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Leveraging Competition in Healthcare to Bring About Price Transparency

July 23, 2014 in health care costs, health care quality, Hospital Bills, Member Stories, Quality of care

by Randy Cox

Executives and administrators in the healthcare industry will tell you that competition in their business is not new. It just looks different. There tend to be few if any TV or internet ads touting 50%-off discounts, or facilities matching the rates of the clinic down the street. But 21st century American healthcare has plenty of positioning on price, expanding of services provided, healthy marketing departments, and reports analyzing trends in patient volume compared to other facilities in the region.

Invisible Competition

No, competition is there. But other than the plastering of quality awards and ER wait times across websites and along freeways, much of the competition in healthcare is not consumer-facing.

You might ask, “Isn’t invisible competition the same as no competition?”

The quick answer is yes. Providers don't typically act like competing businesses on the outside. Their expenses are often unreasonably high, and they don't seem to care if a patient has a 2-hour wait or gets milked for thousands more than necessary. Nor is there any way to properly evaluate the merits of one surgeon or clinic compared to another, causing patients to be more easily taken advantage of, both in their pocketbooks and in poor quality of care.

But the medical industry is not a true monopoly (yet), and so its competitive forces can be leveraged to benefit consumers.

Price Comparisons Can Backfire

How exactly is that to be done? A common but naive view held by many in my industry is that simple, direct price comparisons will bring about the type of competition that will address most of the problems in healthcare affordability. It won’t, and here’s why.

The imaging centers and surgery centers we talk to have experimented with listing some of their prices on a few of our competitors’ sites, sites that use sort-by-price lists or some notion of a “fair price”. At first it seems natural that mimicking an electronics or hardware retailer is a step forward for consumers wanting to “shop” for medical care.

The effect of this type of comparison however is the cheapening of care. Providers are obviously opposed to this. Ironically, so are patients. Though it would seem that quick and easy price comparisons could provide less expensive care, people are strongly against the treatment of their health being trivialized and commoditized, even with routine procedures that have little to no risk, and yes, even if it saves them money.

When it comes to a person’s health, anything that smells like trivialization will be met with distrust. Price transparency accompanied by hype, advertising, and plays at “online shopping” are largely ineffective, and may actually drive people away, rather than attract them.

Medical institutions continue to resist being represented on sites that cheapen care in any way, not primarily because it affects their margins, but because it discredits the quality of their establishment. And, interestingly, we’ve received a number of reports that patient customers who are referred by “sort-by-price” sites are typically described as trashy, unreliable, unserious.

Where Price Transparency Can Add Value

Pricing Healthcare takes a different approach. We certainly believe in publishing prices (hence our name), and we believe that facilities’ prices should be compared. But we do not line prices up in a lowest-at-top sorted list like so many do. We take pains to represent facilities and their services in the best possible way.

Because of competitiveness among facilities, they are willing to promote themselves on our site, and to list prices for many of their procedures. We thus use competition to bring about price transparency, rather than the other way around.

We aren’t opposed to searching by location, by facility type, or by procedure, but we believe that when showing results, there are a number of problems with oversimplifying comparisons on price.

First, in some cases there may be dozens of reasons why services with the same name (and the same medical code) may not in actuality be the same, and may in fact require additional outlays that are difficult to enumerate. This is true even for treatments that have become fairly standardized in terms of what procedures and services are involved.

Knowing beforehand what a procedure will cost is of immense value to individuals and employers, and it of course needs to be visible. An upfront price puts limits on how much a person can be taken for, and increases options for those on a budget. But what is and isn’t included for that price needs to be accurately listed next to the procedure. The proper design of pricing data visibility can thus 1) make price a great resource in the hands of someone trained to use it properly, while 2) preventing the untrained eye from putting too much value on the sticker price alone.

Second, it can be dangerous to detach medical treatment from all other considerations besides affordability. Perverse utilization of care (either too much or too little) can be caused as easily by price transparency as by per-procedure provider reimbursement.

It takes a fair amount of reading and research for a patient to become educated sufficiently to use provider comparison tools wisely. And even with all the information available online today, there is still a need for consultation with a physician.

Third, quality matters. There can be considerable differences even between highly skilled, conscientious, experienced surgeons. Equipment, nursing staff, attention to detail in a myriad of aspects at the facility, can also make a big difference in how well a procedure is performed and a person’s quality of life afterward. How are these to be valued when it comes to one’s health? What kind of price can be given to care quality, not to mention the ability to avoid unnecessary post-treatment expenses? These types of things should be considered carefully, much more than the sticker price.

Physicians’ principled adherence to giving the best care with no consideration of cost has merit. Not that prices shouldn’t be known ahead of time, but that having too much focus on something as quantifiable as cost detracts from things of much greater importance and enormous variability.

A Bright Future

As American healthcare institutions are given the chance to present themselves and their services in the best possible light on price transparency sites, we believe there will be less trepidation about the publishing of rates.

One of the exciting things we’re seeing at Pricing Healthcare is a growing number of hospitals, surgery centers, imaging centers, and in fact healthcare facilities of all types across the country, wanting to publish pricing information. By doing so, they brand themselves as patient-friendly in terms of price and quality transparency. In turn, patients worry less about sticker shock and become more comfortable obtaining proper care. Ridiculously priced outfits will certainly lose volume, but we believe patient volume overall in the U.S. will increase, with more individuals and families able to afford to pay for the care they need.

 
 

Randy Cox is the Founder and CEO of Pricing Healthcare, an open, independent, direct-pay marketplace where healthcare facilities present services and prices online. Facility pages, including pricing information, are free for anyone in the world to access.

To see how Pricing Healthcare presents facilities and their prices, go to a page of Utah dentists accepting new patients or a list of California facilities publishing price lists.

Accepting bids – who’ll do the cheapest colonoscopy?

April 19, 2014 in health care costs

If you can’t compare health care prices in advance of paying for an MRI or some other test, maybe you should ask for bids.

I came across Medibid last year when I needed a colonoscopy, and decided to give it a try. I had to answer some questions about my health, explain what I was looking for, say when I wanted to have the test (within 1-2 months) and how far I was willing to travel (not outside my state).

Over the course of a year (plus), I got back three bids, all were a long way from Boston.

The folks in McMinnville, Oregon pitched their location (3,238 miles from my home) as a plus.

“Sorry I’m not in your state, but at $500 you could take a trip to Oregon wine country and get your colonoscopy and probably still save money. We would be happy to help if we can be of service to you.”

The bidder in Baltimore, at $1500, was clear and succinct.

“Includes anesthesia, facility fee, and physician fee.”

And the facility in Nashville, while the most expensive, made a good case.

“The pricing includes physician, facility, anesthesia and pathology fees. We are a Joint Commission and Medicare certified facility with an emphasis on providing high quality care to our patients. We are located in central Nashville on the St. Thomas Midtown campus (previously Baptist Hospital). It would be our pleasure to care for you/your family member in a warm, friendly atmosphere.”

But I’m not up for becoming a medical tourist for something as routine as a colonoscopy. Would anyone travel for this test? Should I be surprised that no one in my home town, the medical mecca, put in a bid?

For my colonoscopy, I chose quality over cost

December 21, 2013 in health care costs, Quality of care

I finally got that colonoscopy that I started shopping for almost a year ago. I’m really good at proscrastinating when fasting and voluntary diarrhea is involved.

I had a good experience in the end. I probably spent more than I should have, but…

1) I wanted to go someplace close to home. You’re not supposed to drive after this procedure and I didn’t want to drag a designated driver too far out of the way.

2) So I compared a doctor recommended by my PCP, who is at Beth Israel Deaconess Medical Center with a team of docs at Faulkner Hospital. Yes, the Faulkner is owned by Partners, but rates I’ve seen for the Faulkner are more in the community hospital range. I’m pretty sure BIDMC would be more expensive, but I don’t have the exact charges

The problem was, I couldn’t get any quality info from the Faulkner. I called four times and spoke to someone twice. They said they couldn’t answer my questions about: polyp detection rates, complication rates, withdrawl time and how often the doctor reaches the beginning of the colon (the cecum).

So I went to BIDMC, which had offered quality info earlier this year and where I had a frank conversation with my doctor (although not until just before the procedure).

I came away with an interesting, gross to some of you, set of slides of my doc’s work. Dr. Chuttani always, apparently, gets to the cecum and takes a picture. You can click to the next page to see mine (I don’t want to force it on you). Did you doctor show you results of the procedure?
Read the rest of this entry →

Out-of-network Medical Costs Affect Everyone

October 5, 2013 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt, Member Stories

According to a survey this year by America’s Health Insurance Plans, 12% of all medical claims received by insurance carriers were out-of-network in 2011. That translates into huge out-of-pocket costs for American consumers, and sometimes uncapped costs. Out-of-network charges can be nearly 100 times (100 times!!) the rate that Medicare allows (typically you will be no more than 2 or 3 times the Medicare rate with insurance).

Don’t think any of that applies to you because you have good insurance? Think again.

Excessive out-of-network fees are typically not covered by your insurance carrier to the full extent, and are often not applied to your deductible. This means you could not only be on the hook for large fees for some services, but those amounts could be uncapped, the equivalent of being uninsured, even while having a very good insurance plan. New Obamacare plans don’t solve this, as they are not required to cap out-of-network charges. And almost all carriers are shrinking their networks further for new exchange plans. How did this slip through the Affordable Care Act?

Health insurance carriers negotiate rates with a number of physicians and hospitals to get lower rates with its plan holders. These providers and facilities form a health plan’s “network”. When patients go to providers “in-network”, the insurance carrier pays significantly less. It is reasonable then that a plan might want to discourage you from going with a provider not in that network. It is also reasonable for a carrier to remove all but the lowest-cost providers from its network over time. The ACA also wants to keep people away from the highest-priced providers, in an effort to reduce healthcare costs overall.

The trouble is, sometimes going out-of-network is the best or only way to ensure critical healthcare. Specialists and key facilities in various parts of the country may not have a relationship with your carrier. There are also many cases when you end up receiving services from an out-of-network provider because of the nature of integrated care by professionals from a number of different companies. For example, even though you know your physician and hospital are in-network, you may not think to ask if the anesthesiologist is.

The 12% figure will surely rise under the ACA. More individuals will find that their preferred doctor is no longer in their plan’s network. Employers are beginning to cut spouses and children from plans, which will add to the confusion about which doctor you should be going to for which family member.

Some of the largest carriers like UnitedHealthcare and Aetna will only cover out-of-network fees up to what they consider a “fair” amount, and then you have to pay the rest yourself, even if you’ve already met your deductible. Good luck finding out what the cost will be beforehand. Doctors and nurses don’t know, and many facilities are known to not provide that information even if you call their billing department.

For more information on out-of-network services and payment, see FairHealth’s website. You can also see the websites of UnitedHealthcare and Aetna on how they deal with out-of-network costs.

 

Randy Cox
Founder & CEO of Pricing Healthcare

Reframing Healthcare in the Minds of Younger Americans

August 27, 2013 in fitness, health care costs, health care quality, Health Insurance, lifestyle, mental health, nutrition

The clock is ticking towards October 1, 2013 when public insurance exchanges are set to go live and begin offering health plan benefits to an estimated 30 million previously uninsured Americans. And as that day draws closer, all parties involved—plans, providers, employers, and patients—are scrambling to figure out just what it will mean to them from a cost and quality of care perspective. Yet, perhaps one of the biggest conundrums associated with the health insurance marketplace is how to deal with the potential sticker shock facing younger Americans and the ripple effect it could have on everyone. Specifically, with an age band as narrow as 3:1, there is a possibility that premiums for younger people (who tend to be lighter users of service) will be considerably higher in order to compensate for older Americans, who typically utilize more health care services. When combined with a relatively low penalty for not getting coverage, there is a very real fear that many of these ‘young invincibles’ will forgo coverage and simply choose to pay the penalty.

So, the question becomes, ‘how do we articulate the value of health coverage to this younger generation?’ or, in other words, convince them that coverage is relevant (and worth it) to them?

We need to help this younger population understand and believe that healthcare is not solely about supporting the sick – support is also critical for the well. For example: a recent college grad that is just starting out in his/her career and may have issues dealing with the stress of that new job; the twenty-something who runs marathons but wants to improve their nutrition; the new mother who wants to start a workout program to shed some of the baby weight; or the avid skier who suffers a knee injury on the slopes and wants to understand what treatment options are available to them.

These scenarios play out each day across the U.S. and could happen to just about anyone between the ages of 18-35, not solely older people or those with chronic conditions. And there are programs, resources and tools focused on shared decision making and wellness that are critical components of modern healthcare that young people can take advantage of. So at the core, the solution for this current dilemma needs to be about making the younger population aware of these resources because they support behaviors that contribute to better health and wellbeing. Specifically, we need to create a  culture that encourages all people—including the younger population—to think differently about their health, make more informed choices, and understand not only the resources at their disposal but also the value they provide.  If we can do that, we will go a long way in positively impacting the health and wellness of these younger generations and controlling spiraling healthcare costs.

Robert Mandel, MD, MBA, is the CEO of Health Dialog and has more than 15 years’ experience in senior leadership positions in health systems and health plan management. 

Patients Exposing Medical Prices, Taking Matters Into Their Own Hands

August 14, 2013 in health care costs, Hospital Bills, Insurance Bills, News

The medical world is moving toward price transparency — very slowly.  Unfortunately the amount of data available is still relatively sparse, considering the wealth of useful data that could be published. What users are shown is often nothing more than an average or calculated estimate for an area.  When the rare facility-specific data is revealed, it is too often list prices (which almost no one pays) or several years old.

One reason for the crawling pace is the healthcare industry’s reticence to let consumers compare costs, which would surely send a great deal of business to lower-priced facilities and put downward pressure on prices.  It would be disastrous to their revenues.  And don’t think for a minute that the federal government is in a hurry to bring about transparency. The “Affordable” Care Act was carefully crafted to keep hospital revenues in tact, influenced by the billions politicians receive from healthcare lobbyists (more than 4 times greater than the next 3 largest lobbying groups combined). Patients just don’t stand a chance against such powerful forces.

Enter Pricing Healthcare, a relatively new addition to the playing field. They’re asking consumers for a little (anonymous) pricing data from their medical bills in an effort to expose what should be openly and readily available to patients. The company is interested not just in the prices hospitals and physicians charge, but more importantly what real patients are actually paying, in the form of discounted and insurance-negotiated rates. Users can enter data from bills going back nearly 3 years, but as people enter more recent data, it keeps the content current. The website makes the process relatively easy, and patients from all over the U.S. have already started submitting data, many with a great deal of enthusiasm.

Crowd-sourcing isn’t Pricing Healthcare’s only source of price information on the user-friendly site. While consumer data is being collected, the company is also pulling in data from other sources (as can be seen from the large amount of San Francisco data they have published). For the first time the company says, consumers can compare cash prices for scores of hospitals in a large metro area. They company is asking patients in the San Francisco area to help them discover insured rates (the hardest prices to come by) by supplementing the data already on the site from their own medical bills.

Grass roots efforts have done a great deal to influence the course of American history. The internet age certainly makes it easy for individuals to band together and force change. Pricing Healthcare hopes citizens will be concerned enough about the high cost of healthcare to lend their voices and make a difference. Time may be running out.

 
For more information, visit https://pricingHealthcare.com, or send the company a message at https://pricingHealthcare.com/contact.
 
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by HCSavvy

If you’re shopping for the best place to get a new hip or knee…

July 17, 2013 in health care costs, health care quality, Hospital Bills, Medical Care

take a look at this article.

You can pay $23,000 for the highest quality hip, knee or ankle or, if you prefer, spend $64,000 for the lowest quality procedure in Boston, according to an analysis from Castlight. In Washington, D.C., the cheapest top quality operation is $30,000 as compared to $69,000 for the most expensive low quality job.Picture 2

Picture 3

Many of us routinely opt for the most expensive option, assuming more expensive equals better.  There’s a growing body of research that proves us wrong, but changing that association (the Nieman Marcus effect) is really hard, especially since we don’t usually have to pay the difference.

In NYC and LA higher quality joint replacements do cost more than the lower quality procedures.  What gives?  Are patients there smarter shoppers?

Picture 4

Another example of the insanity of “pricing” in the US health care “system”

July 16, 2013 in health care costs, Health Insurance, Insurance Bills

A family member had some lab work done by Quest Diagnostics, which is under contract with Harvard Pilgrim Health Care, our health insurer.  Because we have a high deductible plan, we were expecting a bill.  No problem.  The bill comes and it lists each test’s CPT Code along with a description – although admittedly I have no idea what these tests are – as well as the “charge” the “insurance discount” and a column that indicates “patient owes,” among others.

Here’s what was listed on the laboratory invoice:

Date CPT Code Test Description

Charge

Insurance Discount

Insurance Paid

Medicare/ Medicaid Paid

Patient Paid

Patient Owes

05/29/13 86036 ANA SCREEN, IFA

78.00

05/29/13 82784 GAMMAGLOBULIN

$56.15

05/29/13 83516 TISSUE TRANSGLUTAMIN

$157.04

05/29/13 83516 GLIADIN (DEAMIDATED)

$227.76

05/29/13 86039 ANA TITIER

$44.72

06/26/13 ADJUSTMENT

($483.20)

$563.68

(438.20)

$0.00

$0.00

$0.00

$80.48

 

I called Quest to get an explanation about the invoice.  In particular, I didn’t understand what they meant by “Insurance Discount” vis-à-vis the “Charge.”  After some back and forth, it was explained that the insurance discount is the difference between what Quest charges someone without insurance – i.e., their “list” price – and the amount that Harvard Pilgrim pays them for the test.  In my instance, it’s the difference between what I would pay if I didn’t have insurance and the amount that I owed because we’re covered through Harvard Pilgrim.

Their so-called charge for these services – the amount that they would charge me if I were to walk in off the street and get some routine blood work done – is more than SEVEN times the amount that they charge my insurance company.  Read the rest of this entry →

Where’s the best? Prices in health care mean nothing unless you answer that question first

June 4, 2013 in health care costs, health care quality, Member Stories

The New York Times makes a strong argument for paying more attention to the price of a colonoscopy: “Colonoscopies Explain Why the US Leads the World in Health Expenditure.

But most Americans will be very uncomfortable choosing the cheapest test unless there’s proof the quality is just as good as the more expensive options.

(ex_magician/flickr)

(ex_magician/flickr)

But here’s where health care information breaks down. If you think it’s hard to find the price of colonoscopy – finding out who provides the safest, most reliable test, is close to impossible.

I, with the help of some brave docs in Boston, put together a sample chart.

There’s a much better example of how to shop for a quality colonoscopy here, from the folks at Quality Quest for Health.

Until someone can tell me where I can get the best colonoscopy, I’m going to resist shopping based on price.

Exercises to ease back pain

May 15, 2013 in fitness, health care costs, lifestyle, Member Stories

I’ve always been a money-saver  When I was younger, my mom looked in wonder as I handed her my birthday money and asked her to put it in the bank for me. I might not have had a Razor scooter like all of the other kids, but hey, I was able to pay off a third of my college loans before I even graduated. This frugal attitude has lead me to believe that I can save money in any situation, even when it comes to my health.

Photo Credit (www.mybackpain.info)

I still go to the doctor when I have to (broken bone, the flu, etc.), but if I ever see a chance to avoid a trip to the doctor, I’ll take it. A couple of years ago I hurt my upper back when I was playing in a rugby match (poor choice of sport), and now I have a tight muscle that flares up every now and then. When the injury initially occurred, an athletic trainer told me that I could get an MRI, but that it wouldn’t do much for me. In a nutshell, the MRI could possibly reveal what was wrong with my back, but even if it did, the doctor would probably recommend the same thing that I could have come up with on my own: exercise.

According to an article on Health.com, Read the rest of this entry →

Crazy, irrational hospital billing (with no connection to quality)

May 8, 2013 in health care costs, health care quality, Hospital Bills

Try explaining this…

One hospital in my state, Massachusetts, bills Medicare $75,197 to take care of a patient with heart failure, another charges $13,960.

There’s a huge gap in the charge for patients with breathing problems who are put on a ventilator: $23,044 to $120,888.

Thanks to The Washington Post for this article with a great graphic that shows how much prices vary in each state, using data released today, by the Centers for Medicare and Medicaid Services.

Why are there huge differences in what hospitals charge?

Don’t expect a satisfying answer. Read the rest of this entry →

Claim Modifiers: More Code-Speak on Your Medical Bills

April 26, 2013 in health care costs, Health Insurance, Hospital Bills, Insurance Bills

If you have ever been hospitalized or had a major test/procedure performed, you may have received a frustratingly hard to decipher medical bill from your provider. And, if you are insured, you will also have received a similarly cryptic Explanation of Benefits (EOB) describing your insurance company’s payment decision. (The EOBs can sometimes be a bit clearer and more detailed than the average provider bill.) To the average lay person, medical bill jargon does not sync with customer psychology in the way that other bills, like retail, residential services, etc. do. Most other industries present their bills in a careful way, focusing on clear billing, to make sure that customers know why they have financial responsibility.

CPT and Claim Modifier Codes

With that in mind, let’s look more closely at some of the usual suspects that show up on an unreadable medical bill. One type of common code is called a Current Procedural Terminology or CPT code. This code, in plain English, represents a service that a doctor (or other medical professional) provides.

CPTs often do not “read” well. Patients not involved in the medical industry themselves may have no idea what one of these codes represents on a bill. Looking at the charge associated with it can be frustrating when there’s no common-vocabulary explanation to make the patient remember just what was done in the provider office. This means that patients who are proactively concerned about their care, and costs, will often call providers or insurers just to ask “what does this CPT code mean?”

About Claim Modifiers

Claim modifiers are additional digits attached to a CPT to explain to an insurer or other party how a procedure may have differed from “the norm.” Some modifiers are also used to differentiate a core service from an advanced service level based on the doctor’s documentation. Read the rest of this entry →

PricingHealthcare.com : healthcare prices in full view for facilities nationwide

April 10, 2013 in health care costs, Hospital Bills, Insurance Bills, Member Stories

Pricing Healthcare is blowing the doors off of healthcare pricing by exposing the closely guarded pricing secrets of insurers and healthcare providers – nationwide.

When we release our free Beta in June 2013 (pricingHealthcare.com), we won’t be just another site providing over-generalized estimates or very small fragments of the pricing picture for medical services.  We let consumers go to a single, easy-to-use website where they can compare actual procedure-level prices across all the healthcare facilities in their area.  There are a lot of prices out there: providers’ list prices, insurance-negotiated rates, and the “black market” price – discounted rates for cash payers not claiming insurance.  We show people all of it.  You wouldn’t believe how varied they can be, and you might find that paying cash is considerably cheaper than going through your insurance.  This doesn’t exist anywhere else, and it has the potential to save a lot of people in America hundreds and thousands of dollars in medical costs.

Other companies have tried to get ahold of pricing information from hospitals and insurers for years, but it’s in the best interests of the medical establishment to keep their prices from patients.  Open pricing leads to competition, when tends to lower prices.  The only people who benefit from this is consumers (exactly!).

The data that could transform the healthcare industry is out there.  It’s sitting in our file cabinets and in the pile of bills on our kitchen counter. Our model is to help patients come together at the grass roots level, and anonymously share the pricing data from their healthcare bills online.  That data is then combined and shown for your specific community, anywhere in the country.  It’s as simple as it is revolutionary.

Imagine what we could all do, collectively, with all the data from our healthcare bills anonymously online and freely available to other consumers.  Healthcare providers, like all American businesses, will have to compete on quality and price.

We are running a crowd-funding campaign to let consumers participate early and help ensure the revolution is a reality.  You can learn more about us at http://igg.me/at/pricingHealthcare.

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Cutting Your Prescription Costs

March 20, 2013 in health care costs

Castlight Health is out with an app that lets members compare retail vs. mail order prices for prescriptions and find the closest pharmacy with the best deal. There are a growing number of places online where patients can find some health care prices, but most don’t include pharmaceuticals. More sites will likely follow suit because consumers are realizing they can save money by checking the mail order price or making a few calls to find out which local pharmacy offers the best deal.

You, your employer and your health

March 19, 2013 in health care costs, Health Insurance, News

Is your employer offering rewards or penalties if you participate in a wellness program, stop smoking or lose weight?

photo credit (www.pgcompanies.com)

CVS is joining a growing list of employers who tie wellness participation to rewards and penalties. In this case, the pharmacy chain says employees can save $50 a month on their insurance if they have a series of tests (body mass index, blood pressure, etc.).  Employees who don’t have the tests lose the money, $600 a year.

CVS Caremark spokesman Michael D’Angelis told the Boston Herald that the policy will help “colleagues take more responsibility for improving their health and managing health-associated costs.” The company says a third party will review and manage the employees’ test results. Some privacy advocates worry CVS and other firms will use the information to discriminate against less healthy workers who drive up health care costs.

More companies are expected to follow the example of CVS by offering incentives/penalties in exchange for monitoring employees’ health.  Affordable Care Act rules that encourage these options take effect January 1, 2014.  The Obama administration says expanding wellness programs “may offer our nation the opportunity to not only improve the health of Americans, but also help control health care spending.”

What’s happening in your workplace?

 

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Searching for a Nursing Home?

March 14, 2013 in health care costs, Medicare, Member Stories

Our parents and grandparents often drain the last of their savings to pay a nursing home bill. So it makes sense to shop around, both for cost and quality. UPI has a story about this site which looks like a good place to start if you want to compare options for a friend or loved one.

The site does not show ANY nursing homes in Massachusetts with a five star rating. There are nine with four stars. In Boston, the average daily charge is $323.70 and the avg. quality rating is 2.9 stars. That’s a lot of money for average quality.

Affordable Care Act looks to prevent chronic diseases in women

March 12, 2013 in health care costs, Health Insurance, Medical Care, Women's care

Like many people in the United States, I’m aware that the Affordable Care Act was signed into law by President Obama and that it aims to make sure that everyone has healthcare; however, until now I hadn’t taken the time to ask how it affects women like me. A quick glance at the services provided under the umbrella of the Affordable Care Act shows that there are a handful of preventive services that I never knew I should consider, let alone take advantage of.

photo credit (qualityquest.org)

One of the major elements of the act is encouraging women to visit their doctor in regards to preventive care services since, according to HealthCare.gov, chronic diseases that are often preventable are responsible for 7 of 10 deaths among Americans each year and account for 75% of the nation’s health spending. If the preventive services cut down on the percentage of people with chronic diseases, then the nation’s spending spent on health will presumably go down.

Some of the services offered to women are screenings for anemia, cervical cancer, gestational diabetes, gonorrhea, Hepatitis B, and osteoporosis. Additionally, in August 2011 the Affordable Care Act introduced eight new preventive care services for women including Read the rest of this entry →

Please Medicare, you can do better than this

March 5, 2013 in health care costs, Hospital Bills, Member Stories

I wrote to Medicare a while back, asking for a price. I know nothing is simple in the world of health care costs, but I just needed one number, a number Medicare uses, I assume, to calculate payments to doctors and hospitals all the time.

Here’s what I wanted to know: how much does Medicare pay a particular hospital in Boston for a colonoscopy (it was for a story I wrote about searching for the best colonoscopy in our medical Mecca).

The first response I got, at a time when we’re supposed to have more price transparency, was ridiculous. If I can figure this out, I should be awarded an honorary masters in something, don’t you think?

For the inpatient hospital side:

If you want to calculate a hospital specific DRG payment for a specific fiscal year, look at that year’s IPPS Impact file to get the hospital’s wage index.

Then you can look at Table 5 for the FY 2009 Final Rule to get the relative weights for the MS-DRGs you are interested in. Finally, you can determine the FY 2009 labor related share and non-labor related share rates from Table 1A in the FY 2009 Final Rule.

These files and tables can be found here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Acute-Inpatient-Files-for-Download-Items/CMS1247872.html

Then the hospital specific DRG payment can be calculated as follows: (wage index x labor related share + non-labor related share) x DRG relative weight.

For the outpatient side:

Medicare Part B data by procedure code for specific years are posted: http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/NonIdentifiableDataFiles/PartBNationalSummaryDataFile.html Data are presented by 5-digit code so you would need to know the code for CT scan and MRI. Code range categories are identified in the readme file which is included in the zipped file.

A colonoscopy for the inpatient side does not affect the MS-DRG assignment. You will only be able to narrow it down by looking at the procedure codes. Below are the two most common reported.

ICD-9-CM procedure code 45.23, Colonoscopy

ICD-9-CM procedure code 45.25, Closed [endoscopic] biopsy of large intestine – this code includes colonoscopy with biopsy

So I write back to Medicare. Really, I ask, is this what I have to do to find out how much you pay a hospital for a basic test? Read the rest of this entry →

Preventing Child Medical Identity Theft

January 29, 2013 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care

Along with being able to talk to providers and insurance companies from an informed standpoint, you will also benefit from knowing more about how criminals work to fraudulently bill others for various items including health care services. There has been a flurry of reports about a growing practice that’s pretty disturbing, especially to new parents. It involves criminals simply using children’s identities to bill medical services and other items to credit accounts.

Doesn’t The Government Check a Consumer’s Age?

You would think that children would be safe from identity theft because of their age. But, the reality is that with the complex database systems of many governments and private businesses, it’s often possible for criminals to commit fraud by using the Social Security number and other identifying information of a minor. At the same time, many of these efforts are successful specifically because nobody else is checking the credit account for a minor. Since a child can’t usually make purchases or access his or her credit, everyone figures the accounts will be dormant. What some unlucky parents are finding out, though, is that to many government agencies and businesses, one Social Security number is as good as another, and the issue of age does not factor into many of these fraudulent accounts. In some cases, criminals who open these kind of accounts can keep using them for months or even years.

What To Do About Child Identity Theft

Much of what consumer advocates recommend in terms of deterring child identity theft is the same as what you would do to prevent adult identity theft. Read the rest of this entry →

Worked 40 years, now disabled, can’t get care – What Happened?

January 10, 2013 in health care costs, Medical Care

I have have a low back problem since 1992 when I became hurt at work. I needed a laminectomy @ L/4 L/5, I was fine for a while until my wife and I were rear-ended on the 91 frwy. in Orange County, Ca. 1997. Then my back slowly got worse. In 2003 I had a Dorsal Column Stimulator” inserted in my body, it worked for a while but in 1995 the battery died and they removed the unit. Although the Doctor removed the spinal lead implanted in T/6-T/7 area it still gives me problems to this day. I am now 57 and on permanent disabilty through (SSA).

I also started having stomach problems in 2009, serious doubled over pain like no other. I was diagnosed with chronic pancreatitis and have been hospitalized 3-seperate times for this issue. The medication I need is ”creon” and there is no generic brand so it costs $380.00 per month. I am now on Medi-cal which doesn’t pay anything because the government/county program thinks I receive too much money to qualify. So I have to pay for ”ALL” my medications. Thats over $600 a month, towards a $1512 (soc) or share of cost. That’s monthly by the way. What the hell has happened to our medical in this country? I have worked 40 years and did not want to be disabled, but it happened. Now I can’t get the medical care I need.