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?

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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?


Here’s one reason you can’t find health care prices…

March 18, 2013 in Health Insurance, Hospital Bills, Member Stories

Most states don’t have laws requiring hospitals and other providers to tell you how much anything costs.

That’s the finding of a report that gives 29 states an “F” for transparency in health care pricing and nine a “D.” As Kaiser Health News reports, a group that includes some of the country’s largest employers plans to issue annual report cards on transparency.

Massachusetts and New Hampshire are the only two states (in blue) that get “A”s. The provision of the Massachusetts law that says insurers and providers will have to give you a price for an MRI, if you call, takes effect later this year. I’ve tried to find out how much hospitals and labs in the Bay State charge for services; it’s very difficult.  So for now, the “A” awarded to Massachusetts must be for intent, not action.

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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.

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One of the major elements of the act is encouraging women to visit their doctor in regards to preventive care services since, according to, 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 →

Say goodbye to annual Pap smears

March 5, 2013 in Medical Care, Member Stories, Women's care

(photo credit,

Every year since I’ve turned 18 I’ve had a Papanicolaou test, also known as a Pap smear, to screen for cervical cancer. And every year it’s the same story. The cold, uncomfortable test takes less than two minutes, and then I’m sent out of the doctor’s office and asked to make an appointment for the following year.

Our recent post on the regularity of physicals got me wondering how often it’s suggested that females get a Pap smear. According to my family doctor, Dr. Marilyn Lange, women should get a Pap smear annually.

“If you’re having multiple partners, then every year,” says Dr. Lange. “If you’re in a stable relationship, then every two years. That’s my opinion.”

However, while Dr. Lange is in favor of women getting a screening every one or two years depending on their sexual activity, updated reports 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:

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: 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 →

Gum, popsicles, Meow Mix, what’s “food” in your state?

February 28, 2013 in Member Stories, nutrition

My state, Massachusetts is debating whether soda and candy are food and should continue to be exempt from the state sales tax.  That made me wonder…what do other states put in the category, “food”?

The always helpful folks at the National Conference of State Legislatures sent me this breakdown. Turns out there’s a lot of variety.

Gum is a food in Colorado but not in California.

Which looks more like food? Gum or… (photo credit, AP)

In D.C., Puppy Chow and other pet foods aren’t subject to the state sales tax,  but pet owners in Arizona pay it.

ice cream? (photo credit/AP)

Florida taxes ice cream and popsicles. Massachusetts does not.

Some states tax prepared food (your pre-made Caesar salad and such) some don’t.  Most take-out food that is hot is taxed.  The rules about taxing prepared cold food varies and are, in a few cases, elaborate:  Here’s Indiana…”food sold without eating utensils provided by the seller” that include “two or more food ingredients combined by the seller for sale as a single item….”  How does Indiana enforce this rule?

Very few states consider vitamins food, or the seeds used to grow vegetables, Read the rest of this entry →

Should annual physicals actually be annual?

February 26, 2013 in Health Insurance, Medical Care, Member Stories

I’ve been going to my childhood doctor every year for as long as I can remember. She’s helped me through the chicken pox, flu shots, ear infections, and the perils of puberty. But as my mom pointed out a couple of weeks ago, I’m now in my twenties, which is too old to still be going to a pediatrician. The nostalgia in me wants to scream, “No, you can’t make me go to a new doctor,” but the logic in me says, “I guess it’s time I go to a doctor’s office where the waiting room isn’t filled with Legos.”

My healthcare conscience mother and me.

My healthcare conscience mother and me.

But how urgent is it for me to find a new doctor for my annual physical? Here are the facts: I’m a 22-year-old female, I haven’t had a physical in almost 14 months, and I don’t believe that I have a serious illness that has surfaced since my last visit. Can’t I just skip a year and wait until I’ve found a new doctor that I like?

While my mom might say no, my pediatrician says yes. Dr. Marilyn Lange, a doctor in Los Angeles and a graduate of Tufts University School of Medicine, says that a woman of my age can get away with only having a physical every three to four years unless she has a medical problem. “There are definitely reasons to do it,” says Dr. Lange, “but if you want to skip a year, that’s fine.”

An article published by Duke Medicine supports Dr. Lange’s claim and says that how often you get a physical depends on your age and disease risk factors. Assuming you are healthy, the article suggests you get a physical every two to three years if you’re under 30, every one to two years if you’re between 30 and 40, and every year if you’re over 50.

Additionally, a Danish study released in 2012 found Read the rest of this entry →

Informed Patient Institute

February 25, 2013 in Member Stories

Hi all. I’m a recent addition to this group, but I’ve been working in and around health care from a consumer/patient/family perspective for some time.  I run a Maryland-based non profit called the Informed Patient Institute (or IPI). We provide credible access to online information about health care quality and patient safety.   We work in two areas – health care report cards and tip sheets about “what to do if you have a concern about quality.” We have a database of hundreds of doctor, hospital and nursing home report cards nationwide.  We grade them “A” thru “F” and tell you what we like about them and what could be improved.  In the tip sheet area, we’ve written plain language information about what to do if you have a concern about quality in a doctor’s office, hospital or nursing home.  In MA, because of the good work of  Health Care for All,  we link to their information about hospital quality concerns.  In the future we’d like to do work in the state on quality concerns in doctor’s offices or nursing homes.  We have this information now in CA, ME, NY and PA.  Check us out!

The Need to Know is Powerful

February 6, 2013 in Medical Care

The following story is by Dr. Robert Fenster, a psychiatry resident based at Brown University in Rhode Island , and a winner of the 2012 Costs of Care Essay Contest.

“I’d really feel better if we got the MRI,” Ms. James said. “I understand you think it’s a migraine, but I want to know, just in case. Wouldn’t you?”

Ms. James and I sat in her darkened hospital room—the light bothered her eyes and exacerbated her headache. She was a dialysis nurse with many years of experience in the healthcare field, and I was a first-year doctor trying to convince her that she was most likely suffering from a migraine and did not need additional tests.

Ms. James had woken up the morning before with very concerning symptoms. Her head hurt terribly. She got out of bed, but she felt nauseated and had to lie back down. She thought she needed her morning coffee, but she felt too sick to go downstairs to make some. Her headache had worsened, and she began to notice shooting pains in her left arm. She was scared. A few hours later, her daughter arrived to find her mother’s speech was slurred. The daughter called an ambulance.

By the time Ms. James reached the Emergency Department, her speech had improved, but her headache remained. The fluorescent lights bothered her, and the loud noises of the hospital grated her nerves.  A neurology resident was called to evaluate her. He felt that she was most likely experiencing a migraine and recommended that she be given some medication to help with her pain. He thought it was possible that she could have suffered a TIA—a transient ischemic attack, in which the blood supply to a part of the brain is temporarily blocked—but he felt that this was a less likely possibility. He did not think she would need an MRI scan of her brain unless her slurred speech returned.

The craft of medicine requires doctors to constantly manage probabilities. Read the rest of this entry →

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Might as well laugh instead of cry

February 1, 2013 in Medical Care

These two gems are back to back in the latest issue of The New Yorker:

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 →

Empowering Healthcare Consumers

January 29, 2013 in Member Stories

By Undersecretary of Consumer Affairs Barbara Anthony

Until now, if consumers asked their doctors or hospitals how much a particular service will cost, they would be told that the price depends on their insurance plan. When consumers asked their insurance carriers the same question, they would be told that price of a health care service depends on each provider’s contract.

Thanks to Massachusetts’ recent health care quality and cost containment law, that’s about to change. Insurance companies must now develop toll-free numbers and websites through which consumers can determine the prices of provider services. Most notably, the law requires carriers to tailor the information presented to the insured’s plan, taking into account plan-specific information such as co-pay, deductible, and co-insurance.

To their credit, major Massachusetts insurers are already preparing to roll out these consumer information tools—see my January 8th op-ed  and Rob Weisman’s excellent reporting in this past Sunday’s Boston Globe. This is a great example of what industry can do to lead the way through innovation and technology that benefits competition and consumers.

We have seen an appetite on the part of insurers to get this information out there and a hunger for consumers to have it in an easily digestible way. For this reason – my office will be launching a Health Care Consumer Empowerment campaign to bring together carriers, providers, non-profits, employers, and consumers to put consumers in charge of the way they shop for health care services.

Health care consumers, like consumers in other markets, should be able to shop around and compare services including price and quality. We cannot reign in health care costs if consumers are kept in the dark about the price of health care services.

Empowering consumers with pricing information is a necessary first step toward a patient centered culture that can result in the more efficient delivery of lower cost, high quality health care services. Armed with price, consumers can continue to consider quality, location, and other factors when selecting health care services.

Senior Citizens, Sign Up Now: “Medicare Open Enrollment” Ends March 31

January 29, 2013 in Medicare

OK, I bet you thought “Medicare open enrollment1” for 2013 ended December 7, 2012.

That’s the conventional wisdom.  Actually enrollment time for Original Medicare is now through March 31, 2013 and those who sign up will start receiving their benefits beginning July 1, 2013.  And they’ll start paying their Medicare Part A and/or B premiums (unless qualified for “free” Medicare Part A and/or B) from that point in time forward. And they will start paying their Part A and/or B premium penalty (if due) from that point in time forward.

Actual Original Medicare open enrollment gets minimal publicity because most seniors don’t wait until Medicare open enrollment time to sign up.

Read the rest of this entry →

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An anxious month for social workers, psychologists and psychiatrists

January 28, 2013 in Insurance Bills, Member Stories, mental health

If you visit your therapist this month or next and he or she seems stressed out, it could be about money. Here’s why.

Therapists who accept health insurance submit a bill that includes a code for your visit.  90862 was, for example, a very common code for a medication adjustment visit to a psychiatrist.  As of this month, almost all the mental health codes are changing and this is causing a lot of anxiety.

Therapists aren’t sure which code to use and, they aren’t sure how much they’ll be paid.  Insurers say the new codes, which are reviewed and set by the American Medical Association, will likely mean lower reimbursement rates for therapists who don’t prescribe drugs.  Insurers say they won’t cover some of the codes at all. Many therapists are angry and discouraged.

“The Governor and the President are asking for more emphasis on mental health, but then the coding requirements increase and the reimbursements go down,” says Jonas Goldenberg with the Massachusetts chapter of the National Association of Social Workers.

Psychiatrists may see an improvement in payments for some visits because they’ll be able, for the first time, to bill for medical care they provide while monitoring the effects of medications.  But the new codes do not resolve ongoing concerns about whether mental health providers are paid at the same rate as are doctors who deal with physical health.  Under the new codes, it does not appear that psychiatrists who evaluate a patient’s physical response to medication will be paid what an internist would to make a similar evaluation.

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The $55,000 cat bite and other stories you won’t believe

January 24, 2013 in Hospital Bills

OK folks – we’re starting a new tab up there at the top of the page called, “You Won’t Believe This One….”

photo credit David Lazarus, his cat, Bear.

The inspiration is David Lazarus’ story about a cat bite that became infected and cost $55,000 to treat.

David tells the story and lays out the costs here.

Unfortunately, we hear lots of stories like David’s. And, there are lots of us who never even see the bills we pile up, so aren’t aware of how much we’re spending, and in some cases wasting, when we go to a clinic or hospital for care.

David, so glad your hand healed. We have to take issue with one claim in the your story…that the Affordable Care Act will get rid of “funny money” in health care…not a chance.

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.

The Rise of U.S. Health Care Consumers: Lessons from Abroad

January 5, 2013 in health care costs, Health Insurance, International Health Care, Medical Care, Quality of care

Can you imagine buying gas from a station with no signs to let you know the prices? Or having the clerk at a clothing store pick the “right” jeans for you, with no opportunity to figure out for yourself which ones fit best? In a sense, this is how Americans buy something far more important: health care.

Economists and policy makers have long emphasized the challenges in treating health care as a consumer good. Supply generally drives demand; there is little correlation between cost and quality; and end users have neither visibility into costs, nor much incentive to find out. Lack of price transparency makes it nearly impossible to find health care cost information even for someone motivated to look for it. Consumers also have little basis for evaluating quality; often the data that is available is dense and hard to interpret. In other words, most Americans do not have the practice or capacity, let alone the information they would need, to make informed health care decisions.

But it does not need to stay this way – and, indeed, it cannot if health care reform is to succeed. Under the Affordable Care Act, 12 million consumers are expected to purchase their own health insurance via a health insurance exchange by 2014, growing to 28 million in 2019. Americans, including lower-income individuals qualifying for subsidized health insurance, will have new health plan choices, and new means of comparison shopping. Even without reform, health insurers are designing and employers are increasingly offering products that shift costs and choices to the consumer.

Remarkably, as a nation and a health care industry, we have not prepared our population for the increased responsibility and decision-making power they will soon assume. Yet there are places around the world that have a lot to teach us in this arena, and they’re not necessarily the ones you might guess – or the ones health economists tend to focus on. Read the rest of this entry →

I want information about costs AND quality

January 1, 2013 in Medical Care, Quality of care

I’ve been thinking about this push from e-Patient Dave to redefine and rename “transparency.”

“If I mention ‘transparency’ to people in my community,” says Dave, “most have no idea what I mean. But when I say ‘We need to see what things cost – and nobody can tell us,’ everybody does see what a problem that is.”

And so, says Dave, what we need is “Visible prices, please. Before we make our purchase decisions.”

OK – no disagreement. Transparency is one of those wallpaper words.  Everyone uses it; but it feels plastic.  And, I strongly agree that we can’t make wise spending decisions about where to go for care if we have no idea how much anything costs.

Huntington Hospital in Pasadena, CA is one of the few hospitals I know of that posts prices for procedures, based on your insurance coverage.

But cost is only part of what we, patients, need to see in clear, user-friendly terms.

The other critical factor in choosing where to go for care is QUALITY.  Which doctor or hospital will give me the best results after knee surgery or the best chance of catching problems through a colonoscopy or the best normal delivery?

I don’t think any of us want to get to the point where we are buying care based on price alone.  So transparency, or whatever we call it, has to help us decide where to get the best care at the lowest price.  So Dave – what do we call that?  Don’t say “value.”  Anyone?

Protect Yourself from Medical Debt Overload with Self-Advocacy

December 27, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt

You or someone you know may be closing out the year with large amounts of medical debt even after insurance payments or what you thought were relatively minor surgeries or other procedures. In fact, you may feel like you’ve been hit by a blizzard by the sheer number of bills related to that one procedure. And they keep on coming.

One step you can do is confirm or validate the bill, especially if a lot of time has elapsed since the initial service. This simply means you want proof that you had the services rendered and do in fact owe the balance due. Under the Fair Credit Reporting Act, credit agencies are supposed to help consumers to ensure that bills are correct and fair before payment is rendered. But without good knowledge of these laws and taking the time necessary to investigate, you could end up paying much more than you owe. Here are a few other ways to stand up for yourself and your bottom line.

Keep Proof of Charges

The bad apples that pollute our debt collection environment may be operating on an entirely fraudulent basis. There have been many news stories of consumers receiving calls from phone bank operators, posing fraudulently as legitimate debt collectors. A tip off is that in many instances, the caller will fail to fully identify him/herself, their company, and the nature of the call. There are also reports that unprincipled companies are using ‘bread crumbs’ of financial data in order to manufacture phony debts that their workers demand payment for during outbound telephone calls. Collectors have been known to threaten litigation or other legal action without any legal basis as well as fail to provide written proof that a debt is owed when requested by the consumer.

One big part of your arsenal is the paper trail of charges, as well as Explanation of Benefits (or EOBs) that show whether or not the insurance company paid their fair share. Keep all of these documents on hand so that you can prove any overcharges and trigger an analysis by a credit agency.

Get Credit Bureaus In On the Action Read the rest of this entry →