This Could Be the Obamacare Outcome we’ve All Been Waiting For

This often-overlooked long-term goal of Obamacare may be finding the mark according to this latest study from the American Cancer Society.

The third open enrollment period for the Affordable Care Act, best known as Obamacare, has been ongoing for roughly five weeks now. And as seems to be the trend around this time of year, more questions than answers appear to be swirling around healthcare’s law of the land.

Big changes lead to an uncertain future

Obamacare is facing a number of changes in the 2016 calendar year, and, frankly, no one is certain yet how those changes might affect enrollment or patient mix for insurers.

For example, insurance premiums are rising at about their fastest rate in about a decade. The Great Recession held premium rate inflation in check for years, but the failure of more than half of Obamacare’s health cooperatives, coupled with many low-cost insurers coming to the realization that their rates were unsustainably low, are leading to big premium hikes in the upcoming year.

Data from the Washington Examiner showed that 231 insurers requested double-digit percentage premium price hikes in 2016 compared to just 121 in 2015. Furthermore, the magnitude of these hikes — 61 plans are looking for a minimum premium increase of 30% this year — is much higher than 2015. In short, there’s concern that higher premiums could reduce the affordability of the program for those who don’t qualify for a subsidy, leading to a higher uninsured rate.

Meanwhile, the employer mandate will be fully implemented on Jan. 1, 2016. The employer mandate will require that businesses with 50 or more full-time-equivalent employees (FTE’s) offer eligible health coverage to those FTE’s and their dependents under the age of 26, as well as provide financial assistance in instances where low-income FTE’s would be paying more than 9.5% of their modified adjusted gross income out of pocket toward their premium. If qualifying businesses fail to follow the rules, they could be looking at a $2,000 to $3,000 fine per employee.
The big question here is how businesses will respond. Will bigger companies step up and supply health insurance for their workers or will we see layoffs, hour cutbacks, or a move to private health exchanges? Obamacare’s big changes in 2016 are leading to a seemingly uncertain enrollment outlook in the near term.

Obamacare’s incredibly important goal that you probably overlooked

The easiest way to measure the success of Obamacare has always been by its overall enrollment totals. Obamacare was first and foremost designed to reduce the number of uninsured and to utilize the individual mandate and employer mandate to make that happen. The Centers for Disease Control and Prevention reported in Q1 2015 that just 9.2% of U.S. adults remained uninsured, including Medicare patients, which is the lowest figure on record. By this token, Obamacare would appear to be hitting its primary goal.

But there’s an even more important long-term goal that’s often lost on critics when discussing Obamacare’s success or failure — namely, the impact that preventative (and earlier) medical access could have on reducing long-term medical costs.
For insurers, Obamacare is a bit of a give and take. Insurers are enrolling more people than ever, and they’re also being required to accept members with pre-existing conditions. The result is that some insurers, such as the nation’s largest, UnitedHealth Group, are dealing with adverse selection and losing money on their individual marketplace plans because they’ve enrolled a large number of sicker individuals. Even though some of its large peers such asAnthem are healthfully profitable, the margins most insurers are generating on Obamacare plans (if they’re even profitable in the first place) are relatively small.

Now here’s the catch: In exchange for spending more money on their members up front, it’s possible that chronic and serious diseases that are the primary expense culprit for insurance companies can be caught before they become a serious issue. Thus, while health benefit providers may be spending more now than they would like to, their long-term outlook is also looking brighter presuming the current generation of members is now going to be healthier than the last generation given expanded access to medical care.

This could be the outcome we’ve been waiting for.

This last point sounds great on paper, but it’s difficult to prove that Obamacare is really making a dent in lowering long-term healthcare costs, especially since it’s only been the law of the land for about two years. All that consumers and critics can focus on at the moment are the rapidly rising premium prices.

However, a new study from the American Cancer society that was published online in the Journal of the American Medical Association late last month appears to show that there is a correlation between Obamacare’s expansion and a higher rate of cervical cancer diagnoses in select patients.

Researchers from the Department of Epidemiology at Emory University and from the ACS’ Department of Intramural Research analyzed a large database of cancer cases within the United States, separating cervical cancer diagnoses for women ages 21 to 25 in one group from cervical cancer diagnoses in women ages 26 to 34 in the other cohort. The reasoning behind this split? Persons under the age of 26 are still eligible to be covered under their parents’ health plan under Obamacare, and thus the expansion of this dependent clause should give researchers a reasonable correlation of how well Obamacare is affecting the rate of cervical cancer diagnoses.

After examining cervical cancer diagnosis rates for both cohorts before and after the implementation of Obamacare, researchers noted that there was a substantial increase in the number of cervical cancer diagnoses for women ages 21 to 25, whereas the age 26-34 cohort had a relatively consistent number of diagnoses before and after Obamacare’s implementation.

On the surface, a rising rate of cervical cancer diagnoses may not sound good at all. But, in a different context it could be just the news we’ve been hoping for. The key to beating cervical cancer is discovering it early, and presumably being able to stay on their parents’ health plans until age 26 helped the 21- to 25-year-old cohort gain this vital medical access. It’s possible that this early diagnoses not only saved lives, but for insurers that it kept them from shelling out big bucks in mid- to late-stage cancer treatments.

Keep in mind that this is just one example, and one example does not make a trend. However, it’s long been postulated that reducing the barriers to health insurance would lead to a higher medical utilization rate for consumers and a better chance of discovering potentially serious and chronic conditions at an earlier time, thus saving the patients’ lives and cutting insurers’ long-term medical expenses. It’s possible we could be witnessing the first signs of that.

Understandably, we’ll want to see additional studies emerge that examine disease diagnosis and treatment rates in a pre- and post-Obamacare setting so we can make a conclusive ruling as to whether or not Obamacare could actually lower long-term healthcare costs and improve long-term patient survival rates. The initial signs, though, are very encouraging.

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How 6 key trends are driving the employee benefits landscape

Interesting report on trends shaping the design and delivery of employee benefits for the Workplace Benefits Summit.

By Melissa Winn, Employee Benefit Advisor

Emerging trends in the health care insurance and benefits landscape threaten to have a lasting impact on the way employers provide and administer employee benefit packages. Benefit advisers hoping to not only remain relevant to their clients, but to thrive during this time of adversity, will need to adjust to the changes ahead, according to Rick Lindquist, president of Zane Benefits.

He told attendees of the Workplace Benefits Summit that his company is focusing product development on 6 key trends in the industry today.

  • First and foremost is a sharp rise in the cost of employer contributions for health care insurance.
    (This trend is driving employers to seek ways to fix the cost of offering benefits so they can sustain them.)
  • Second, employee costs are also rising, and rising faster than wages, causing dissatisfaction.
  • The third trend is shifting more financial responsibility for benefits to consumers.
  • The fourth trend is the increased use of consumer technology, a trend which actually aids employers and advisers in shifting more responsibility to individuals.
  • Trend number five is the decrease in unemployment rates, will increase importance on employers’ compensation and benefit packages.
  • Last, millennials are entering the workforce in droves and will comprise the majority of the workforce by 2025. Millennials want to own their own way when it comes to benefit selection. They demand to operate at their own convenience.

The four characteristics of modern benefit offerings, Lindquist said, include:

  1. They are technology-driven, including through the use of a mobile experience and a Facebook like interface
  2. They offer maximum choice and convenience
  3. They are employer-funded, employee-owned
  4. They offer a better value than cash

For advisers these trends mean they must be able to deliver direct to consumer employee services, or broker a third party service.

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Group Health Premiums Inch Up While Deductibles Jump

By Jerry Geisel, Business Insurance

Excellent summary of a survey of employee benefits cost conducted by the Kaiser Family Foundation and the HRET. While premiums rose modestly in 2015, the employee’s share of healthcare cost went up significantly. No surprise that out-of-pocket costs will remain high for consumers around the country.

Group health insurance premiums continue to rise modestly, according to a survey released Tuesday by the Kaiser Family Foundation and the Health Research & Educational Trust.

The survey of nearly 2,000 employers conducted from January through June found that the premium for family coverage rose an average of 4.2% in 2015, increasing to $17,545. That 4.2% increase compares with average premium hikes of 3% in 2014, 3.8% in 2013 and 4.5% in 2012.

While premium increases were modest, cost-shifting to employees in the form of higher deductibles was not. This year, the average deductible for employees with single coverage increased to $1,318, up 8.3% over 2014.

“With deductibles rising so much faster than premiums and wages, it’s no surprise that consumers have not felt the slowdown in health spending,” Kaiser President and CEO Drew Altman in Washington said in a statement.

Other findings in the Kaiser/HRET survey include:

• Premium costs are considerably higher at larger employers than at smaller organizations. For example, the average premium cost in 2015 for family coverage among larger employers — defined as those with at least 200 employees — was $17,983. That compares with an average premium cost of $16,625 among employers with between three and 199 employees.

• Employees working for smaller companies pay a much greater share of the premium than those working for larger employers. For example, in 2015, employees working at organizations with between three and 199 employees paid an average premium of $5,904 for family coverage, $1,355 more than employees working at larger employers who paid an average $4,549 in premium contributions.

• Thirty-nine percent of employees with single coverage are enrolled in plans with an annual deductible of at least $1,000, up sharply from 32% in 2014 and three times higher compared with 2009, when just 13% of employees with single coverage faced deductibles of at least $1,000.

• The percentage of employers offering coverage to their employees varied considerably by employer size. For example, 97% of employers with at least 100 employees offered coverage to employees in 2015, up from 94% in 2014, while 54% of employers with between three and 49 employees offered coverage in 2015, up from 52% in 2014.

While enrollment in private health insurance exchanges remains modest — just 2% of covered employees in firms with more than 50 employees are enrolled in a private exchange — 17% of firms with more than 50 employees and 22% of employers with at least 5,000 employees are considering offering benefits through an exchange.

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Finding Help for the High Costs of Cancer Care

This article from the Philadelphia Enquirer contains valuable information about the high cost of cancer care and the options people have in managing those costs.

The good news is more Americans are surviving cancer.

The bad news? We pay big bucks to stay free and clear of the disease.

Nearly 14.5 million American cancer survivors remain alive and well as of Jan. 1, 2014, according to the American Cancer Society, the National Cancer Institute, and the Centers for Disease Control and Prevention. By 2024, cancer survivors will number 19 million people.

So how much does it cost to stay cancer-free? Quite a lot, says Zhiyuan Zheng, Ph.D. and senior health services researcher with the American Cancer Society in Atlanta.

For American men, the three most prevalent types of cancer among survivors are prostate (43 percent), colorectal (9 percent), and melanoma (8 percent). Breast (41 percent), uterine (8 percent), and colon and rectum (8 percent) are most common among women who survive cancer.

Prostate, colorectal, and breast cancers account for about 30 percent of all cancer-related health-care costs. The survivors incur higher medical expenses, are at higher risk of secondary cancer, and require more tests and follow-up care.

Total cancer treatment costs in 2004 were $72 billion, about $120 billion in 2014, and will increase to $180 billion by 2024, Zheng adds.

How does that break down per person? In the first 12 months, breast cancer treatment costs roughly $20,000, colorectal cancer $30,000, and prostate $10,000.

Lost workdays add to the total annual economic burden per cancer survivor: $20,238 for colorectal, $14,202 for breast, and $9,278 for prostate, for those under age 64, the researchers found.

Fortunately, cancer patients can now turn to medical bill negotiators who bargain with medical providers.

“We have a number of cancer patients who’ve hired us. Plus we’re also seeing a higher success rate” among cancer patients, says Derek Fitteron, founder and CEO of Medical Cost Advocate in Wyckoff, N.J.

One customer was a family facing $125,000 in bills incurred in a year for treatment of a rare childhood cancer.

“We reviewed the bills for billing accuracy and found comparable pricing negotiating savings of more than $85,000 with several Pennsylvania facilities,” Fitteron said.

Resources Cancer maintains a list of organizations that help patients financially

The Cancer Financial Assistance Coalition is a group of national organizations that provide financial help.

The nonprofit CancerCare provides limited financial assistance to people affected by cancer. It also has a foundation to help fund copays, the CancerCare Patient Assistance Foundation

The HealthWell Foundation similarly provides financial assistance to cover copayments, premiums, and deductibles for certain medications and therapies.

Partnership for Prescription Assistance helps qualifying patients who lack prescription-drug coverage obtain the medications they need.

Needy Meds offers information on companies assisting those who can’t afford medication.

The Patient Access Network Foundation assists patients with out-of-pocket costs associated with their treatment.

Patient Services Inc. assists with insurance premiums and copayments for people with chronic diseases.

RxHope.com helps patients obtain free or low-cost prescription medications.

The Assist Fund provides financial support to chronically ill patients with high-cost medications.

The Patient Advocate Foundation provides education, legal counseling, and referrals for people with cancer who need assistance managing insurance, financial, debt crisis, and job-discrimination issues.

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Hospital Charges Surge for Common Ailments, Data Shows

This excellent NY Times article is based on Medicare data on over 3,000 hospitals nationwide for what they charged in 2012. The data shows that the prices that hospitals charge is highly variable and has risen across the board. The article correctly points out that these increases in charges do not necessarily affect what Medicare pays because Medicare is so large that they tell hospitals what they are going to pay them independent of what they bill.

By JULIE CRESWELL, SHERI FINK and SARAH COHEN –  JUNE 2, 2014

Charges for some of the most common inpatient procedures surged at hospitals across the country in 2012 from a year earlier, some at more than four times the national rate of inflation, according to data released by Medicare officials on Monday.

While it has long been known that hospitals bill Medicare widely varying amounts — sometimes many multiples of what Medicare typically reimburses — for the same procedure, an analysis of the data by The New York Times shows how much the price of some procedures rose in just one year’s time.

Experts in the health care world differ over the meaning of hospital charges.

While hospitals say they are unimportant — Medicare beneficiaries and those covered by commercial insurance pay significantly less through negotiated payments for treatments — others say the list prices are meaningful to the uninsured, to private insurers that have to negotiate reimbursements with hospitals or to consumers with high-deductible plans.

“You’re seeing a lot more benefit packages out there with co-insurance amounts that require the holders to pay 20 percent of a lab test or 20 percent of an X-ray. Well, 20 percent of which price?” asked Glenn Melnick, a professor who holds a Blue Cross of California endowed chair at the University of Southern California. “Some hospitals will charge 20 percent of what Blue Cross Blue Shield will pay; others will play games.”
Data released by the federal government shows that hospitals across the country charge Medicare differing amounts for the same types of cases. The data includes bills submitted in 2012 by 3,300 hospitals nationwide for the 100 most commonly performed treatments and procedures like hip replacement, heart operations and gallbladder removal, among hospitals that reported at least 11 cases.

Charges for chest pain, for instance, rose 10 percent to an average of $18,505 in 2012, from $16,815 in 2011. Average hospital charges for digestive disorders climbed 8.5 percent to nearly $22,000, from $20,278 in 2011.

In 2012, hospitals charged more for every one of 98 common ailments that could be compared to the previous year. For all but seven, the increase in charges exceeded the nation’s 2 percent inflation rate for that year, according to The Times’s analysis.

Experts say the increase in the price of some of the most common procedures may be offsetting rising technology or drug costs, declines in the number of patients being admitted to hospitals and a leveling out of reimbursements from Medicare. Between 2011 and 2012, Medicare increased payment rates by only 1 percent for most inpatient stays.

The number of patients admitted for chest pain under Medicare’s fee-for-service plans plummeted more than 28,000, to 107,224 in 2012, and inpatients with digestive disorders decreased more than 29,000, to 217,514.

Over all, the number of Medicare patients discharged from hospitals for the comparable 98 most common diagnoses dropped from 7.5 million to 7.2 million. The total amount Medicare paid for their care also declined somewhat between 2011 and 2012, from $62.8 billion to $61.9 billion.
In an effort to reduce overall health care costs, hospitals have been encouraged to admit fewer patients for conditions like asthma, for example, in favor of less expensive outpatient care.

(more…)

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A Look at the Lives of American Nurses

Fantastic new book, film and website explores nurse’s critical role at the bedside working within the state of our current healthcare system. This film has received nationwide acclaim and is worth seeing.

By Nancy Szokan, Washington Post

Photographer and filmmaker Carolyn Jones created “The American Nurse” after publishing a coffee-table book on the subject two years ago, and the film builds on the same mix of powerful images with words of men and women whose lives are devoted to healing.

Over the film’s 78 minutes, viewers see Jason Short, an auto mechanic, describe how a bad motorcycle accident taught him what it was like to be helpless and in need of care; he is now a home health nurse in Appalachia. They follow Tonia Faust into her job at the Louisiana State Penitentiary: “People ask me how I can take care of people who have committed such horrific crimes,” she says.

“But when I’m at their bedside, I’m taking care of just another human being.”

The other nurses are a nun who runs a nursing home in Wisconsin, a labor and delivery nurse at Johns Hopkins Hospital in Baltimore and a former Army medic who rehabilitates wounded soldiers in San Diego.

After its premiere before an invited audience, the movie will be distributed nationwide through theaters and health-care centers. To see a trailer and a schedule of screenings go to: www.AmericanNurseProject.com.

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The Hospital-Dependent Patient

By PAULINE W. CHEN, M.D.

Interesting piece about the unintended cost and consequences of hospital re-admissions.  Spectacular advances in medical science have led to a growing population of patients who are “hospital-dependent” adding great cost to the healthcare system.

“He’s back?” my colleague asked, eyes widening as she passed the patient’s room. “He’s in the hospital again?”
Slender, pale and in his late 60s, the man had first been admitted nearly a year earlier with pressure in his chest so severe he had trouble breathing. When his heart stopped, doctors and nurses revived him by injecting the latest life-saving medicines into his veins and applying the newest electrical defibrillator paddles to his chest.

Within minutes, the cardiology team arrived, but when the blockage in the arteries of his heart proved too extensive for even their state-of-the-art techniques and equipment, they handed him off to the waiting surgeons. The surgeons, in turn, cooled down his heart until it stopped beating, sewed in bypass conduits with threads finer than human hairs, restarted the heart with a few well-placed jolts of electricity and then transferred the patient to the cutting-edge intensive care unit to recover.

The man survived. Sort of.

Weakened by this string of emergencies, he required a breathing machine for several days. When excess fluid in his lungs caused shortness of breath, he needed intravenous diuretics. When his heart began beating erratically, he was obliged to take a finely tuned cocktail of heart medications. And when his chest wound became infected, he had to return to the operating room.

Finally, after nearly two months in the hospital, he was discharged to a skilled nursing center. But then a urinary tract infection made him dizzy and confused, and he went right back to the hospital, beginning a cycle of discharge and re-admittance that would persist for almost a year.
To many of us who had cared for the man, it seemed as if he had spent more days in the hospital than out.

“What kind of life is that?” my colleague asked as we stood in the hallway and watched the man’s wife help him once again put on his hospital gown and pack away his street clothes. “You’ve got to wonder,” she whispered, “did we really do him a favor when we ‘saved’ him?”
I was reminded of the frail man and the many patients like him whom I have known when I read a recent Perspective piece in The New England Journal of Medicine titled “The Hospital-Dependent Patient.”

Over the last 30 years, American hospitals have become a showcase of medical progress, saving lives that not long ago would have been lost.

“Rapid response teams,” drilled in precision teamwork and the latest techniques of critical care, have become commonplace. Cardiac and respiratory monitors, once found only in intensive care units, are now standard equipment on most wards and even in many patient rooms. CAT scanners and M.R.I. machines, once rare, have become de rigueur, with some hospitals boasting duplicates and even triplicates.

But up to one-fifth of patients treated with these new medical advances and then deemed well enough to leave the hospital end up being re-admitted within 30 days of their discharge, at considerable cost. Insurers and third-party payers have begun penalizing health care systems for these quick re-admissions; and hospitals, in response, have begun significant efforts to improve the transition from hospital to home, creating clinics that remain open beyond usual working hours and marshaling teams of care coordinators, post-discharge pharmacists and “care transition coaches.”

The problem persists, though, because our spectacular advances in medical science have led to a growing population of patients who are “hospital-dependent,” according to the authors of the Perspectives article.

Hospital-dependent patients are those who, a generation ago, were doomed to die. Now they are being saved. But they are not like the so-called hot spotters, a group of patients more commonly associated with frequent re-admissions who return to the hospital because of inadequate follow-up care, failure to take prescriptions correctly or difficult socioeconomic circumstances. Instead, hospital-dependent patients come back because they are so fragile, their grasp on health so tenuous, that they easily “decompensate,” or deteriorate under stress, when not in the hospital.

Medical advances can snatch them from the clutches of death, but not necessarily free them from dependence on near-constant high-tech monitoring and treatments.

“They are like a house of cards,” said Dr. David B. Reuben, lead author of the article and chief of the division of geriatrics at the Geffen School of Medicine at the University of California, Los Angeles. “When one thing goes wrong, they collapse.”

Not surprisingly, hospital-dependent patients feel more secure and are happier in the hospital than at home. While clinicians and even family members may judge theirs a diminished existence, these patients find their quality of life acceptable, relishing their time with friends and family or engaged in passive hobbies like watching sports or reading the newspaper, albeit in the hospital.

Over time, however, their recurring presence can result in conflicted feelings among those who were responsible for saving them in the first place. Some clinicians even begin to resent their obligation to continue administering resource-intensive care. “Physicians are socialized to cure patients, then move on,” Dr. Reuben observed. “They want to treat patients, not adopt them.”

Dr. Reuben and his co-author offer potential solutions, such as specialized wards or facilities that would be more intensive than skilled nursing homes yet less costly than a hospital. But they are quick to add that more research must also be done. Their concept of “hospital-dependency” is a new one, so no research is available to help identify patients at risk of becoming hospital-dependent, estimate the percentage of early re-admissions they are responsible for or calculate the costs they incur.

Even without studies, it’s clear that the numbers of these patients are increasing. With every triumphant medical advance, there are patients who are cured but who remain too fragile to live beyond the immediate reach of the technology that saved them. Until we begin making different decisions regarding how we allocate our resources, their presence will be a constant reminder of which medical research and health care we consider worthy and which we do not.

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When Health Costs Harm Your Credit

By ELISABETH ROSENTHAL New York Times

This is an excellent article outlining the problems people can run into by allowing medical bills to go unpaid. It takes a long time to decipher what you actually owe, but providers can report you to credit agencies for late payment very quickly.  People in these types of situations have reason to worry.

LIKE most people, I am generally vigilant about paying my bills — credit cards, mortgage, cellphone and so on. But medical bills have a different trajectory. I (usually) open the envelopes and peruse the amalgam of codes and charges. I sigh or swear. And set them aside for when I have time to clarify the confusion: An out-of-network charge from a doctor I know is in-network? An un-itemized laboratory bill from a doctor I’ve never heard of? A bill for a huge charge before my insurer has paid its yet unknown portion of a hospital’s unknowable fee?

I would never countenance the phrase “60 days past due” on my Visa card statement. But medical bills? Well… with the complex negotiations that determine my ultimate payment, it often takes months to understand what I actually owe.

Unfortunately, I may be playing a dangerous game. Mounting evidence shows that chaos in medical billing is not just affecting our health care but dinging the financial reputation of many Americans: While the bills themselves frequently take months to sort out, medical debts can be reported rapidly to credit agencies, and often without notification. And even small unpaid bills can severely damage credit ratings.

A mortgage initiator in Texas, Rodney Anderson of Supreme Lending, recently looked at the credit records of 5,000 applicants and found that 40 percent had medical debt in collection, with the average around $400; even worse, most applicants were unaware of their debt. Richard Cordray, director of the federal Consumer Financial Protection Bureau, has noted that half of all accounts reported by collection agencies now come from medical bills, and the credit record of one in five Americans is affected.

A single medical bill reported to a credit agency can easily become a “millstone around your neck” said Mark Rukavina, principal at Community Health Advisors, a health care advisory service. He added: “It will take a long time to make that right, even once the bill is paid. I’ve had mortgage brokers call me and say ‘I have these people with great credit. They’ve refinanced before, but now they’ve got this medical bill and even though they’ve paid it off, I can’t get them a good rate.’ ”

Part of the problem is that there are few standards governing medical debts: One billing office might give you — or your insurer — 60 days to pay before pursuing collection. Another might allow you to pay off a bill slowly over a year. Many will sell the debt to collection companies, which typically take a cut of the proceeds and decide when or whether to report unpaid debt to credit agencies.

The problem is accelerating for several reasons. Charges are rising. Insurance policies are requiring more patient outlays in the form of higher deductibles and co-payments. More important, perhaps, is that while doctors’ practices traditionally worked out deals for patients who had trouble paying, today many doctors work for large professionally managed groups and hospital systems whose bills are generated far away, by computer.

Both Congress and the protection bureau have been trying to better insulate patient credit scores from the inefficiencies of our market-based medical system. Various proposals have been considered to differentiate medical debt from other forms; it could be erased once it has been paid off or not reported to credit agencies at all, for example. So far, the credit industry has fought successfully against such efforts, noting that they could allow some genuine scofflaws to evade legitimate charges. But it’s also good business, since health care bills are now the largest source of business for collection companies, according to consumer protection agency officials.

Having spent the last year reporting a series on American health costs, I’ve heard plenty about credit casualties.

Gene Cavallo, 61, a New Mexico businessman who put his children through college, had always paid his bills promptly and had an excellent credit rating, until he required surgical excision of a melanoma on his shin two years ago. The more than 60 bills generated for the surgery and six months of follow-up visits — arriving sporadically and ranging from 18 cents to $17,000 — came to $110,000; his insurance covered about $70,000.

When various providers asked him to pay the remaining $40,000, he requested itemized bills and balked at some of the “ridiculously inflated prices,” such as $85 for tweezers and $20 for a box of tissues. He argued the bills point by point, and ultimately agreed to pay $25,000.
But during the negotiations some of the debt was sent to collection. Two years later, he no longer answers the daily robocalls from collection agencies and has had a couple of credit cards canceled because his score has fallen. “It was a scary thing to do because I own a business and dabble in real estate, so the ability to borrow has always been important to me. And now I have no ability, I assume, to borrow for any reason.”
Michael S., who declined to give his full name so as to protect his reputation with business clients, had to declare bankruptcy in Wisconsin more than five years ago after a fraught year in which his toddler was evaluated for what proved to be a benign neurological condition that required no treatment: “You’d get bills for several different doctors’ groups and for tests and M.R.I.s and you don’t know what they are. I was having trouble figuring out who we owed what. And then, if it goes to collection, then suddenly they’re saying we need this paid now.”

With medical expenses, unlike most other purchases, you generally don’t know the price the hospital will charge in advance. And the subsequent bills and insurance statements — so-called explanations of benefits — are often layered in obfuscation and pressure tactics.

Consider Chris Sullivan of Pennsylvania, whose $2,770 bill for an echocardiogram offered a “prompt payment” discount of 20 percent if he wrote a check within 21 days — meaning a discount for not asking questions on a bill for a test he was told would be under $300.

Another “explanation of benefits” statement notified Joe Cotugno of New York City that his two-day hospital stay for a hip replacement was billed at $99,469.70 (doctors’ fees not included). Cigna paid $68,420.53 after knocking off some $28,000 and requiring Mr. Cotugno to pay $3,018.41. So, it informed him, “You saved 96 percent.” Huh?

The Consumer Financial Protection Bureau has been studying the impact of medical billing on credit scores since 2012, acknowledging that unpaid medical bills in collection “frequently end up on consumer credit reports,” as an outgrowth of “very complex and confusing systems of figuring out who owes what after a medical procedure.” Mr. Cordray, the bureau’s director, said it would take appropriate action if harmful practices were identified.

Bills in Congress that would regulate the practices have been stalled for years. The Medical Debt Relief Act was passed by the House in 2010, but never made it to a Senate vote. After a modified version of the bill failed to pass again last year, another act was recently introduced in the Senate and House.

Meanwhile, patients are right to worry. When Matt Meyer, who owns a saddle-fitting company in New Hampshire, set up a monthly payment plan after some surgery, he was distressed to notice that the invoices came from a debt collector. “I had no idea this was considered debt,” he said, and wondered: “Are they reporting that” to a credit agency?

Good question.

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Americans don’t know what’s in Obamacare, do know they don’t like it

By Sarah Kliff, Washington Post

Fifty percent of Americans now say they oppose the Affordable Care Act. This is the highest number that Kaiser Family Foundation’s poll has seen since October 2011, when Republicans were in the midst of a primary cycle and lots of anti-Obamacare rhetoric was in the air. The easiest explanation for the recent upswing in negative sentiment would be that lots of Americans tried, but failed, to buy insurance through HealthCare.gov. They ran into technical barriers that plagued the site in October and November. But Kaiser’s data don’t really bear out that thesis. There’s actually only been a tiny uptick in the number of Americans who say the health-care law has affected their lives over the past three months. A full 59 percent of Americans still report no personal experience with the law. 

Most Americans don’t know that Obamacare has, at this point, pretty much fully taken effect. When surveyed in January, after the insurance expansion began, 18 percent said they thought “all” or “most” provisions of the Affordable Care Act had been put into place.

There’s lots of confusion, too, about what policies are and aren’t part of the health-care law. Most Americans know there’s a mandate to purchase health insurance. A lot fewer are aware that the law provides financial help for low- to middle-income Americans (the tax subsidies) or gives states the option of expanding Medicaid.

For many Americans – particularly the 68 percent who get coverage through their work, Medicare and Medicaid — the launch of the exchanges probably doesn’t affect their coverage situation. They’ll continue getting insurance in 2014 just the same way they did in 2013. For them, an expansion of Medicaid or an end to the denial of coverage for people with pre-existing conditions isn’t a big change (unless, of course, they lose their current coverage).

So what’s driving the negative opinions of Obamacare? The Kaiser survey does point to one potential culprit: negative news coverage. More Americans say they’ve seen stories about people having bad experiences with the Affordable Care Act than good ones.

Politico’s David Nather had a great line on this recently, in a story about the very high bar for success stories about the Affordable Care Act.

“Here’s the challenge the White House faces in telling Obamacare success stories: Try to picture a headline that says, ‘Obamacare does what it’s supposed to do,’ ” Nather writes. “Somehow, the Obama administration and its allies will have to convince news outlets to run those kinds of stories — and to give the happy newly insured the same kind of attention as the outraged complainers whose health plans were canceled because of the law.”

We don’t have a great sense yet of what type of experience Obamacare’s new enrollees are having — whether they’re disproportionately bad or if the bad stories are just more interesting to cover. But the more negative news coverage does seem to have played some role in the recent uptick in negative opinions about the new law.

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The battle of the anecdotes: Gird yourself for Obamacare’s newest fight

By Sarah Kliff

Below is an interesting piece by Sarah Kliff on how the Affordable Care Act is changing the American health-care system — and being changed by it. At this stage, the report card for the program depends largely on who you ask.

Fliers promoting the Get Covered Illinois health insurance marketplace sit in a box at the Bureau County Health Department offices in Princeton, Illinois, U.S., on Wednesday, Dec. 18, 2013. Today’s deadline for Americans to sign up for Obamacare health coverage effective Jan. 1 was extended until midnight tomorrow as heavy traffic to the online enrollment system caused a queuing system to be activated.

If you want to believe Obamacare is going great, you should call up Linda Browne. She’s a 62-year-old retired accountant from California who already has an appointment to see her new primary-care doctor at Kaiser Permanente, the new health insurer she signed up with through Covered California.

“I thought I would have to wait a long time,” Browne says. “But when I called, they said she had an appointment Wednesday for a physical.”
If you’d prefer to believe Obamacare is going terribly, then Michael D. Scott has got a story for you. He’s a 36-year-old Texan who turned up at a pharmacy last week trying to fill a $700 prescription for anti-seizure medication — only to find the technicians had no record of his enrollment.
“I’m stuck,” says Scott, who takes the prescription to treat a genetic condition called Ehlers-Danlos syndrome. “I’m going to have to start buying a couple days’ worth on my own if they can’t figure things out. It’s disappointing.”

Both Browne and Scott signed up for health insurance through the Affordable Care Act. Browne has had the law work pretty well; Scott has spent hours on the phone with customer service representatives (actually, he spent one hour and 37 minutes on his last call — yes, he timed it). And stories like theirs are about to become central to the next Obamacare fight, what I like to think of as the battle of the anecdotes.

The battle of the anecdotes is all-but-guaranteed because access to health care is really difficult to measure, even more so than the number of people who have enrolled or how well HealthCare.gov is functioning. With enrollment, for example, HealthCare.gov can track all the people who pick a private insurance plan, as can the 14-state based insurance exchanges. That’s how we know 2.1 million people have selected private insurance plans (although we don’t know how many have paid their first month’s premium, which is due, for January coverage, by this Friday).

The federal government can gauge how well HealthCare.gov is working by tracking how long it takes pages to load, or how many enrollment files — known as ‘834s’ — contain errors. And the call centers know, too, how long customers have to wait to get a person on the line.

But when it comes to access to health care, there’s no analogous metric. Our health-care system is really fragmented. Since HealthCare.gov shoppers are buying private coverage, and not a government plan, we have no central clearing house to understand whether more shoppers are having an experience like Scott in Texas — or like Browne in California.

Nonprofit institutions do study these types of questions. The Commonwealth Fund, for example, regularly looks at how long patients in different countries have to wait to see a primary-care doctor or a particular surgeon. But these surveys take months to conduct and analyze, meaning that we will probably have to wait until late 2014 or early 2015 to get a sense of what access looks like under the Affordable Care Act.

Enter the anecdote, which can be great to understand how new policy programs are impacting the way that Americans receive health care. But they can also be a really terrible way to gauge whether Obamacare is going great — or is a complete disaster. One or two stories don’t do a great job of capturing the experience of the millions of Americans who have signed up for health plans.

And even the anecdotes themselves can be nuanced, portrayed in different ways to make Obamacare seem great, or horrible. Take Browne: She called for an appointment in her new network the morning of Jan. 2. But she couldn’t get through to a real, live person until that afternoon; she kept getting a message that said “all circuits are busy.”

(more…)

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