyl alcohol costs $1.79. Cut your toenails then apply with q
tip. No more nail fungus. One bottle = many years supply.
I'm amazed people will take pills to cure nail fungus. So Dumb.
$14.000 annual toe cream. Dumb dumb dumber.
Thanks for posting these absurd bills. It lays bare the financialized health care holocaust
underway in the USA.
I pay less for my medicines when I pay cash as the pharmacy gives me a discount. But,
because Part D has a penalty for not enrolling, I use it for 5 of medicines and then pay cash
for one of them and pay about $5 more per month. Not to mention my doctor offered to do my
stints for half price if I paid for cash. The whole healthcare system is a mess.
I don't know about other countries, but here in the U.S. you should always, always, always
assume that in any transaction you engage in, the seller has been financialized and will
actively try to squeeze more money out of you, the ideal being to take all your available
money and give you nothing in return. Be wary.
There are plenty of honorable exceptions, like the honest doctors and the mechanics
described above. Cherish those sellers, patronize them, spread the word of mouth, especially
if you think capitalism is the best of all possible economic worlds. The rent-seekers, if
they continue unchecked, will destroy capitalism, because it requires some minimum level of
trust to work. The odds that the seller will provide a good product or service have to be at
least better than even.
Philia is a necessary casualty of identity politics. Society depends on the collective
will of people to take actions that are not in their direct benefit because they know others
will make them. The "Tragedy of the Commons" does not occur when philia is strong because
people know they can trust others not to abuse common resources. Once people do not trust
others to act for the greater good it is a race to the bottom. The problem with identity
politics is that it creates distrust of others outside ones own identity group as 'others'
who cannot be trusted.
oh yes identity politics created that, as if there wasn't far stronger prejudice by
dominant groups long before identity politics was even a glimmer in it's dad's eye.
Ten years ago or so in Corte Madera California, I was very lucky to find a podiatrist who
was doing research on toenail fungus. I had nine of ten toe nails involved, some since high
school (so for decades). His protocol for this was
1) pulse dose of two Lamasil tablets at the start of treatment
2) OTC bottle of fungoid tincture (with little brush built into the cap) from drug store with
half a Lamasil tablet dissolved in it
3) every morning in the shower, scrub the nail ends with a toothbrush and a chlorine powder
cleaner like Comet
4) brush a small amount fungoid tincture onto nail ends after morning shower and at night
before bed.
5) keep nails short with clean cut ends
As I recall, the Lamasil pulse dose kills the fungus in the nail bed right away, and the
fungoid tincture wicks into the nail every time and carries the anti-fungal drug to the
fungus residing within the nail. The chlorine cleaner acts as a dessicant and pH
modifier.
Ultimately, he gave me the few necessary Lamasil tablets as free samples, and back then
the fungoid tincture was maybe $4/bottle at walgreens.
The new nails grew in from the nail beds perfectly, and after many months I had perfect
toe nails and ceased treating them. They have remained so ever since.
I have always wondered if this approach was ever published in a medical journal. No
significant money to be made from it by the manufacturer of Lamasil, so it's hard to see who
had an incentive to promote it.
Disclaimer: I am not a doctor and am not giving medical advice. Pursue at your own risk.
Thanks!!
Why
your pharmacist can't tell you .
WASHINGTON -- As consumers face rapidly rising drug costs, states across the country are
moving to block "gag clauses" that prohibit pharmacists from telling customers that they
could save money by paying cash for prescription drugs rather than using their health
insurance The pharmacist cannot volunteer the fact that a medicine is less expensive if
you pay the cash price and we don't run it through your health plan ."
The White House Council of Economic Advisers said in a report this month that large
pharmacy benefit managers "exercise undue market power" and generate "outsized profits for
themselves."
I'm going to get in trouble for saying this but toenail fungus isn't exactly leprosy. I've
had a case continuously for 40 years after damaging my toenails in an accident. About 20
years ago I went to a doctor to see what could be done to get rid of it. He said I can give
you a prescription that may cure it . But would you rather risk your liver or take the fungus
with you to the grave after a full and healthy life with the fungus. I dont know what it
would have cost because I chose the fungus. If it had cost $1500 and he hadn't told me the
cost I would have been most unhappy.
This is shameful and absurd. However, the article mentions that there are "pills" that can
be prescribed to treat the toe fungus, but some people taking those pills (terbinafine aka
lamisil) have developed severe liver damage leading to liver transplant or death.
Why does this prescription cost $1,650 per month and not $16,500? Or $165,000? Or
$1,650,000? Who decided that $1,650 was reasonable and $1,650,000 wasn't?
I'm a lawyer. I took Contracts 25 years ago in law school, but I seem to remember that
there are certain elements to a contract that have to be present before the parties can be
bound. Let's see
Now, it seems to me that Consideration can't just be left blank. It is a very rare
(non-medical) contract indeed where the buyer says, "I want X, no matter what it costs."
If I stay at a hotel and they have a mini-fridge with various refreshments and snacks, and
I take a Diet Coke and a Milky Way, they can't legally charge me $10,000 for that.
I don't know why this isn't considered defrauding the consumer. We should be able to sue
the crap out of these companies.
Give the medical practitioners a break! So now they need to puruse the Wall St Journal
daily to see what pirate has acquired what formerly cheap generic drup to monopolize it and
raise the price 500%?
Yes, the price was outrageous. How is the practitioner supposed to know every patients
health care coverage and what one particular insurance carrier will cover for what drug?
What's $50 for one person is $1500 for another, depending on their insurance.
Our entire health care system sucks. The only people who like it are the Insurance and
Pharma execs.
That's a fantasy: "It is important to lock this agreement in, quickly, before my account is sold to a third-party collection
agency, which is nowhere near as likely to accept such a deep discount" Many hospitals sells you to collection immediately.
Mostly this is a cheap self-promotion of a yet another snake oil salesmen... Some more tidbit still might be useful You
are warned.
If you try to fight medical-industrial complex alone most of the time you will be crushed. As a minimum you need a legal help.
Often you need insurance too: at the end it is cheaper to have insurance then to fight astronomic bills. But those bottom feeders
still can get to you via balance billing. and in most case, when you stay in hospital they do get back to you with the
additional biils. That's why you will need a lawyers to fight this.
The usual trick of this scammers is to get "out of the network" ambulance and bill you $5K or more. Even the transfer from
one hospital to another via ambulance can cost you tons of money.
Unnecessary procedures is another important danger. Stents is one such danger, in case of suspicion for the heart attack.
You can get several several of them even if do not need them as a courtesy of those greedy jerks ;-)
And they will never agree for Medicare rates. Forget about it.
Notable quotes:
"... As we have already learned, all healthcare services have been assigned a code by the AMA, a five digit CPT code. So, if you trip and fall off your patio, you might get a doctor's bill like the following table located in your handouts: ..."
"... You may receive other bills from several doctors such as anesthesiologists and radiologists, as well as laboratory services, therapists, and the ambulance company. The bills all look similar, and the strategy and tactics I am presenting, today, should work for each of them as well. ..."
"... The purpose of this overpricing by the medical providers is to force the insurance companies to the negotiating table. The insurance company is bringing a large volume of patients to the medical providers, the members in their network, so they are able to negotiate a lower discounted allowable fee from the medical providers. However, if the insurance carrier is not able to negotiate a contractual allowable fee schedule, then they will end up paying the higher billed charges of the out-of-network provider for the members that still end up being treated by that medical provider in emergencies when precertification is not required. ..."
"... Now, on to where you can find these prices. Well, if you have insurance, then after you receive medical care and the healthcare providers send their claims to the insurance carrier, you should receive from the payer an Explanation of Benefits (EOB), or you probably can go online and view an Electronic Remittance Advice (ERA). For every CPT code that the providers billed , you will see both a billed charge and allowable. ..."
"... Fortunately, as you will now learn, there is a much more simple and better way to be 100% certain of your diagnosis, diagnosis code, procedure, procedure code, and even the medications the physician will offer you, at least for elective conditions. Here it is. If it isn't an emergency, then make a doctor's appointment! ..."
"... Does this sound unlikely? Too good to be true? Then consider this: Medical providers are highly incentivized to give the patients they treated huge discounts. Why? Because they know that collecting money from patients foments malpractice litigation. They would rather have you pay them pennies, than have you sue them for millions. ..."
"... I recently had breakfast with a pharmacist friend of mine that has worked as a manager for Walgreens for more than a decade. mrs_horseman is probably smiling when she hears that I have a pharmacist friend, because she knows how I feel about most of the people in that industry. Nonetheless, I told him about this presentation I am making, and asked if he had any advice for negotiating directly with the pharmacies for medications. It turns out, he does, and I would have never guessed the tactic he described. ..."
Approximately 63% of Americans have no emergency savings for things such as a $1,000
emergency room visit or a $500 car repair, according to a survey released Wednesday of 1,000
adults by personal finance website Bankrate.com, up slightly from 62% last year. Faced with an
emergency, they say they would raise the money by reducing spending elsewhere (23%), borrowing
from family and/or friends (15%) or using credit cards to bridge the gap (15%).
You are going to need five things, which I am going to give to you, today, free of
charge!
Some absolutely critical industry vocabulary
A clear understanding of how healthcare is priced in the USA
Insight into to actual pricing
A proven negotiation strategy, including:
a. The point of contact
b. Foreknowledge of what prices medical providers will usually agree to
c. A sample offer and agreement
The confidence to successfully negotiate
Unfortunately, I couldn't come up with a better way to impart to you an understanding of the
industry lingo, other than these simple handouts. However, this information is so important for
you to be able to understand any negotiation strategy that I simply must slog through each term
with you now. Please, I ask that you hold your questions and comments until I get through the
vocabulary. Many of the terms are cross-referenced, and will become more clear after we here
them all.
Premium: The monthly amount enrollees pay the insurance company to be covered.
Deductible: The amount paid by the member before insurance will begin to reimburse services.
It is reset annually, and based on the level of benefits or amount of premium paid. For
example, with a $1,000 deductible the patient must pay medical providers for the first $1,000
of allowable expenses incurred by the patient each year, after which costs may be split
according to a coinsurance arrangement, and/or may be limited to the patient's out of pocket
expenses.
Coinsurance: A cost-sharing requirement of some insurance plans where the patient assumes a
percentage of the costs for covered services after the amount of the deductible has been met.
Coinsurance is described as a ratio, for example 30/70, meaning the patient is responsible for
paying 30% and the insurance will pay 70% of the allowable.
Copayment (co-pay): The amount to be paid to a physician by or on behalf of the patient in
connection with the services rendered by the physician. It is due at the time of service, is a
fixed dollar amount determined by the insurance company based on the level of benefit, and is
usually found printed on the patient's insurance card.
Out of Pocket Expense: The total of covered health care expenses that are paid for by the
member or patient, not including any premium. This is typically the total of the deductible and
any coinsurance paid during a year. It may be a maximum amount where after 100% of allowable
expenses are paid by the insurance company.
Explanation of Benefits (EOB or ERA: Electronic Remittance Advice): The insurance company's
explanation of the benefits they have, or have not, paid to a medical provider, along with any
remaining amounts for which the patient is responsible, if any.
CPT code: Current Procedural Terminology codes maintained by the American Medical
Association. These five digit codes describe most medical, surgical, and diagnostic services
and are used for administrative, financial, and analytical purposes such as on fee schedules
and bills. These CPT codes are also known as Level 1 HCPCS codes, with Level 2 HCPCS codes
being for non-provider medical services like ambulances and prosthetic devices. The CPT code is
equivalent to a part number, SKU Stock Keeping Unit, or UPC Universal Product Code.
Inpatient Prospective Payment System (IPPS): A system of payment for the operating costs of
acute care hospital inpatient stays under Medicare Part A (Hospital Insurance). Under IPPS,
each case is categorized into a diagnosis-related group (DRG). Each DRG has a payment weight
assigned to it, based on the average resources used to treat Medicare patients in that DRG.
Diagnosis-Related Group (DRG): a system to classify hospital visits into similar groups. Its
intent is to identify the products that a hospital provides, such as an appendectomy. DRGs are
assigned by group based on diagnosis (ICD code). DRGs may be further grouped into Major
Diagnostic Categories (MDCs). DRGs are used to determine how much Medicare and some insurance
plans pay hospitals and other services like home health.
ICD code: The International Statistical Classification of Diseases and Related Health
Problems provides codes to classify diseases and a wide variety of signs, symptoms, abnormal
findings, complaints, social circumstances and external causes of injury or disease.
Supposedly, every health condition can be assigned to a unique category and given a code.
Billed charges (usual and customary fees): The undiscounted fees a healthcare provider lists
on the bill (list price, or retail). These fees are usually set well above the highest
allowable of all the provider's contracts, sometime as much as 800% or even 1,000%. The purpose
of this overpricing is to force the insurance companies to the negotiating table.
Allowable: The discounted fee for service a healthcare provider has contractually agreed to
accept from an insurance company. It is listed by CPT code on the EOB or in a fee schedule
available from your insurance company, Medicare, or Medicaid. UNDERSTANDING THIS TERM IS THE
KEY TO UNDERSTANDING HEALTH INSURANCE AND TO NEGOTIATING DIRECTLY WITH MEDICAL PROVIDERS.
Global Period: The number of days after a medical procedure when the fee for office visits
is included, contractually, in the allowable for the procedure. It is typically 30, 60, or 90
days.
Elective: For our purposes, care for any medical condition that is not an emergency.
Emergency: A medical condition manifesting itself by acute symptoms of sufficient severity,
which may include severe pain, such that the absence of immediate medical attention could
reasonably be expected to result in serious jeopardy to patient health, and/or serious
impairment to bodily functions, and/or serious dysfunction of any bodily organ or part.
EMTALA: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that
requires anyone coming to an emergency department of a hospital with an emergency condition to
be stabilized and treated, regardless of their insurance status or ability to pay.
Insurance Verification: the process where a healthcare provider contacts the financially
responsible party (usually an insurance company, Medicare, or an employer) and verifies that
coverage is in effect and the information current. This generally includes the amount of the
deductible met by the patient, copayment amounts, and coinsurance terms.
Precertification: The process of obtaining approval from insurance, in advance, for a
proposed treatment or diagnostic test, and is NEVER required for emergency care.
Medicaid: The United States health program for eligible individuals and families with low
incomes. It is a means-tested program that is jointly funded by the states and federal
government, and is managed by the states. Generally is the lowest allowable fee for medical
care.
Medicare: a social insurance program funded by taxes and administered by vendors hired by
the United States government. Medicare provides health insurance coverage to people who are
aged 65 and over, or who meet other special criteria such as a disability. Generally it
reimburses close to the average allowable fee for medical care. It is the easiest fee schedule
to access at: www.CMS.gov
Tricare: Health insurance for military personnel and their dependents.
Workers Compensation: Insurance that provides medical care for employees who are injured in
the course of employment. It is usually has the highest allowable fees for medical care.
... ... ..
To begin to understand how healthcare is priced, we are going to look at
the doctor's
bill given to a patient,
the claim forms the doctor and hospital send to the insurance
carrier, and
ERAs that the insurance carrier then send back to the patient and the
providers.
As we have already learned, all healthcare services have been assigned a code by the AMA, a
five digit CPT code. So, if you trip and fall off your patio, you might get a doctor's bill
like the following table located in your handouts:
On the hospital's bill you might see something like this:
It is important to understand that the amounts shown on both of these bills are
un-discounted Billed Charges (Usual and Customary Fees). They are the highest price the
provider might ever hope to receive for the service, also known as full retail, or MSRP. Don't
panic when you get these bills, because as everyone knows, "Never pay retail."
You may receive other bills from several doctors such as anesthesiologists and radiologists,
as well as laboratory services, therapists, and the ambulance company. The bills all look
similar, and the strategy and tactics I am presenting, today, should work for each of them as
well.
If you have insurance, the providers will send your carrier a claim with essentially the
same data as is on the bill they will provide to you if you are not insured, or if you simply
request a copy.
An important fact is that Federal Law, as a requirement for the medical provider's
participation in Medicare, requires that a medical provider charge every patient the same
amount for a given CPT item. What it does not require, however, is that a medical provider
accept the same payment amount from every patient for a given CPT item. This allows insurance
companies, government payers, and you to negotiate a discounted fee, known as a contracted
allowable, and not be in violation of the law.
The purpose of this overpricing by the medical providers is to force the insurance companies
to the negotiating table. The insurance company is bringing a large volume of patients to the
medical providers, the members in their network, so they are able to negotiate a lower
discounted allowable fee from the medical providers. However, if the insurance carrier is not
able to negotiate a contractual allowable fee schedule, then they will end up paying the higher
billed charges of the out-of-network provider for the members that still end up being treated
by that medical provider in emergencies when precertification is not required.
This creates a tiered-pricing structure for medical services that looks very much like this
table in your handouts:
At this point, if you are paying close attention, then it should start to dawn on you where
I am leading you with this talk, which, after all, is titled: How to negotiate directly with
physicians and hospitals.
Spoiler Alert: You are learning how to negotiate for Medicare rates, at worst, and Medicaid
rates, at best. In our example, a bilateral elbow fracture patient in Texas received surgeon
and hospital bills totaling $179,219. Medicare allows $30,542 and Medicaid $22,600, which means
the government negotiated an 83% or 87.4% discount, respectively. You can too!
Before we move on to providing you with access to these fee schedules, and then a
negotiation strategy, do you have any questions about how healthcare is priced in the USA?
Now, on to where you can find these prices. Well, if you have insurance, then after you
receive medical care and the healthcare providers send their claims to the insurance carrier,
you should receive from the payer an Explanation of Benefits (EOB), or you probably can go
online and view an Electronic Remittance Advice (ERA). For every CPT code that the providers
billed , you will see both a billed charge and allowable.
Quick show of hands: how many of you have received a medical bill, or an EOB, and threw it
away because you could not understand it? That is intentional! They want you to be confused.
However, after today, I doubt that you will ever do that again.
What if we do not have insurance, or we want to know the allowable, because we think this is
important information to know so that we can negotiate before receiving healthcare? Think
having a baby or elective surgery. Do not worry! The federal government provides us with the
Medicare rates online, and I believe that each state provides its Medicaid fee schedules
online.
You would soon discover, however, that it is much easier to determine the allowable for a
physician service than a hospital service, for which you will likely need to look up the DRGs
for the ICD codes and then try to cross-reference them with the IPPS Fee Schedule, at a
minimum, or you may even need to look up and calculate conversion factors. It is not easy,
again, intentionally so!
Regardless, we would first need the CPT codes for the services you are seeking from the
physician, and probably the ICD codes, too, in order to price hospital services. You could try
to guess at the diagnosis and the services you think the doctor is going to provide to you, and
then try to use a search engine to determine the ICD codes and CPT codes, or buy a coding
book.
"I know I need a hip replacement. My trainer at the gym told me so. I'll just Google,
hip replacement ICD and CPT code."
Good luck with that! The odds of you guessing the correct diagnosis and appropriate
procedures (without going to medical school) are incredibly slim, especially with the new
ICD-10 diagnosis codes. Also, chances are good that your athletic trainer doesn't know what the
hell she is talking about when it come to medicine, and in reality, you probably just need a
new athletic trainer, and not a new hip.
Is your head spinning, yet? Good! Now, stop it, because you will see that we don't need to
do any of that! It's all just a red herring designed to keep us confused and the health
insurers in business and profitable. Sounds a lot like our banking system, no?
Fortunately, as you will now learn, there is a much more simple and better way to be 100%
certain of your diagnosis, diagnosis code, procedure, procedure code, and even the medications
the physician will offer you, at least for elective conditions. Here it is. If it isn't an emergency, then make a doctor's appointment!
You may be thinking, "Isn't that putting the cart before the horse? Don't we want to know
the costs in order to negotiate the fees before the services are provided?" The surprising answer is, no! Why? Well, because we only need to negotiate the fee schedule, specifically, Medicare or
Medicaid, and not the exact fee. This is very important. Think back to the tiered-pricing
structure.
Eventually, we may want to know the actual (or sometimes estimated) allowable amounts in
order to budget for elective procedures, but this occurs after, or at the time of the
physician's office visit, when they can provide us with the ICD codes, CPT codes, and usually
the allowable amount, too! Later, we may choose to audit the allowable amount they give us, to
make sure it is correct, and we were not over charged, but this is seldom done, as most people
still trust their doctor, and the discounts you will be receiving are so HUGE you may feel a
little guilty. Also, I will tell you, the auditing process is very tedious, not to mention the
appeal process.
Therefore, we are now going to start talking about a negotiating strategy before we even
attempt to access any pricing data. Again, we first need to know the diagnoses and proposed
treatments. So, the solution is to start with a simple negotiation with the physician's office,
probably just for the cost for the initial office visit, at the very least, and maybe some
expected diagnostic tests. This is best done over the telephone, is easier and more successful
than you might think, and is analogous to finding a mechanic to, "just take a look," at your
car and tell you what is wrong with it, and then getting an estimate to repair it. Just like we
expect to pay a little bit for the mechanic to diagnose our car, we should expect to pay a
little bit for the doctor to diagnose us. The funny thing is that my mechanic and Medicare both
charge or allow about $100 for a diagnosis. This is not so funny if you are the surgeon that
spent 13 more years in school than the auto mechanic with a high school diploma.
Here we go, step by step:
1) I usually prefer to skip the added expense of going to a GP or family practice
intermediary just to get a referral to a specialist that can actually help, especially when I
can determine what medical specialty is likely to be most helpful for by medical condition by
visiting the website of the American Board of Medical Specialties. (Is your ignition system
acting up, your suspension riding a little rough, need new tires, brakes squeaking,
transmission grinding?)
2) Use the links on abms.org to visit the appropriate specialty board's website, and then
use their "find a physician" with the sub-specialty likely to be most helpful for the
condition
3) Start calling the sub-specialty physician offices listed, tell them you are a prospective
new patient, and ask to speak to the Business Office Manager. Ask him or her the following
questions:
a) "Do you accept Medicare and/or Medicaid insurance?" If yes, then...
b) "Super! Do you accept cash payment at the time of service?" If yes, then...
c) "Great! Then, of course, you will accept as payment in full, the Medicaid allowable, but
paid in cash by me to you, directly, at the time of service? Correct?" If yes, then (e). If no
then (d).
d) "I guess I understand. Well, then surely you will at least accept as payment the
Medicare allowable, paid in cash by me to you, directly, at the time of service? If yes,
then (e). If no then conclude the call, because you cannot fix stupid.
e) "Thank you! Can you please tell me what the estimated amount is for an office visit,
using this fee schedule, so I can know how much money to bring, and please make a note on my
account that we have negotiated a Single Case Agreement for me to pay these rates to you, in
cash, at the time of service?
f) Tell him or her your specific reason for the visit (I am leaking red fluid on the floor
of my garage) and that you want to be fully prepared for the visit. Ask what diagnostic tests,
if any, are usually required for this type of problem, lab, X-ray, CT, MRI, ultrasound, etc.,
and which ones would probably need to be done outside the physician's clinic?
g) Make sure to get the BOM's name and contact information, and the appointment time and
date.
After your office visit, if it turns out that you need a procedure such as day surgery at an
Ambulatory Surgery Center (ASC), an inpatient admission at a hospital, a diagnostic test like
an MRI or CT, or a series of treatments such as physical therapy, then you simply repeat the
above negotiation, starting with the facility your physician recommends, and in the case of a
hospital or ASC, always where he or she has privileges. ASC's allowable rates are always much
lower than a hospital, so act accordingly. When telling the BOM that you are a prospective new
patient, make sure to give the name of your physician. Instead of just making a note of any
negotiated agreement in your account, the BOM and you should execute a written Single Case
Agreement. It is usually a one-page agreement that looks something like this sample found in
your handouts:
It should be obvious to you why, when possible, these negotiations should occur before
treatment, which is more often than you might imagine. In general, elective conditions are
negotiated in advance in this manner. Next, we are going to look at emergency conditions, which
are more than likely negotiated after examination and treatment.
Before we do, are there any questions?
Ok, so I experience some kind of true medical emergency, where my life or limb is in
jeopardy, like a heart attack. mrs_horseman puts me in an ambulance that rushes me to the
Emergency Room at the hospital, and they run all kinds of tests, and give me some very
expensive medications. Fortunately for me, a long enough timeline has not yet passed, my
survival rate has not dropped to zero, and I don't even get to go to the cath lab or have
emergency heart surgery. However, we do get several large medical bills from the hospital, ER
doctor, ambulance, laboratory, and cardiologist. I either have no insurance, am self-insured,
or I have a catastrophic insurance plan with a very high deductible that I am not likely to
meet with this event, or this year. What do I do?
When I receive each bill, I immediately call each provider and get the name and address of
the BOM. I then draft a Single Case Agreement Offer and Acceptance, and I offer to pay the
estimated Medicaid allowable clearly labeled as such (by using the tiered-pricing structure I
covered earlier) and expiring 10 days after it is received. I may also include some horseshit
narrative about how I just received a small windfall, and was advised by my attorney to settle
my hospital bill before I piss it away on fast women and slow horses, or worse, squander it. I
send this to the BOM, Certified Mail-Return Receipt Requested , with my attorney copied on the
bottom of the offer. The BOM may argue the accuracy of my Medicaid estimate, and make a counter
offer with a more accurate Medicaid allowable, but the odds are very, very, high that he or she
either agrees to the Medicaid allowable, or counters with something like a Medicare allowable.
Either way, at this point I have successfully negotiated somewhere around an 83% - 87% discount
on average, less for doctors, more for hospitals.
It is important to lock this agreement in, quickly, before my account is sold to a
third-party collection agency, which is nowhere near as likely to accept such a deep discount,
and far better than a healthcare provider at actually getting blood from a turnip. Medical
providers are now turning their accounts over to collections as soon as 90 days from the date
of service, which can mean that you are still being treated for this condition when this
happens! Do not let this happen to you! Open the bills! Mail the offer! Maybe they say no, but
that is not likely. On the other hand, the collections agencies are working very hard to get
you on a payment plan for Billed Charges, with interest, for the rest of your life!
Does this sound unlikely? Too good to be true? Then consider this: Medical providers are
highly incentivized to give the patients they treated huge discounts. Why? Because they know
that collecting money from patients foments malpractice litigation. They would rather have you
pay them pennies, than have you sue them for millions.
There it is. I said it. Think about that for a moment.
Now, considering the minimal risk of negotiating, and the large potential reward, do you now
have the confidence to successfully negotiate directly with physicians and hospitals?
Before I spend just a few more minutes talking about pharmacies, and then finally some
self-insurance goals, are there any questions or comments?
I recently had breakfast with a pharmacist friend of mine that has worked as a manager for
Walgreens for more than a decade. mrs_horseman is probably smiling when she hears that I have a
pharmacist friend, because she knows how I feel about most of the people in that industry.
Nonetheless, I told him about this presentation I am making, and asked if he had any advice for
negotiating directly with the pharmacies for medications. It turns out, he does, and I would
have never guessed the tactic he described.
Are you ready? Coupons and free discount cards. He explained that if one simply goes online and searches for Walgreens coupons, it is
usually possible to save between 5% and 60%. He specifically recommends Good Neighbor Pharmacy
Prescription Savings Club.
He says that when you purchase medications, then you have 5 days to return to the same
location Walgreens and bring a coupon for reimbursement of any savings. He says that if you are paying cash, then you must be sure to request a generic, if
available. For long term meds, he explains that the drug manufacturer's web sites will often offer a
free co-pay assistance card. If you have insurance, then you can present the free card from the
manufacturer to the Walgreens pharmacy, and it will cover your co-pays. In closing, I want to talk just a bit about insurance and one of the situations where we
would want to be able to negotiate directly with physicians, hospitals, and pharmacies.
As we have discussed, today, one of the primary benefits of having health insurance is to
take advantage of the discounts negotiated by the insurance company or government. However, we
just learned that providers are usually willing to accept similar discounted rates from cash
pay patients.
The other big benefit of health insurance is to share with other people the risk of having
to pay large bills that are the result of serious and unexpected injuries or illnesses. This is
the traditional role of insurance. However, the costs and benefits of sharing risk are directly
related to the health and healthcare consumption habits of all the members of the risk pool. As
the post-vasectomy head of a healthy household, do I really want to be swimming in the
Obamacare risk pool with millions of morbidly obese, perpetually pregnant, HIV infected drug
abusers? No. It is too expensive!
What to do? Well, what do many smart employers in Texas do to save money with Worker's Compensation
Insurance? They self-insure! They have money put away in case of an emergency. If they have an employee
that is injured, then they negotiate directly with the healthcare providers, and pay deep
discounts well below the statutory Worker's Compensation allowable, which we learned earlier is
usually the highest allowable. They pay themselves a premium each month, which is effectively a
forced savings plan. Sometimes, these companies may also purchase a relatively inexpensive
health insurance plan called catastrophic, just in case a really big and expensive event
occurs, like the whole oil refinery blows up and puts a few hundred employees in the hospital.
However, if nothing happens, and the employees don't have any accidents, the company gets to
keep most of the money, instead of giving it all to the insurance companies!
Hmmm. I wonder. Could I do that for my health insurance? Yes, and in fact mrs_horseman and I
do exactly this. We have a high-deductible catastrophic health insurance plan and a $600
savings line item in our budget that we pay ourselves every month. We bet on ourselves to be
healthy, unlike an HSA, where you bet on yourself to be unhealthy. This is true, and why we
simply refuse to take the pre-tax bait of an HSA.
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.
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
This is s very interesting insight into healcare in the USA. The cost is shocking.
I live in the UK and the healthcare system is paid for from taxation.
When it was established over 70 years ago it's
The health service would be available to all and financed entirely from taxation, which meant
that people paid into it according to their means.
It was the best thing in my view that government has ever done.
Good healthcare should be available to all and not dependent on peoples ability to pay.
However there always a private healthcare system that ran alongside it
And over the years it had been unpicked as successive governments have tried to privatise
it. Claiming they will save the taxpayer money
– opticians and dentistry have become part private after 18 if you are employed.
Which many people do not mind.
-Elderly care was also privatised as it's the most expensive
-care for the disabled also is a issue for local councils
-Mental health became care in the community – society's problem!
Privatisation has meant profits for businesses, poor services to vulnerable groups.
And yet still more and more taxation is needed for the NHS!
The issue of more money was even part of the Brexit debate as it was stated that leaving the
EU would mean more money for the NHS which people are proud of.
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.
In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the
Council of Europe a report on allegations of inhuman treatment of people and illicit
trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister
Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a
"mafia-like" network that killed captives in order to sell their organs on the black market
was yesterday endorsed by a Council of Europe committee.
Bold text emphasis added.
Nothing came of the charges that I am aware of and it is business as usual with Kosovo and
Albania.
Per Wikipedia:
The Washington Times reported that the KLA was financing its activities by trafficking
the illegal drugs of heroin and cocaine into western Europe.[16]
A report to the Council of Europe, written by Dick Marty, issued on 15 December
2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of
trafficking organs taken from Serbian prisoners.
On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became
Prime Minister of the newly independent state.
So, there you have it – the war criminal, drug runner, murderer and organ
thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a
wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist
and genocidally inclined West.
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.
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.
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.
This is s very interesting insight into healcare in the USA. The cost is shocking.
I live in the UK and the healthcare system is paid for from taxation.
When it was established over 70 years ago it's
The health service would be available to all and financed entirely from taxation, which meant
that people paid into it according to their means.
It was the best thing in my view that government has ever done.
Good healthcare should be available to all and not dependent on peoples ability to pay.
However there always a private healthcare system that ran alongside it
And over the years it had been unpicked as successive governments have tried to privatise
it. Claiming they will save the taxpayer money
– opticians and dentistry have become part private after 18 if you are employed.
Which many people do not mind.
-Elderly care was also privatised as it's the most expensive
-care for the disabled also is a issue for local councils
-Mental health became care in the community – society's problem!
Privatisation has meant profits for businesses, poor services to vulnerable groups.
And yet still more and more taxation is needed for the NHS!
The issue of more money was even part of the Brexit debate as it was stated that leaving the
EU would mean more money for the NHS which people are proud of.
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.
In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the
Council of Europe a report on allegations of inhuman treatment of people and illicit
trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister
Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a
"mafia-like" network that killed captives in order to sell their organs on the black market
was yesterday endorsed by a Council of Europe committee.
Bold text emphasis added.
Nothing came of the charges that I am aware of and it is business as usual with Kosovo and
Albania.
Per Wikipedia:
The Washington Times reported that the KLA was financing its activities by trafficking
the illegal drugs of heroin and cocaine into western Europe.[16]
A report to the Council of Europe, written by Dick Marty, issued on 15 December
2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of
trafficking organs taken from Serbian prisoners.
On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became
Prime Minister of the newly independent state.
So, there you have it – the war criminal, drug runner, murderer and organ
thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a
wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist
and genocidally inclined West.
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
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.
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.
"... "No, I mean I'm sorry that you've inherited such a miserable, collapsing Old Country. A place where rich Bankers own everything, where you've got to be grateful for a part-time job with no benefits and no retirement plan, where the most health insurance you can afford is being careful and hoping you don't get sick ..."
"... "Until fairly recently, every family had a cornucopia of favorite home remedies–plants and household items that could be prepared to treat minor medical emergencies, or to prevent a common ailment becoming something much more serious. Most households had someone with a little understanding of home cures, and when knowledge fell short, or more serious illness took hold, the family physician or village healer would be called in for a consultation, and a treatment would be agreed upon. In those days we took personal responsibility for our health–we took steps to prevent illness and were more aware of our bodies and of changes in them. And when illness struck, we frequently had the personal means to remedy it. More often than not, the treatment could be found in the garden or the larder. In the middle of the twentieth century we began to change our outlook. The advent of modern medicine, together with its many miracles, also led to a much greater dependency on our physicians and to an increasingly stretched healthcare system. The growth of the pharmaceutical industry has meant that there are indeed "cures" for most symptoms, and we have become accustomed to putting our health in the hands of someone else, and to purchasing products that make us feel good. Somewhere along the line we began to believe that technology was in some way superior to what was natural, and so we willingly gave up control of even minor health problems." ..."
"... The Complete Family Guide to Natural Home Remedies: Safe and Effective Treatments for Common Ailments ..."
"... "The vast wealth of the financial oligarchy, expressed in their ownership of massive corporations, must be seized and expropriated, while the complex technologies, supply chains, and advanced transportation systems must be integrated in an organized, planned manner to harness the anarchic force of the world economy and eliminate material scarcity. ..."
"... Interesting article. Looks like the rot in the US is terminal. ..."
"... This is s very interesting insight into healcare in the USA. The cost is shocking. I live in the UK and the healthcare system is paid for from taxation. When it was established over 70 years ago it's. The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means. It was the best thing in my view that government has ever done. Good healthcare should be available to all and not dependent on peoples ability to pay. ..."
"... Privatisation has meant profits for businesses, poor services to vulnerable groups. ..."
"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 privatised healthcare insurance model.
Funnily enough I'm currently considering changing my private health insurer. I'm with Medibank Private at present but considering
maybe going with a smaller non-profit health fund like Australian Unity or Phoenix Health Fund.
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 healcare in the USA. The cost is shocking. I live in the UK and the healthcare system
is paid for from taxation. When it was established over 70 years ago it's. The health service would be available to all and financed
entirely from taxation, which meant that people paid into it according to their means. It was the best thing in my view that government
has ever done. Good healthcare should be available to all and not dependent on peoples ability to pay.
However there always a private healthcare system that ran alongside it
And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer
money
– opticians and dentistry have become part private after 18 if you are employed.
Which many people do not mind.
-Elderly care was also privatised as it's the most expensive
-care for the disabled also is a issue for local councils
-Mental health became care in the community – society's problem!
Privatisation has meant profits for businesses, poor services to vulnerable groups.
And yet still more and more taxation is needed for the NHS!
The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the
NHS which people are proud of.
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.
In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations
of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister
Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives
in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.
Bold text emphasis added.
Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.
Per Wikipedia:
The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine
into western Europe.[16]
A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader
of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.
On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.
So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created
and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist
and genocidally inclined West.
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
"... So should Mr Azar be confirmed as Secretary of DHHS, the fox guarding the hen house appears to be a reasonable analogy. ..."
"... In this post, I'd like to add two additional factors to our consideration of Azar. The first: Democrat credentialism makes it hard for them to oppose Azar. The second: The real ..."
Clearly, Alex Azar, nominated yesterday for the position of Secretary of Health and Human Services by the Trump Administration,
exemplifies the case of the "revolving door," through which
Flexians slither on their way to (or from) positions of public trust. Roy Poses (
cross-posted at NC ) wrote, when Azar was only Acting Secretary:
Last week we noted that Mr Trump famously promised to “drain the swamp” in Washington. Last week, despite his previous
pledges to not appoint lobbyists to powerful positions, he appointed a lobbyist to be acting DHHS Secretary. This week he is apparently
strongly considering Mr Alex Azar, a pharmaceutical executive to be permanent DHHS Secretary, even though the FDA, part of DHHS,
has direct regulatory authority over the pharmaceutical industry, and many other DHHS policies strongly affect the pharmaceutical
industry. (By the way, Mr Azar was also in charge of one lobbying effort.)
So should Mr Azar be confirmed as Secretary of DHHS, the fox guarding the hen house appears to be a reasonable analogy.
Moreover, several serious legal cases involving bad behavior by his company, and multiple other instances of apparently unethical
behavior occurred on Mr Azar’s watch at Eli Lilly. So the fox might be not the most reputable member of the species.
The literature makes clear that the revolving door process is a source of valuable political connections for private firms.
But it generates corruption risks and has strong distortionary effects on the economy , especially when this power is
concentrated within a few firms.
The ongoing parade of people transiting the revolving door from industry to the Trump administration once again suggests how
the revolving door may enable certain of those with private vested interests to have excess influence, way beyond that of ordinary
citizens, on how the government works, and that the country is still increasingly being run by a cozy group of insiders with ties
to both government and industry. This has been termed crony capitalism.
In this post, I'd like to add two additional factors to our consideration of Azar.
The first: Democrat credentialism makes it hard for them to oppose Azar. The second: The real damage Azar could do is on
the regulatory side.[1]
"I am glad to hear that you have worked hard, and brought fair-minded legal analysis to the department," Democratic
Sen. Max Baucus said at Azar's last confirmation hearing.
And:
Andy Slavitt, who ran the Affordable Care Act and the Centers for Medicare & Medicaid Services during the Obama administration,
said he has reason to hope Azar would be a good secretary.
"He is familiar with the high quality of the HHS staff, has real-world experience enough to be pragmatic, and will hopefully
avoid repeating the mistakes of his predecessor," Slavitt said.
So, if Democrats are saying Azar is "fair-minded" and "pragmatic" -- and heaven forfend that the word "corruption"[2] even be
mentioned -- how do they oppose him, even he's viscerally opposed to everything Democrats supposedly stand for? (Democrats do this
with judicial nominations, too.) Azar may be a fox, alright, but the chickens he's supposedly guarding are all clucking about how
impeccable his qualifications are!
Second, let's briefly look at Azar's bio. Let me excerpt salient detail from
USA Today :
1. Azar clerked for Supreme Court Justice Antonin Scalia .
2. Azar went to work for his mentor, Ken Starr , who was heading the independent counsel investigation into Bill
and Hillary Clinton's Whitewater land deal.
3. Azar had a significant role in another major political controversy when the outcome of the 2000 presidential election
hinged on a recount in Florida . Azar was on the Bush team of lawyers whose side ultimately prevailed [3]
For any Democrat with a memory, that bio provokes one of those "You shall know them by the trail of the dead" moments. And then
there's this:
When Leavitt replaced Thompson in 2005 and Azar became his deputy, Leavitt delegated a lot of the rule-making process to Azar.
So, a liberal Democrat might classify Azar as a smooth-talking reactionary thug with a terrible record and the most vile mentors
imaginable, and on top of it all, he's an effective bureaucratic fixer. What could the Trump Administration possibly see in such
a person? Former (Republican) HHS Secretary Mike Leavitt explains:
"Understanding the administrative rule process in the circumstance we're in today could be extraordinarily important because
a lot of the change in the health care system, given the fact that they've not succeeded legislatively, could come administratively."
1) Administratively, send ObamaCare into a death spiral by sabotaging it
2) Legislatively, gut Medicaid as part of the "tax refom" package in Congress
3) Through executive order, eliminate "essential health benefits" through "association health plans"
As a sidebar, it's interesting to see that although this do-list is strategically and ideologically coherent -- basically,
your ability to access health care will be directly dependent on your ability to pay -- it's institutionally incoherent, a bizarre
contraption screwed together out of legislation, regulations, and an Executive order. Of course, this incoherence mirrors to Rube
Goldberg structure of ObamaCare itself, itself a bizarre contraption, especially when compared to the simple, rugged, and proven
single payer system. ( Everything Obama did with regulations and executive orders, Trump can undo, with new regulations and
new executive orders . We might compare ObamaCare to a child born with no immune system, that could only have survived within
the liberal bubble within which it was created; in the real world, it's not surprising that it's succumbing to opportunistic infections.[2])
On #1, The administration has, despite its best efforts, not achieved a controlled flight into terrain with ObamaCare; enrollment
is up. On #2, the administration and its Congressional allies are still dickering with tax reform. And on #3 . That looks looks like
a job for Alex Azar, since both essential health benefits and association health plans are significantly affected by regulation.
So, yes, there are worse scenarios than the revolving door; it's what you leave behind you as the door revolves that matters.
It would be lovely if there were a good old-fashioned confirmation battle over Azar, but, as I've pointed out, the Democrats have
tied their own hands. Ideally, the Democrats would junk the Rube Goldberg device that is ObamaCare, rendering all of Azar's regulatory
expertise null and void, but that doesn't seem likely, given that they seem to be doing everything possible to avoid serious discussion
of policy in 2018 and 2020.
NOTES
[1] I'm leaving aside what will no doubt be the 2018 or even 2020 issue of drug prices, since for me that's subsumed under the
issue of single payer. If we look only at Azar's history in business, real price decreases seem unlikely.
Business Insider :
Over the 10-year period when Azar was at Lilly, the price of insulin notched a three-fold increase. It wasn't just Lilly's
insulin product, called Humalog. The price of a rival made by Novo Nordisk has also climbed, with the two rising in such lockstep
that you can barely see both trend lines below.
The gains came despite the fact that the insulin, which as a medication has an almost-century-long history, hasn't really changed
since it was first approved.
Nice business to be in, eh? Here's that chart:
It's almost like Lilly (Azar's firm) and Novo Nordisk are working together, isn't it?
[2] Anyhow,
as of the 2016 Clinton campaign , the Democrat standard -- not that of Poses,
nor
mine -- is that if there's no quid pro quo, there's no corruption.
[3] And, curiously, "[HHS head Tommy] Thompson said HHS was in the eye of the storm after the 2001 terrorist attacks, and Azar
had an important role in responding to the resulting public health challenges, as well as the subsequent anthrax attacks "
Oh please, stop quoting Andy Slavitt, the United Healthcare Ingenix algo man. That guy is the biggest crook that made his money
early on with RX discounts with his company that he and Senator Warren's daughter, Amelia sold to United Healthcare. He's out
there trying to do his own reputation restore routine. Go back to 2009 and read about the short paying of MDs by Ingenix, which
is now Optum Insights, he was the CEO and remember it was just around 3 years ago or so he sat there quarterly with United CEO
Hemsley at those quarterly meetings. Look him up, wants 40k to speak and he puts the perception out there he does this for free,
not so.
I think you're missing the context. Lambert is quoting him by way of showing that the sleazy establishment types are just fine
with him. Thanks for the extra background on that particular swamp-dweller, though.
Alex Azar is a Dartmouth grad (Gov't & Economics '88) just like Jeff Immelt (Applied Math & Economics '78). So much damage
to society from such a small department!
Since 2014, Ross has been the vice-chairman of the board of Bank of Cyprus PCL, the largest bank in Cyprus.
He served under U.S. President Bill Clinton on the board of the U.S.-Russia Investment Fund. Later, under New York City Mayor
Rudy Giuliani, Ross served as the Mayor's privatization advisor.
I don't believe that the President's "swamp" ever consisted of crooked officials, lobbyists, and cronies I think it has always
consisted of those regulators who tried sincerely to defend public interests.
It was in the sticky work of those good bureaucrats
that the projects of capitalists and speculators bogged down. It is against their efforts that the pickup-driving cohort of Trump_vs_deep_state
(with their Gadsden flag decals) relentlessly rails.
Trump has made much progress in draining the regulatory swamp (if indeed
that is the right way to identify it), and no doubt will make considerably more as time wears on, leaving America high and dry.
The kind of prevaricator Trump is may simply be the one who fails to define his terms.
I think we've moved past the revolving door. We hear members of the United States Senate publicly voice their concerns about
what will happen if they fail to do their employers' bidding (and I'm not talking about "the public" here). In the bureaucracy,
political appointees keep accruing more and more power even as they make it clearer and clearer that they work for "the donors"
and not the people. Nowhere is this more true than the locus through which passes most of the money: the Pentagon. The fact that
these beribboned heroes are, in fact, setting war policy on their own makes the knowledge that they serve Raytheon and Exxon rather
than Americans very, very troubling.
I suspect Azar's perception is that he is just moving from one post to another within the same company.
Big pharma indeed has so much defense from the supposed left. It combines their faith in technological progress, elite institutions,
and tugs on the heart strings with technology that can save people from a fate of ill health or premature death. Of course, the
aspect of the laws being written to line the pockets of corrupt executives is glossed over. While drug prices and medical costs
spiral ever higher, our overall longevity and national health in the US declines. That speaks volumes about what Democrats really
care about.
.