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Demystifying Medicine One Month at a Time

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Costs of Care

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Ever received a bill for a health service that troubles you? Does it seem too much?

Is it hard to understand what you owe from what insurance pays? Does it seem like the share you pay always goes up?

Medical costs are a universe unto themselves. How doctors and medical facilities (hospitals, radiology practices, etc.) come up with their charges seem to lack any rational basis.

Famously, in his article that became a book, author Steven Brill challenged the CEO of a big health insurance company to explain his ‘explanation of benefits’ (the bill-like statement you get that is NOT A BILL), and the CEO couldn’t do it. Here Brill recounts the story in an interview with Minnesota Public Radio. Context — Brill had a big operation for an abdominal aortic aneurysm, so he decides to use himself as a test case:

After I got home, about 2 or 3 days later, I received in the mail 36 different explanations of benefits from my insurance company, in 36 different first class envelopes, which tells you something about how inefficient the system is.

As I started to open them, I thought to myself: I’m the world’s leading expert on hospital bills and insurance bills, this is going to be fun. When I opened the third envelope, it said the following. This is an explanation of benefits from United Healthcare, which is headquartered in Minnesota: Amount billed: $0; amount paid by insurance: $0; amount you owe: $154.20. I looked at it and I looked at it. If nothing was billed, how could I owe $154.20? I turned it over, I tried to decode it, I couldn’t figure it out.

As it happened, before I went into the hospital, I had scheduled an interview with the CEO of United Health out in Minnesota … So as soon as I was able to travel, I went out to Minnesota and I did the interview. … And then at the end, I reached into my pocket and took out that explanation of benefits and handed it to him. I said: “I’m wondering if you could just help me understand this, I’m having trouble figuring out what this means. How could I be billed $154 if nothing was billed?”

He looked at it and he looked at it, he turned it over, he looked at the coding, and finally looked up and said to me: “I could sit here all day and I could not explain that to you. I have no idea what it means. I don’t know why they sent it to you.”

I said, “Aren’t you they?

That explanation of benefits is the single most common form that consumers receive in what is by far the largest industry in the United State: The healthcare industry. Tens of millions of those explanations of benefits go out from United Healthcare every year, and the head of the company can’t even understand what it means, so how are the rest of us supposed to understand what it means?

As an entree to discuss the issue of health costs in the U.S., and people’s disparate reactions to them, I share with you the story of Mrs. Sutton, a patient of mine who had a somewhat atypical reaction to the cost of her colonoscopy — even though she owed nothing out of pocket. I also want to emphasize how poorly doctors do in helping patients anticipate their costs of care. Reliable pricing information is hard for us to come by, too — as some commenters note. But some new companies (apps, of course) are trying to tackle this issue head-on.

Click on the box below to read it. Feel free to add your own story to the mix.

Evidence shows that in spite of mutual doctor-patient desire to discuss drug costs, we docs usually shirk the duty, writes Dr. John Henning Schumann.

Posted by NPR on Saturday, January 16, 2016

Thanks for reading.

Big Brother (er, Your Boss) is Watching You

corporate health raceJulie Appleby of Kaiser Health News wrote a nice story about the growing trend of employers that offer wellness programs to their employees.

There are a multitude of reasons why employers do this: mainly, it’s with a binary goal of encouraging employees to lead healthy lifestyles and in turn save money on health insurance premiums — both for the employees themselves but also as a business cost.

As Appleby’s article points out, neither the wellness benefits nor the savings are all they’re cracked up to be. First, the tests that are offered are not always recommended by the best available medical evidence — they’re superfluous in many cases and wind up costing time, money, and anxiety when they return a result considered ‘abnormal.’ Secondly, the evidence regarding workplace wellness programs is that they don’t save money — to the contrary, offering unnecessary testing to people that don’t need it simply adds to our national health expenditure.

All of the above is debatable, of course — proponents of testing cannot be swayed from the viewpoint that ‘catching things early’ is an unalloyed good. What’s not debatable is that as workplace wellness programs grow, more companies are using them as carrots and sticks — offering discounts on premiums, cash bonuses, or higher cost-sharing to those that don’t participate.

To get a flavor of how some employees view these types ‘optional-but-not-really-optional’ programs, I offer a couple of comments from NPR’s website in response to Appleby’s article.

From silicon28:

“Biometrics are growing,” as a way to help workers know if they face health challenges “they may not even know they have,” said Paul Coppol…”

That is complete baloney. Biometrics… including the current ones through my workplace insurance that are now tied to the “rebate” on our premium (a nice way to coerce everyone into the program to keep from paying a penalty, in reality) are all about saving money for the company and the insurance provider. Actually assisting the individual? Not even in the top ten reasons as to why this strange “big brother” monster keeps growing. I’m currently eating the $300 per year that I was initially supposed to have as a “reward” for being involved; now it’s tied to actual readings with BP / cholesterol, etc. that I have to “pass” before I can receive it. Even though I’m fully involved with my healthcare and none of these would be problematic, I’m not about to let the company that far into my HIPPA privacy. This entire phenomenon should be making people very, VERY afraid of what the next steps are that are coming…

From Averal:

Tying health insurance to employment is insane.
So what’s to keep your employer from finding something wrong with your performance, attitude, or SOMETHING.
when they discover you have early stage disease that has the potential to cost them a fortune to treat?

“Well he was a really nice guy, and he did his job, but it just wasn’t cost effective to keep him on the payroll.”

It’s well worth a look — click over and read the article.

Doctor, Don’t Treat Thyself. Or Family Members.

The day I started medical school, I called home to tell my parents about it. My mother, a hypochondriac, didn’t want to hear about the class schedule or the amount of work.

“I have a new rash I need you to take a look at,” she told me.

What did she think? That after one day, I’d suddenly been imparted all the knowledge I’d need to treat her? (As you’ll see later, I would come to wish that had happened.)

Silly Mom. As if I’d been admitted to some special club.

This comes up more often than you might think in medical practice. The ethics are fairly clear — it’s not illegal to treat family members or friends, but it’s unethical because those friends and family members cannot exercise their full autonomy when making medical decisions.

Just published on NPR’s Shots blog is a column I wrote about our experience caring for our daughter during this past winter’s flu season, and a couple of stories of familial ethical challenges from other doctors. Please click over and take a look. Thanks to Katherine Streeter for great collage art.

Gotta get me one of those “Dad” hats, but I’m not much into argyle.

“Everything’s Fine.” [Not.]

npr_alzheimers_final_wide-1b09fc6b3928be310d8acbe0f86a53047a7b100f-s800-c85Over the years, I’ve cared for many patients that come to the doctor because a loved one has urged them to.

Asked why they are visiting, they’ll often reply “My _____ made me.”

Most often, that blank is filled with “wife,” though not always.

Click over to NPR’s Shots to read about one such patient I cared for and what I missed.

Thanks to Lucinda Schreiber for gorgeous artwork that accompanies the piece.

Stories of Hope and Miracles

christmasgiftartHolidays can make us…sentimental.

Sometimes in spite of a worldview that prioritizes scientific rationality above all us, we see things that aren’t easily explained.

Its important to be open to wonder. Even for docs.

Post by NPR.
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