healthcare advocacy

Trump and Congress Tried to Make Coronavirus Testing and Treatment Free, but People are Still Getting Big Bills when They Go to the Hospital

Maria Montecillo Leave a comment

In the early stages of the pandemic, the rules regarding insurance and patient billing for a suspected or confirmed COVID-19 diagnosis were not very clear. One must do his/her due diligence in asking your own insurance company how they will be processing a claim. Many provider billing departments send out invoices automatically via computer. Make sure you check your invoices carefully, as Coronavirus testing and treatment should be “free.” What this truly means is “no out-of-pocket costs or cost-sharing” for the patient.

Kimberly Leonard – Businessinsider.com – 5/21/20

The Trump administration set up a fund for the uninsured. But Imad Khachan, a coronavirus patient who is uninsured, received a large medical bill after a hospital stay.
– Congress and the Trump administration tried to protect coronavirus patients from getting large medical bills, but problems are popping up.
– Two patients who tried to get treatment for coronavirus symptoms didn’t get tested, but still received large medical bills.
– One uninsured patient living in New York City got a nearly $50,000 bill after a three-night hospital stay for coronavirus care.
David Anthony in New Jersey received a $1,528.43 bill for a chest X-ray.
Lindsay Hill in Milwaukee spent 30 minutes in a triage tent and later received a $1,186 bill in the mail.
Imad Khachan from New York City received a bill for nearly $50,000 after a three-night hospital stay.
Patients who seek medical attention for COVID-19, the disease caused by the coronavirus, are not supposed to be getting large charges like these.
President Donald Trump signed two measures into law to protect patients with the coronavirus — and those who seek help because they fear they have it — from having to pay for testing and treatment. His administration is also letting hospitals bill the government directly for coronavirus testing and treatment for the uninsured, instead of charging patients.
But the changes aren’t happening seamlessly. Whether because of bad timing, an incorrect billing code, or being unable to get tested, documents sent to Business Insider show patients who sought medical help for the coronavirus are still facing big bills.
Business Insider previously reported on loopholes in the laws that were passed to protect patients from big medical bills related to the coronavirus. Michael Santos, for instance, received a $1,689.21 bill after unsuccessfully seeking a coronavirus test and getting a flu test and X-ray instead. His insurer decided to cover the cost of his emergency department visit after Business Insider inquired about it.
Christen Linke Young, a fellow with the USC-Brookings Schaeffer Initiative for Health Policy, said part of the reason patients are still getting large medical bills is that healthcare providers are “dealing with a whole bunch of new payment options.” On top of that, she said, there are loopholes in the new laws and regulations.
“It’s going to result in a significant amount of confusion on the consumer end,” she said, adding that “people’s fear of bills could deter them from seeking care.”

Uninsured small businesman in NYC gets COVID-19

Khachan, 56, the patient in New York City, spent three nights at the end of March in the hospital being treated for the coronavirus.
Khachan owns a chess shop called the Chess Forum in Greenwich Village that has been shut down since March 20. He had been covered by private health insurance until Dec. 31, 2019, but had foregone coverage for 2020 because of cost.
On March 24, while still in the hospital, Khachan paid the hospital $5,000 out of pocket for care, according to a receipt he received from Northwell Health, the health system the hospital belongs to.
“Everyone in the hospital was extremely kind and nice and wonderful and the hospital itself is a great medical facility that offers great medical care,” Khachan said in an email to Business Insider.
A couple of weeks after he was discharged, he was stunned to receive a bill for $47,915.20. He also received several other smaller bills for treatment and tests, as well as a $788.50 ambulance bill. He said he couldn’t afford the bills and had expected to pay roughly another $5,000.
In a later email from the hospital that Khachan shared with Business Insider, Lenox Hill said he owed a lower amount of $32,864.20.
Khachan appeared to be a victim of bad timing. He received his bill before the Department of Health and Human Services set up a website where hospitals can request reimbursement for coronavirus testing and care for the uninsured.
The administration announced the fund for the uninsured on April 22 and the website wasn’t up until May 6, which was after Khachan received medical care and his first bill. Payments from the federal government to hospitals started going out May 18, according to the Trump administration.
Under the fund’s rules, hospitals can get paid for anyone who is uninsured who received testing or care for the coronavirus starting on Feb. 4. Hospitals aren’t obligated to use the fund, and it is not yet clear how many will choose to participate.
Terry Lynam, a spokesman for Northwell Health, said the hospital first had to enroll to use the online portal, which took a few days, and then started filing claims for uninsured coronavirus patients on May 14.
Khachan’s claims would be included, meaning he won’t have to pay for the medical care and will be refunded his $5,000 deposit, Lynam said. Northwell plans to call Khachan to double check his information and will send the check before the end of this week, Lynam said.
Hundreds more patients were uninsured and treated for the coronavirus at Northwell’s hospitals alone. Bill Fuchs, who oversees billing at Northwell, said so far its hospital system filed coronavirus claims to the government for roughly 800 uninsured patients.
The hospital system said it’s also instituting a 60-day hold on all patient bills, which prevents them from being turned over to collections. The hold can be renewed depending on financial hardship.
As for the bill for the ambulance, which was provided through the New York City Fire Department, that won’t be covered by the federal uninsured fund, because the department isn’t eligible to use it, a spokesman for the department said.
Federal health officials won’t say how much money they set aside for the uninsured and it’s not clear whether the funding will be adequate at a time when nearly 39 million people have lost their jobs — and, many of them, the insurance that came with them. The Kaiser Family Foundation estimated that the cost of treating uninsured patients with the coronavirus could land between $13.9 billion and $41.8 billion.
Linke Young from Brookings said people with the coronavirus who have smaller bills were likely to pay them rather than contest them under the new rules because they don’t know about the federal fund for the uninsured.
She said she would advise patients to call the hospital or doctor’s office and explain why they believe the provider is entitled to reimbursement from the federal government, and for the patient to ask the provider to pursue that option.
“There is nothing that tells providers they can’t bill the consumer first,” she said.
“These funds didn’t use to exist and providers were just doing what they have always done — sending bills,” she added.
Patients sought help for coronavirus but ended up with no answers and big bills.

Patients are getting billed in other instances
Anthony, 34 — who asked to use his middle name for this story to protect his family’s privacy — did a video visit on March 23 because he feared he had the coronavirus after he had chest pain that lasted several weeks and spread to his abdomen. His doctor recommended he get an X-ray, so he did.
He didn’t receive a coronavirus test and, after examining the X-ray, the doctor told him he likely had inflammation in the lungs and advised he take Advil.
A couple of weeks later, Anthony got a $52.94 bill for the online consultation. A couple of days later he received a bill for $1,528.43 for the X-ray. He was confused about the telehealth bill because he had understood all virtual visits were supposed to be covered without a copay — a change his insurer, United HealthCare, announced March 18.
He received the bill because he hadn’t yet met the deductible for his insurance plan, Anthony told Business Insider. His insurer told him the healthcare provider billed for pleurodynia, a lung infection that causes chest pain.
Anthony paid the bill with money from a health savings account.

‘Textbook COVID’ and a $1,186 bill
Hill, 39, the patient from Wisconsin, on April 5 visited a triage tent at St. Luke’s Medical Center because she worried she had the coronavirus.
Nurses measured her temperature, her pulse, and her oxygen levels, and listened to her lungs. Over a video inside the tent, Hill spoke to a nurse practitioner who told her that her symptoms were “textbook COVID.”
But, the nurse told Hill, she wouldn’t be admitted to the hospital because her oxygen levels were healthy. And because she wasn’t being admitted, the hospital wouldn’t be performing a coronavirus test.
“She told me that I ‘most likely’ had it, told me to quarantine myself for two weeks, take extra cleaning precautions around my family, and come back to the ER if my breathing became even more labored,” Hill told Business Insider in an email. “I was in and out of the triage tent in about 30 minutes. No tests were run on me, but my discharge papers read, ‘suspected COVID-19.’”
At the end of April, she received a $1,186 bill.
“It was my understanding from what I had read and what I had heard that there would not be a bill for it,” she told Business Insider.
Anthony and Hill both sought care because they worried they had the coronavirus. Under Trump administration rules, “presumed cases” of coronavirus are supposed to be covered, but it’s left up to healthcare providers to bill an insurance company for COVID-19.
“A presumptive case of COVID-19 is a case where a patient’s medical record documentation supports a diagnosis of COVID-19, even if the patient does not have a positive in vitro diagnostic test result in his or her medical record,” said a Health Resources and Services Administration spokesperson.
When patients see doctors, they sometimes order other tests to rule out similar conditions. That means patients can still get charged for those tests even if they only went to a provider in the first place because they feared they had the coronavirus.
Linke Young from Brookings pointed out that other patients could end up in similar situations. For instance, patients could get big bills after getting checked out at a hospital that didn’t have coronavirus testing, or after going to a clinic and finding out they didn’t have the coronavirus after all.
“There is nothing to protect them from getting those bills,” she said.

Health insurers revisited the medical bills
When Business Insider asked about Anthony’s charges, United HealthCare said that it was waiving all out of pocket charges for him after reviewing the services he received, and said it would refund his payments. The company is waiving charges for coronavirus treatment from February 4 to May 31, and providers have to bill the visit as related to COVID-19.
Hill is appealing her bill. She called her insurance provider, Blue Cross Blue Shield of Illinois, which told her that its billing practices had changed since the beginning of April because of the pandemic. The insurer called St. Luke’s to re-code the diagnosis so that it would be covered.
Hill said her insurer was helpful, and she will find out the result of her appeal within 30 days. BCBS Illinois told her that if for some reason the hospital doesn’t recode the bill, then she can appeal to the insurer and submit her discharge papers that read “suspected COVID-19.”
Asked about company’s practices, Katherine Wojtecki, spokeswoman for BCBS of Illinois, didn’t comment specifically on Hill’s case but said in an email that “our focus is on helping our members access medically necessary care amid the coronavirus public health emergency and ease the burden of individuals who may be facing challenging circumstances, so they can focus on their health and well-being.”
LeeAnn Betz, spokeswoman for Advocate Aurora Health, the health system St. Luke’s belongs to, also didn’t comment on Hill’s case but said in an email that patients who arrive at facilities with symptoms of coronavirus will get tested.
“We’ve had to react quickly to changes that insurance companies made in how they wanted services billed during this pandemic, but it’s a priority that our patients are informed on what services they are receiving and why they are being performed,” she said. “In most cases, insurance companies are paying for COVID¬-related services without any remaining patient financial responsibility.”

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How Not To Get “Hurt” Giving Birth: Medical Billing Tips for Parents

Maria Montecillo Leave a comment

The Cost of Giving Birth: What Expecting Parents Should Know About Medical Billing

Giving birth in America comes with a lot of costs, some disclosed and some not. It is possible to manage the cost of childbirth through informed, careful decision-making. The key is to plan ahead. The below article includes quotes by Medical Cost Advocate and appeared on Fatherly.com on August 16, 2019

By Adam Bulger – Fatherly.com

Giving birth

Moments after my daughter’s birth, I basically had to negotiate the cost of a timeshare.

My first job as a new dad was choosing a recovery room at a Manhattan hospital known for luxury accommodations. It was the dead of night. I was exhausted and unsure about our insurance coverage, so I opted for a lower-tier option. Months later, our insurance covered the room but, because of a billing error that took months to resolve, didn’t cover basic care.
Sorting out the cost of birth was confusing and stressful. But compared to other parents, my family had it pretty easy. Giving birth in America is an expensive, confusing process where parents often feel like they have no choices or negotiating power. But medical billing experts and maternity care advocates say it’s possible to manage the cost of childbirth through informed, careful decision-making.

In a 2013 national study of inpatient care costs, pregnancy and childbirth hospitalizations accounted for five of the 20 most expensive conditions for hospital stays covered by Medicaid and three of the 20 most expensive conditions for hospital stays covered by private insurance. The mean hospital stay expense is $18,000. All told, a standard birth could run you roughly $30,000. If a C-Section is required? It’s considerably more. But despite the price tag, births aren’t big money-makers for hospitals. Sean P. Lillis, founder and CEO of New York City–based medical billing services firm Billing Geeks, notes that the high cost of birth for parents doesn’t translate into enormous profits for hospitals.

Per Lillis, hospitals don’t make money off of obstetrics. Hospitals have to devote considerable time, resources, and staff for labor. Despite the overhead, private insurance pays hospitals according to fee-for-service schedules, meaning insurance pays more to hospitals for some types of patients, like the ones undergoing short stay surgical procedures requiring a battery of tests and procedures, than others, like the ones giving birth. “They can’t make their maximum reimbursement charge rate,” he says.

While the real action of having a kid happens in the delivery room, that’s not what you pay for. Most labor costs happen later, during the mom’s short hospital stay following birth.
“Four out of five of all dollars paid on behalf of the mother and the baby across that full episode from pregnancy through the postpartum and newborn period go into that relatively brief hospital window,” says Carol Sakala, Director of Childbirth Connection Programs at the National Partnership for Women & Families.

Some of the hospital costs, like medical tests for the baby and mother, can’t be avoided. Others you might be able to work around. Some hospitals reportedly impose fees for using their TVs; others can charge as much as $20 for an Ibuprofen. Packing an iPad and a bottle of Advil in your go-bag can defray some of those gotchas. But, honestly, saying no to these add-ons is chump change compared to what you can save by doing a little homework ahead of time.

How to Avoid the High Costs of Child Birth
Maria Montecillo, a healthcare insurance and billing advocate for the New Jersey medical billing advocacy firm Medical Cost Advocate, says parents should get in the weeds of their health plan as soon as they know they’re expecting. Knowing what health care providers are in your network makes a huge cost difference. And if your network’s too small, you may be lucky enough to be able to expand it. While it isn’t easy to time a pregnancy, the months leading up to your company’s health care enrollment period are an ideal time to make informed coverage changes.

“If you know you’re going to be pregnant this year, think about changing your insurance coverage,” Montecillo says. “You’ll pay a higher premium now but it’ll work out later.”
And when you’re getting close to the due date, taking your time can save a lot of money. Hospitals often try to slot births into a timetable that benefits the institution but may harm its patients, as there’s evidence early admission correlates with higher rates of labor induction and C-section births.
“The system is, for its convenience, pushing women into giving birth at weekday, daytime, non-holiday hours,” Sakala says. “A vast number of labor inductions, which add costs, could be avoided, a vast number of Caesarians, which add costs, could be avoided.”

Delayed admission to labor, where the mother doesn’t enter the delivery until they’re in active labor, is a simple way to reduce the cost of birth. Under delayed admission, the mother, ideally with the guidance of a midwife, doula, or other birthing professional, monitors the frequency and intensity of her contractions.

If the expectant mother has a hearty constitution or advanced skills in pain management, forgoing an epidural can avoid billing surprises.
“One of the places where people are getting into trouble with out-of-network providers is with the anesthesiologist,” Sakala says. “You didn’t choose that person, and the person who’s on call at that time could very well be out-of-network and those charges could be sky-high.”

It might be possible to skip the hospital — and its price tag — altogether. Sakala is a big proponent of birth centers, non-hospital labor facilities that offer natural births, without epidurals, inductions, or Caesarians or the high costs associated with those procedures. “They’re avoiding many things that are avoidable and pulling in beneficial practices that might be kind of low-tech, like being up and about, as opposed to staying in bed,” she says. “Or being in a tub or being in a shower. Those kinds of things can make a huge difference.”

The first month after the birth, parents have a small window of opportunity to shuffle around their insurance coverage. If the mother and father have separate insurance coverages, a baby’s birth is automatically billed under the mother’s insurance. They have 30 days to add the newborn to either the mother or father’s policy. Tracking the vagaries of insurance coverage can easily slip down the priorities list when you’re dealing with a newborn but ignoring it can court disaster.
“I once had a case where the parents ‘forgot’ to add the baby into their insurance plan, and they had to wait until open enrollment for the baby to be added,” Montecillo says. “As luck would have it, the baby developed complications and needed surgery. The insurance company stuck to their guns and refused coverage for the baby, as this was clearly stated on the policy and the parents were hit with a huge medical bill.”

When your insurance company’s bill for the birth arrives, don’t rush out to the post office with a check. Take your time and scrutinize the charges. Insurance coverage is complicated, even for insurance professionals. Mistakes happen. An insurer may have calculated a payment on the basis of an incorrect fee schedule for your plan or charged you for something that wasn’t performed.
“Look over the bill carefully,” Montecillo says. “It’s just like at a restaurant. You want to see that if you ordered chicken nuggets that they charged you for chicken nuggets.”

Spotting a costly error can be infuriating. Nonetheless, overt hostility is the wrong approach to the discovery. Montecillo says that everything is negotiable — she chiseled down a $60,000 triplet birth to a $1,300 final bill, for example — but only when the person on the phone wants to negotiate. And that means being not just polite but persuasive. “Start with sweetness but if you’re not getting anywhere, ask to talk to a manager,” she says.

And Montecillo speaks from experience. Before working on behalf of consumers, she spent 14 years as billing manager for a large private medical practice.
“I was on the other end of those calls and I know that I can make changes,” she says. “But if you’re nasty or you’re saying mean things about the doctor, I can say no.”

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New Proposal Aims to Address Rising Out-of-pocket Health Care Costs: Prospect for Bipartisanship?

Maria Montecillo Leave a comment

Republicans and Democrats have an opportunity to work together to come up with reforms to address the high cost of health care. A draft discussion was recently released addressing surprise billing and the rising cost of prescription drugs, two of the most common problems for patients. We are hoping that this draft bill will be passed soon to help reduce out-of-pocket health care costs for everyone.

New Proposal Aims to Address Rising Out-of-pocket Health Care Costs: Prospect for Bipartisanship?

by Kara Jones

 

Blog photo 061219

Republicans and Democrats have an opportunity to work together to come up with reforms to address the high cost of health care. There are some areas of agreement on this issue. The Senate Health, Education, Labor, and Pensions (HELP) Committee, led by Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) released a draft discussion of nearly three dozen specific proposals to reduce out-of-pocket health care costs and increase health care price transparency.

The five main parts of the draft bill, the Lower Health Care Costs Act of 2019, include:

1. Tackle surprise medical billing: The bill would make sure that patients are not held responsible for surprise medical bills received when they see an out-of-network doctor that they didn’t choose. The bill lists three different approaches that health care providers and insurance companies could take to resolve payment for these surprise bills.

2. Lower the price of prescription drugs: The bill would ensure that pharmaceutical companies don’t game the system to prevent new and lower-cost generic drugs from coming to market. It would also help generic drug and biosimilar companies to speed drug development and avoid patent infringement by providing a searchable patent database. These actions would get lifesaving drugs into the hands of patients more quickly.

3. Increase transparency in the health care market: The bill would set up a non-profit entity to create an all-payer claims database, which would house anonymous patient health care data that patients, states, and employers could use to better understand their health care costs. The bill would also ban certain anti-competitive hospital contracts, such as those that prevent insurers from sharing pricing information with patients.

4. Improve public health: The bill would authorize grants to address important public health issues such as increasing vaccination rates and reducing maternal mortality. It would also give states an evidence-based guide to develop programs to prevent obesity and other chronic health conditions.

5. Enhance health information technology: The bill would give patients full, electronic access to their own health care claims information and would incentivize health care systems to keep patients’ personal health information private and secure.

Health care reform is a polarizing issue between Republicans and Democrats, and with current gridlock in Congress, it is not possible for either party to pass its own comprehensive reform. However, rising health care costs continually rank in the top three issues that voters are most concerned about. This presents an opportunity for the two parties to come together and compromise on ways to reduce health care costs for all Americans.

Two areas where we are most likely to see movement in Congress are on surprise billing and prescription drug costs. Large surprise medical bills have become a growing problem for patients who unknowingly visit health care providers that are out-of-network. And as insurance deductibles continue to rise year after year, patients are feeling high prescription drug costs more acutely.

There have been numerous bills introduced to address these two issues, and both Republicans and Democrats agree that patients need relief. The Lower Health Care Costs Act of 2019 would directly address these issues, as well as the others listed above, in its aim to reduce out-of-pocket health care costs.

The Senate HELP committee is requesting input on the draft to be submitted to LowerHealthCareCosts@help.senate.gov.The committee plans to hold hearings on the legislation by the end of June and put the bill to a vote later this summer.

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Medical Cost Advocate was featured in a documentary by a French journalist

Maria Montecillo Leave a comment

A French journalist from CAPA TV (the equivalent of 60 Minutes in the US) came to our office and interviewed our CEO Derek Fitteron regarding our advocacy services. The interview was also about our client Stella who is featured on the previous blog. Watch how Stella was very stressed over the thousands of dollars in medical bills that she received when her triplets were born prematurely, and how her Advocate helped her in resolving these bills.

To watch it subtitled in English, go to settings➡️subtitles➡️auto translate➡️English.

You will see Stella, Stella’s advocate Maria, and Derek beginning at the 7:20 mark.

 

 

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Why does it cost $32,093 just to give birth in America?

Maria Montecillo Leave a comment

Our company receives many inquiries like this. Stella had approached us last April, emotionally distraught over the thousands of dollars in medical bills she was receiving related to the premature birth of her triplets. One of our expert medical billing advocates was assigned to take her case. She was very happy with the favorable outcome (a reduction in her final balance by an incredible amount), and so were we. Like Stella, we may be able to help you too. 

The US is the most expensive nation in the world in which to have a baby – and it may factor into thousands of bankruptcies each year.

Tue 16 Jan 2018

Jessica Glenza in New York – The Guardian

Stella Apo

Stella Apo Osae-Twum and her husband did everything by the book. They went to a hospital covered by insurance, saw an obstetrician in their plan, but when her three sons – triplets – were born prematurely, bills started rolling in.

The hospital charged her family $877,000 in total.

“When the bills started coming, to be very honest, I was an emotional wreck,” said Apo Osae-Twum. “And this is in the midst of trying to take care of three babies who were premature.”

America is the most expensive nation in the world to give birth. When things go wrong – – from preeclampsia to premature birth – costs can quickly spiral into the hundreds of thousands of dollars. While the data is limited, experts in medical debt say the costs of childbirth factor into thousands of family bankruptcies in America each year.

It’s nearly impossible to put a price tag on giving birth in America, since costs vary dramatically by state and hospital. But one 2013 study by the advocacy group Childbirth Connection found that, on average, hospitals charged $32,093 for an uncomplicated vaginal birth and newborn care, and $51,125 for a standard caesarean section and newborn care. Insurance typically covers a large chunk of those costs, but families are still often on the hook for thousands of dollars.

Another estimate from the International Federation of Health Plans put average charges for vaginal birth in the US at $10,808 in 2015, but that estimate excludes newborn care and other related medical services. That is quintuple the IFHP estimate for another industrialized nation, Spain, where it costs $1,950 to deliver a child, and the cost is covered by the government.

Even the luxurious accommodations provided to the Duchess of Cambridge for the birth of the royal family’s daughter Princess Charlotte – believed to have cost up to $18,000 – were cheaper than many average births in America.

Despite these high costs, the US consistently ranks poorly in health outcomes for mothers and infants. The US rate of infant mortality is 6.1 for every 1,000 live births, higher than Slovakia and Hungary, and nearly three times the rate of Japan and Finland. The US also has the worst rate of maternal mortality in the developed world. That means America is simultaneously the most expensive and one of the riskiest industrialized nations in which to have children.

American families rarely shoulder the full costs of childbirth on their own – but still pay far more than in other industrialized nations. Nearly half of American mothers are covered by Medicaid, a program available to low income households that covers nearly all birth costs. But people with private insurance still regularly pay thousands of dollars in co-pays, deductibles and partially reimbursed services when they give birth. Childbirth Connection put the average out of pocket childbirth costs for mothers with insurance at $3,400 in 2013.

In Apo Osae-Twum’s case, private insurance covered most of the $877,000 bill, but her family was responsible for $51,000.

Apo Osae-Twum was the victim of what is called “surprise billing”. In these cases, patients have no way of knowing whether an ambulance company, emergency room physician, anesthesiologist – or, in her case, a half dozen neonatologists – are members of the patient’s insurance plan.

Even though Apo Osae-Twum went to a hospital covered by her insurance, none of the neonatologists who attended to her sons were “in-network”. Therefore the insurance reimbursed far less of their bills.

There are few studies that estimate the number of families who go bankrupt from this type of unexpected expense. One of the best estimates is now outdated – conducted 10 years ago. But one of the authors of that research, Dr Steffie Woolhandler, estimates as many as 56,000 families each year still go bankrupt from adding a new family member through birth or adoption.

“Why any society should let anyone be bankrupted by medical bills is beyond me, frankly,” said Woolhandler. “It just doesn’t happen in other western democracies.”

Since Woolhandler conducted that research in 2007, 20 million Americans gained health insurance through the Affordable Care Act health reform law, and consumer protections were added for pregnant women. But Republicans and the Trump administration have pledged to repeal these consumer protections.

“People face a double whammy when they’re faced with a medical condition,” said Woolhandler. Bankruptcy is often, “the combined effect of medical bills and the need to take time off work”.

There is no nationwide law that provides paid family leave in the US, meaning most families forego income to have a child.

And although childbirth is one of the most common hospital procedures in the nation, prices are completely opaque. That means Americans don’t know how much a birth will cost in advance.

Dr Renee Hsia, an emergency department physician at the University of California San Francisco and a health policy expert likened the experience to buying a car, but not knowing whether the dealership sells Fords or Lamborghinis. “You don’t know, are you going to have a complication that is a lot more expensive? And is it going to be financially ruinous?”

According to Hsia’s 2013 study, a “California woman could be charged as little as $3,296 or as much as $37,227 for a vaginal delivery, and $8,312 to $70,908 for a caesarean section, depending on which hospital she was admitted to.”

Apo Osae-Twum and her family only found relief after a professional medical billing advocate agreed to take their case. Medical Cost Advocate in New Jersey, where Derek Fitteron is CEO, negotiated with doctors to lower the charges to $1,300.

“This is why people are scared to go to the doctor, why they go bankrupt, and why they forego other things to get care from their kids,” said Hsia. “I find it heartbreaking when patients say… ‘How much does this cost?’

https://www.theguardian.com/us-news/2018/jan/16/why-does-it-cost-32093-just-to-give-birth-in-america?CMP=fb_gu

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Changes to the Affordable Care Act

Maria Montecillo Leave a comment

This week President Trump made the first move to begin the replacement of the Affordable Care Act. By issuing this executive order, this will drive immediate compliance. However, it will touch off reactions from all healthcare stakeholders including patients, providers, insurers, employers and the government. No matter which side of the political aisle you sit on, be prepared. The coming changes to the Affordable Care Act will require cooperation and compromise not seen from Washington in many years. It should be an interesting year for healthcare in 2018.

By John Tozzi and Zachary Tracer, Bloomberg

‎October‎ ‎13‎, ‎2017‎
The Trump administration is cutting tens of millions of dollars from organizations that help Americans enroll in Obamacare health plans, leaving some of the groups scrambling to shrink their operations weeks before enrollment for 2018 coverage opens on Nov. 1.
The organizations, called navigators, say the funding cuts have been arbitrary, opaque and don’t follow the Trump administration’s stated method for calculating the reductions. The groups had been counting on money for the final year of a three-year grant program, and most didn’t learn how deep the cuts would be until after last year’s funding expired on Sept. 1.
When the Trump administration announced in late August that it would make the reductions, it said they would hold inefficient groups accountable and navigators that met prior enrollment goals would maintain funding.
Navigator groups say it hasn’t worked out that way.
Catherine Edwards, the executive director of the Missouri Association of Area Agencies on Aging, said her group helped 3,945 people last year sign up for health insurance, exceeding their goal. Their grant was cut 62 percent, to $349,251, from $919,902.
“This administration has been doing everything it can to make sure the Affordable Care Act fails,” Edwards said. “They’re tying our hands behind our back to make sure this does fail.”
Edwards’ group had to cut enrollment help and advertising, and will field 52 navigators this year, down from 72, leaving some rural parts of the state without any enrollment assisters.
A spokeswoman for the Department of Health and Human Services declined to provide data on navigator groups’ performance or to explain why some organizations that appeared to meet their goals were cut.
Trump’s Dismantling
Navigators focus on enrolling people with complex family or financial situations, and offer in-person assistance to those who have trouble enrolling online because of language barriers or lack of internet access. Some groups serve ethnic enclaves or vulnerable communities unreached by broader marketing campaigns.
The cuts are likely to hit rural areas the hardest, potentially depressing enrollment in parts of the country where insurers have already pulled back.
President Donald Trump, having watched Republicans in Congress fail to repeal the Affordable Care Act, has taken aim at the law using regulations and executive actions. On Thursday, Trump signed an executive order mean to make it easier for people to buy insurance that doesn’t meet the ACA’s standards, potentially drawing healthy people out of the ACA market. Late that evening, the administration said it would stop making subsidy payments to insurers that help lower-income people afford co-pays and other cost-sharing.
“We’re starting that process” of repeal and replace, Trump said at the White House Thursday.
The administration has also slashed advertising for Obamacare signups by 90 percent, and plans to take down the healthcare.gov website for maintenance periods in the middle of the season. Premiums for next year are rising as insurers say they’re uncertain about the law’s future.
A Nationwide Pattern
What happened to Edwards’ group in Missouri has happened around the country.
Covering Wisconsin, the larger of two navigator programs in that state, enrolled 2,287 people in private health plans and another 1,370 people in Medicaid last year, exceeding targets for both, director Donna Friedsam said in an email. Its funding was cut from to $576,197 this year, from $998,960 last year, a 42 percent reduction. As a result, its navigators won’t be in 11 of the 23 counties it served over the last year.
The Ohio Association of Foodbanks, the primary navigator in the state, helped nearly 9,000 Ohioans enroll in private plans and another 35,000 apply for Medicaid since 2013. The group “met, nearly met, or exceeded” goals for four years, said executive director Lisa Hamler-Fugitt. Despite that, funding was cut by 71 percent, to $485,000, from $1.7 million.
The funding cuts seem like sabotage, not accountability, Hamler-Fugitt said. Her group closed its navigator program and let most of its staff go rather than try to sustain it at the lower funding level.
“If we were such poor performers, why were we not notified and corrective action taken? Because we weren’t,” she said.
Smaller and Sicker
Along with the navigator cuts and other regulatory moves, confusion over Obamacare’s fate will likely lead to “a smaller, sicker group of enrollees,” said Sabrina Corlette, a research professor at the Georgetown University Health Policy Institute.
Customers who don’t shop around for coverage could “have huge sticker shock” if they do nothing and are automatically re-enrolled in their current plans, Corlette said.
The navigator grants are funded by a levy on health plans in the insurance marketplaces, which benefit from the marketing and outreach. Trump administration officials didn’t respond to questions about how unspent fees would be used.
Cut at the Last Minute
The Trump administration said in August that it would cut funding to the navigators by 39 percent, down from $62.5 million the last enrollment period. The cuts apply only to states that have health-care markets run by the federal government — 16 operate their own.
They were announced just days before the new grants were supposed to begin. The agency had affirmed grant amounts earlier in the year.
“All indications were everything was going very well,” said Allen Gjersvig, director of navigator and enrollment services at the Arizona Alliance for Community Health Centers. Staff at CMS told the group as late as Aug. 28 that the funding was on track, he said. Days later, the Alliance’s navigator grant was cut from about $1.1 million to $700,000.
His confusion isn’t unique. Of the 48 navigator programs that responded to a survey from the Kaiser Family Foundation, about half said no rationale was provided, and another 40 percent said the explanation was “very or somewhat unclear.”
The Palmetto Project in South Carolina had its navigator grant cut from $1.1 million to $500,000, and will have 30 navigators instead of the 62 it planned on, said Shelli Quenga, the organization’s director of programs. It plans to leave some rural areas without in-person help.
“I think there will be people who choose poorly,” Quenga said. “There will also be people who just give up.”

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The Affordable Care Act after Six years

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Excellent summary from the Kaiser Family Foundation that clears up some of the confusion around where the Affordable Care Act fits in the overall healthcare system

By Drew Altman, president and chief executive officer of the Kaiser Family Foundation.

The Affordable Care Act generates so much partisan heat and draws so much media attention that many people may have lost perspective on where this law fits in the overall health system.

The Affordable Care Act is the most important legislation in health care since the passage of Medicare and Medicaid. The law’s singular achievement is that 20 million people who were previously uninsured have health-care coverage. What sets the ACA apart is not only the progress made in covering the uninsured but also the role the law has played rewriting insurance rules to treat millions of sick people more fairly and its provisions reforming provider payment under Medicare. The latter is getting attention throughout the health system.

Still, while the ACA expands coverage and has changed pieces of the health system–including previously dysfunctional aspects of the individual insurance market–it did not attempt to reform the entire health-care system. Medicare, Medicaid, and the employer-based health insurance system each cover many more people. Consider:

Some 12.7 million people have signed up for coverage in the ACA marketplaces, and enrollment in Medicaid and the Children’s Health Insurance Program has increased by 14.5 million from pre-ACA levels, the Department of Health and Human Services noted in December. By contrast, 72 million people are enrolled in Medicaid and CHIP, 55 million in Medicare, and 150 million are covered through the employer-based health insurance system. The latter is where most Americans get their health coverage (Medicare and Medicaid share 10 million beneficiaries covered by both programs). All these forms of coverage have been affected by the ACA but operate largely independent of it.

In one presidential debate the moderator confused premium increases in ACA marketplaces (some of which are high, though the average is moderate) with premium increases in the much larger employer-based system. The tendency to overattribute developments, both good and bad, to the ACA is a product of super-heated debate about the law.

Given what the law actually does, it is not all that surprising that half of Americans say they have not been affected by it. Kaiser Family Foundation polling consistently finds that while the political world focuses on the ACA, the public is more concerned about rising deductibles and drug prices and other changes in the general insurance marketplace that have been developing with less scrutiny while attention has gone to the ACA. With so much published and said about the ACA since 2010, these and other important issues have received less attention from policy makers, the media, and health-care experts.

The ACA could get hotter before it cools. There is a case on contraception coverage under consideration at the Supreme Court–with oral arguments heard Wednesday–and another big debate about the law is likely if a Republican wins the White House in November. Such a debate would probably involve legislation characterized as “repealing” the ACA, though such a bill is more likely to focus on changes that stop short of rolling back the law’s popular coverage expansions and insurance reforms that benefit tens of millions of Americans.

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

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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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Finding Help for the High Costs of Cancer Care

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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

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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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