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Tuesday, July 28, 2015

Healthcare shards update. More sand in the gears.

Mixing a couple of metaphors, I know.

Updating my ongoing personal story.

Finally had my endo-rectal coil pelvic/prostate MRI, at Muir Medical Center in Walnut Creek on July 9th ("Bay Medical Imaging," yet another subcontractor).

Boy, that was fun. How far you gonna keep pushing that probe? You gonna floss my teeth with that thing?

Lordy. When they inflated the balloon at the tip of the probe post-insertion was really Special.

My Stanford 2nd-opinion consulting radiation oncologist, who'd ordered the study, called me the next day to apprise me of some net good news, on a number of counts. He was pleased with what he called "great images." Clear absence of evidence of any mets, one solid tumor contained inside the prostate capsule, left side.

We joked about the MRI px. "Yeah, I'm never sure how much I should tell patients about what to expect with that one."

He gave me names of five experienced docs he trusted who specialize in one or more of my tx options; one at Stanford, one at UCSF, one at Alta Bates/Sutter, and two at Diablo Valley Oncology. His NP then called me a couple of days later. She'd reviewed my chart, and assured me that the outcomes data for whatever I chose -- permanent low-dose brachytherapy, inpatient high-dose removable brachytherapy, or IMRT (Intensity Modulated Radiation Therapy) -- were "statistically equivalent," with long-term "cure" rates running in the high 90%'s.

Nuke that puppy.

I'm opting for "Calypso" IMRT, and on the 17th I had an initial consult with the radiation oncologist I'd decided on (the doc at UCSF couldn't even see me until September).

Really like this doctor. Feeling very comfortable with the choice of both doctor and treatment. I have a dear friend who had this same tx a year ago, with a great outcome.

The doc said he would convey the px order for the Calypso beacon implants to my urologist the following Monday. No time to waste; it's a nine-week commitment of M-F low-dose focused-beam rad tx. I may end up missing most of this year's Health 2.0 Conference.

The following Monday I called Urology. No, they had nothing yet.

I called again several times through the week. Left messages. No one got back to me until Friday.

"We've submitted to BCBS for pre-authorization. We can't schedule you until we have it."

I called the radiation oncology clinic. For one thing, no point in getting the Calypso implants if BCBS is gonna deny my treatment. What can you tell me?

Same story. I was told they had to also submit for pre-auth for the IMRT tx. "It could take 7 to 10 business days. We will let you know."

[Expletive deleted]

Given my prior initial MRI denial dustup with BCBS, I was not a happy camper at this news. Anxious to get this thing moving. The relative aggressiveness of my particular adenocarcinoma is in an indeterminate range, based on all of the indices to date (including the OncoType dx genetic assay).

Calypso IMRT is regarded as a "premium" tx option in terms of cost -- which is proving extremely difficult to pin down with any precision (that whole healthcare pricing opacity thing). I worried that BCBS would again throw sand in my gears, interposing themselves between me and my doc.

Which, of course, could also have the perverse effect of making my condition more expensive to treat should significant delay result in mets getting loose.

Then, yesterday, I got calls from both the urologist's office and the radiation oncology clinic.

A 180, from both calls.

RadOnco: "No, we don't need a pre-auth. You have a PPO plan" (meaning, I guess, that my insurance was accepted). The urology office staffer also said Calypso beacons implant px pre-auth was not necessary after all. Given that I've been seeing their doc for more than a year, and he's billed and been paid by BCBS multiple times, I already knew that my insurance was accepted there, but their initial assertion that a pre-auth was necessary for this procedure still has me a bit puzzled. A relatively minor error, but, still, more sand in the gears.

I am now assured that the Calypso beacons are on order and I will be scheduled for the implant px forthwith.

Thrilled to know that it's a "trans-rectal" px akin to the biopsy.

Once I heal up from that (about a week), I will first undergo a Calypso "planning/targeting alignment dry run," after which the nuking festivities will begin as soon as I can be scheduled.

One aspect of this experience, which will effectively be part of my "co-pay," will be the roughly $400 in gas I'm gonna spend schlepping to and from the clinic daily over nine weeks.


They can't do my Calypso beacons implant px until August 11th, and I have to go to Berkelely to get it done, not the Concord office. This means I am unlikely to begin my rad tx until late August, a good 6-7 weeks after my Muir endo-rectal coil MRI.



The Muir ER doc contractor group finally got paid. Only took 3 months. No wonder you're all going broke. Your revenue cycle processes are abysmal.

They billed $623. BCBS gave them $414.88. My balance due (which I paid immediately) was $46.09. Yeah, that's a "10% co-pay" under my plan [$46.09/($414.88+$46.09)]. Total net charge, $460.97 (payor reimbursement plus my co-pay). I guess they're "in-network" after all (there had been some doubt voiced initially).

Interesting, the varying Radiation Oncology charges ("new patient" visit):

My initial rad onc referral visit (less than an hour) yielded a charge of $694.35. BCBS allowed $318.85. My piece was $35.43, again, 10%.

My 2nd-opinion visit at Stanford: billed @ $425, BCBS paying $235.44, my co-pay cut $23.54 (9.09%, go figure).

Other random stuff to date:

This was weird: the endo-rectal coil MRI, billed @ $2,925.00. BCBS paid them $96.00 (that's not a typo: they paid only 3.3% of the charge), my cut was $9.60 (note that $9.60/($96+$9.60) is 9.1%, not 10%).
You have to wonder whether these exorbitant "chargemaster" type gross billings are really just accounting fictions designed to show for tax purposes that they're "losing money."
Finally, this one is another head-scratcher. I had to go get another PSA test blood draw on the 17th. LabCorp makes you leave a credit card number for balances not covered. They gave me a printout saying they would be billing BCBS $192.00 for this single parameter assay.

Well, according to my BCBS subscriber portal, LabCorp got $19.83 for the test. My cut is 21 cents (10.48% co-pay). I checked my AMEX account. No "balance billing" in my current activity. I have not the slightest doubt that LabCorp Accounts Receivables will spend about ten bucks (postage, paper, processing labor) making sure they collect their $0.21 from me. I am reminded of my years in banking.

Before this is all over, I will have blown way past my BCBS Max OoP for the year. Should be interesting to watch how all of it shakes out. I fully expect more bozo EOB stuff.

apropos, I will have to cite this best-selling book by Steven Brill. Just downloaded it. I've known of it for a while but haven't bought it until now. I know there's gotta be good stuff in there pertaining to our absurd billing practices.

For now (and on the topic), an excerpt from an interesting segment of "All In with Chris Hayes" on MSNBC last week (talking of the hapless guy who got a $153,000 bill for treatment of a rattlesnake bite):
HAYES: OK, Pro tip here: no selfies with rattlesnakes. You want to do whatever you can to avoid being near them as Mr. Fassler learned.

Now the San Diego local was lucky enough to have medical care. But the drugs and care that saved his life did come with a shockingly hefty price. After first reporting on the rattlesnake selfie snafu, KGTV reporter Dan Hagarty tweeted a picture of the hospital bill he says Fassler sent him. His bill, a grand total of $153,000. The majority of that, $83,000, coming from pharmacy costs, meaning the cost of drugs.

The bill of over $150,000, due July 27, 2015, less than three weeks after he left the hospital.
Now, we don't know if Fassler has insurance. It is more than likely that even if he did, it wouldn't be asked to pay the full amount. But the $153,000 snakebite bill is a window into what the U.S. health care system so distinct and so dysfunctional, the insane way the U.S. health care system prices drugs and services.

Joining me now, Dr. Zeke Emanuel, MSNBC contributor, chair of medical ethics and health policy at the University of Pennsylvania.

All right, what is going on here with this bill? How do you, as someone who has spent a lot of time studying this system makes sense of this?

EZEKIEL EMANUEL, UNIVERSITY OF PENNSYLVANIA: This is just funny money, it's what in the field is called charges. It`s what hospital charges. They`re totally made up. They bear no relationship to reality.  They bear no relationship to how much effort is needed to care for a patient.

I would note there, Chris, that $40,000 roughly of that bill is for five nights in the hospital, $8,000 a night. You could virtually rent a Caribbean island for that kind of price.
HAYES: You can stay at the nicest place in all of America.

EMANUEL: The whole world.

HAYES: But then explain to me why -- I have to...

EMANUEL: So we call those charges. And then there's costs, which are really what's going to be paid. And of course, there is no such thing as a cost, because commercial insurers like Aetna or United, they pay one rate, Medicare pays a different rate, typically lower, Medicaid pays a different rate, typically even lower than that.

The only people who pay that kind of bill are people paying full price, Chinese billionaires or oil sheikhs, really no relationship to reality.

The problem is, the guys who run the hospital, they don't know how much of that really costs them in terms of effort, activity and supplies.  They`re just guestimating it. And then they rack up the numbers. And they really go into a bathroom and negotiate with the insurers about the prices and Medicare tells them what they`re going to pay.

HAYES: So here -- you have put your finger on something that drives me insane, just personally, in my own life, right. I consider myself a fairly smart individual. I consider myself relevantly erudite.

EMANUEL: You don`t have to prove it, Chris, we agree.

HAYES: Well, let me tell you this, I cannot make sense out of hospital bills. For months and months and months after my second child was born, things would show up in the mail and it would be this inscrutable nonsense spreadsheet that I would devote all of my cognitive capacity to and come up completely empty about what the heck was going on, who was charging who, who was paying for what. It's nonsense.

EMANUEL: Chris, if it makes you feel any better, I've been getting some physical therapy for a problem I have with plantar fasciitis. I get virtually the same things week after week, and the bill varies by hundreds of dollars, and I can`t make any sense of out it.

And I'm a kind of expert in this field. So, they bear no relationship to reality.

And, look, the hope is, my hope certainly, is that as we move further into the reform effort, as we pay doctors and hospitals differently, these bills, this kind of funny money is going to go away.

The most progressive places in the country -- ironically not far from where this guy got treated for his rattlesnake -- they actually have done what are called time and motion studies, they know what it actually costs to deliver care and they can tell you that. And then they can put all the price together and give you actually a price that reflects the actual cost of caring for someone.

Now that's not to say the actual cost of caring for someone is any more rational.
One of the points I like to make is $153,000 for five days -- five nights in the hospital, that is three times the average income in America, three times the yearly income of the average person in America. That is an insane amount of money. We don't -- I mean, they could have done all of that...
Shards and sand.


I'm now deep into Steve Brill's "American's Bitter Pill." It is excellent.

Jumping right out at me:

I USUALLY KEEP MYSELF OUT OF THE STORIES I WRITE, BUT THE ONLY way to tell this one is to start with the dream I had on the night of April 3, 2014.

Actually, I should start with the three hours before the dream, when I tried to fall asleep but couldn’t because of what I thought was my exploding heart.

THUMP. THUMP. THUMP. If I lay on my stomach it seemed to be pushing down through the mattress. If I turned over, it seemed to want to burst out of my chest.

When I pushed the button for the nurse, she told me there was nothing wrong. She even showed me how to read the screen of the machine monitoring my heart so I could see for myself that all was normal. But she said she understood. A lot of patients in my situation imagined something was going haywire with their hearts when it wasn’t. Everything was fine, she promised, and then gave me a sedative.

All might have looked normal on that monitor, but there was nothing fine about my heart. It had a time bomb appended to it. It could explode at any moment— tonight or three years from tonight— and kill me almost instantly. No heart attack. No stroke. I’d just be gone, having bled to death.

That’s what had brought me to the fourth-floor cardiac surgery unit at New York– Presbyterian Hospital. The next morning I was having open-heart surgery to fix something called an aortic aneurysm.

It’s a condition I had never heard of until a week before, when a routine checkup by my extraordinarily careful doctor had found it.

And that’s when everything changed.

Until then, my family and I had enjoyed great health. I hadn’t missed a day of work for illness in years. Instead, my view of the world of healthcare was pretty much centered on a special issue I had written for Time magazine a year before about the astronomical cost of care in the United States and the dysfunctions and abuses in our system that generated and protected those high prices.

For me, an MRI had been a symbol of profligate American healthcare— a high-tech profit machine that had become a bonanza for manufacturers such as General Electric and Siemens and for the hospitals and doctors who billed billions to patients for MRIs they might not have needed.

But now the MRI was the miraculous lifesaver that had found and taken a crystal clear picture of the bomb hiding in my chest. Now a surgeon was going to use that MRI blueprint to save my life...

Brill, Steven (2015-01-05). America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System (Kindle Locations 58-78). Random House Publishing Group. Kindle Edition.

The chargemaster bill for my MRI had been $ 1,950, which my insurance company knocked down to $ 294.

My doctor had sent me for the test because he became suspicious when he took my pulse during a routine checkup. However, most doctors aren’t skillful enough or cautious enough to weed out possible victims that way, nor is taking a pulse anything close to a foolproof way to find an aneurysm. So let’s suppose we spent $ 300, through private insurance coverage or Medicare and Medicaid, to test all 240 million American adults to see if they had aortic aneurysms growing in their chests. That would cost $ 72 billion.

Suppose we economized and tested everyone only every four years. That would average out to $ 18 billion a year. Yet it would potentially save more than three times as many Americans as were lost in the September 11, 2001, attacks, which we have spent hundreds of billions to prevent from happening again, even trillions if you count foreign wars. So, would an aortic aneurysm lobby, consisting perhaps (if I had not been saved) of my widow or children (and backed by the MRI lobby), be so unreasonable in demanding that the country spend the $ 18 billion?

Then again, wouldn’t it be crazy to spend all that money to find the fraction of a fraction of a percent of people— 10,000 out of 240 million— who are susceptible to that, rather than spend it on general preventive care or on cancer research?

Put simply, money is a scarce healthcare resource. We have left it to Washington to allocate it based too often on who has the best lobby or the hottest fund-raising campaign. [ibid, Kindle Locations 7256-7268]
Yeah. Interesting, in light of my own imaging experiences of late. The book is replete with stories of other patients' maddening encounters with our ruinously expensive fragmented non-system. Highly recommended. Much more to cite as I complete reading it.

Stay tuned.

Also recommended, Mr. Brill's related Time article, Bitter Pill: Why Medical Bills Are Killing Us (pdf).

The Bill
Steven Brill on how health-care reform went wrong.


..The economic team felt that health care could use a good dose of market incentives. The Lambrew-DeParle view, on the other hand, was that health care is different: the complex nature of the relationship between patients and their health-care provider is so unlike ordinary economic transactions that it can be governed only through cost controls and complicated regulatory mechanisms. When the two sides argued, they weren’t just reflecting a difference in tactics or emphasis. Their disagreement was philosophical: each held a distinct view about the nature of the transactions that take place around medical care.

Brill sides with the DeParle camp. His solution for the health-care problem is to treat the industry like a regulated oligopoly: he believes in price controls and profit limits and strict regulations for those who work within the health-care world, restrictions that he almost certainly thinks would be inappropriate for other sectors of the economy. A patient, he explains at the beginning of his book, is a not a rational consumer. That was the lesson he took from his own heart surgery. “In that moment of terror,” he writes, of blacking out after his surgery, “I was anything but the well-informed, tough customer with lots of options that a robust free market counts on. I was a puddle.”

But Brill spends very little time examining why he thinks this means that the market can’t have a big role in medicine, where most care is routine, not catastrophic. He just takes it for granted. And because he is not much engaged by the philosophical argument at the heart of the health-care debate, he can never really explain why someone involved in health-care reform might be unhappy with the direction that the Affordable Care Act ended up taking. He tells us who controlled the PowerPoint. But he can’t tell us why it mattered.

It is useful to read “America’s Bitter Pill” alongside David Goldhill’s “Catastrophic Care.” Goldhill covers much of the same ground. But for him the philosophical question—is health care different, or is it ultimately like any other resource?—is central. The Medicare program, for example, has a spectacularly high loss ratio: it pays out something like ninety-seven cents in benefits for every dollar it takes in. For Brill, that’s evidence of how well it works. He thinks Medicare is the most functional part of the health-care system. Goldhill is more skeptical. Perhaps the reason Medicare’s loss ratio is so high, he says, is that Medicare never says no to anything. The program’s annual spending has risen, in the past forty years, from eight billion to five hundred and eighty-five billion dollars. Maybe it ought to spend more money on administration so that it can promote competition among its suppliers and make disciplined decisions about what is and isn’t worth covering...
Not sure how much I agree with Gladwell's take on this book (which I have now finished, btw). He cites Goldhill. I did as well, years ago, in my post "Public Optional."
Then there's David Goldhill's thoughtful Atlantic Monthly essay "How American Health Care Killed My Father."
I’m a Democrat, and have long been concerned about America’s lack of a health safety net. But based on my own work experience, I also believe that unless we fix the problems at the foundation of our health system—largely problems of incentives—our reforms won’t do much good, and may do harm. To achieve maximum coverage at acceptable cost with acceptable quality, health care will need to become subject to the same forces that have boosted efficiency and value throughout the economy. We will need to reduce, rather than expand, the role of insurance; focus the government’s role exclusively on things that only government can do (protect the poor, cover us against true catastrophe, enforce safety standards, and ensure provider competition); overcome our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and rely more on ourselves, the consumers, as the ultimate guarantors of good service, reasonable prices, and sensible trade-offs between health-care spending and spending on all the other good things money can buy...
Six years later we continue to argue about the same stuff.


Large payor mergers have been in the news of late. Anthem + Cigna, and Aetna + Humana. Will the administrative system fragmentation actually get worse, at least in the near term -- a "near term" that may well extend a decade?

The "Big Five" (which includes United Healthcare) will soon become the "Big Three" (absent Justice Department denials on antitrust grounds).

Again, going back to my original "shards" post:
[N]otwithstanding all of recent years' progressive policy push (including those contained in the PPACA) toward "P4P" (Pay for Performance), "ACO's" (Accountable Care Organizations), "PCMHs" (Patient Centered Medical Homes), "patient-centered continuity of care," etc, the legacy FFS (Fee For Service) paradigm and the inertia of industry incumbency will not go quietly into the sunset. Moreover, I have to wonder whether, despite all the news in recent years of healthcare space "consolidations" and "M&A's" (mergers and acquisitions), the fragmentation is actually getting worse, not better. More shards strewn about, and sharper around the edges. Corporate acquisitions are driven by near-term profit potential, not by noble, altruistic notions of materially improved care delivery unwaveringly focused on patients...
What do you think?

No shortage of press reaction.
How merger mania will impact the healthcare industry
By Heather Caspi, July 29, 2015

Anthem’s announcement last week that it will acquire Cigna—on the tail of Aetna’s recent purchase of Humana—officially brings the health insurance industry’s “big 5” companies down to the “big 3,” just as insiders predicted.

While much of the discussion on payer and provider mergers has revolved around the race in the industry for size and scale, and the accompanying antitrust concerns, there’s more to the subject than these major points, says Frank Ingari, CEO of NaviNet. NaviNet is the nation’s largest healthcare communications network, connecting providers to health plans including Aetna, Cigna and UnitedHealthcare. Ingari sat down with Healthcare Dive this week to discuss what he sees ahead for the industry amid all of the “merger mania.”

One point Ingari notes is that it’s likely to be business as usual for quite some time. Based on past events, the regulatory review period for these mergers could be at least a year, he says. Even after that, it’s a lengthy process for such large companies to actually integrate their strategies and operations. In the meantime, they’re likely to call upon their components to continue using their current business models to deliver bottom line performance.

“It tends to be that changes take a lot longer than people realize,” Ingari says. “It could be four to five years before you see one of these mega-mergers operating as if it were one company.”...
Yes, what I've argued as a concern.

More to come...

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