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Friday, July 22, 2011
Guest Blog: Health Care Billing and Cooing
This is a guest blog by Stuart Heady, a freelance writer and political activist who lives in Albuquerque.
Sometimes a tiny thing opens up a great issue, makes it more easily seen.
Health care is one of those issues that generally isn't so easy to see. Usually the terms of discussion are about millions of this and millions of that. Very Abstract.
As Ron Stern, the CEO of the Lovelace Health System, who I emailed and talked with on the phone for a bit told me, "It is all very complicated." I asked him if he could refer me to anyone or any source that could help explain why costs are the way they are and he said that there wasn't. He pointed me to the internet.
I had identified myself, not only as a patient, but as a writer looking for the sort of material that you might research if you were in a graduate MBA seminar. Probably beyond the bounds of an exercise in community outreach.
This happened because, I went to a Lovelace lab to get a simple blood draw for a yearly visit to a doctor for a consult on diabetes. You need to monitor certain factors so as to stay out of the deeper waters of the health care system.
The lab cost had been in the range of about 100 to 150 dollars. The bill I got a few months back for a visit last fall was for almost 1600. The first question when you see a jump like that is about whether this is real. It is the smallest and simplest medical service that one could get. If a such a cost increase can come out of the blue for something that insignificant, what does that say about the entire concept of health care? It would seem to make any at all impossible. CEO Stern continued to explain in terms he evidently hoped would explain the situation, that the system has invested over half a billion dollars in New Mexico and again, that it is all very complicated.
I think the conversation went downhill when I suggested that this tends to sound a bit like one might expect from the mafia. No doubt that was bad form. It is true he took the time to call. However, the analogy isn't too far fetched. There is no where else in the legitimate economy where someone can literally say "pay whatever we say -- or die." Who hasn't had such a thought cross their mind?
I appreciate the fact that Lovelace takes on the burden of some 35 million dollars a year in bad debt for treating people because they are obligated to treat people in emergency rooms before they ask about insurance. I appreciate that systems like UNM have subsidies from taxpayer funded sources and that this is a private enterprise. But I also appreciate the fact that whenever I have called up billing office accountants in any system to ask questions about why costs are so high, and whether they are in fact, correct, I feel as though they aren't used to being asked.
When we had insurance coverage a few years ago, I got used to going over every detail because there was a certain error rate. Someone else's bill would be added to mine, or some other error would result from some computer hiccup. No big deal. Just go over it. Get it right. Mostly people with insurance aren't motivated to get into the details of what is or is not correct and thus, billing office people aren't driven to greater exactitude. The system continues to enlarge due to lack of very critical consumer scrutiny. One wonders if the people who look at costs from within the insurance industry are not benefitting from rising costs due to shareholders with common interests or some other factors not obvious to anyone outside the industry and how it all works.
When you ask billing department people big questions like how health care can be sustainable if charges are allowed to escalate through the roof, even if the insurance companies pay for it, you get the feeling people think you must be crazy to ask such questions. They go into, "I get it. You are trying to get out of paying." They just don't seem to have DNA for the issues or for empathy with what people have to deal with when huge bills are really heavy calamities. They see numbers all day long every day. More balance sheets, more lines of numbers on more data screens. They don't mean anything anymore to the people who have to do this work. I would think you would need to not allow yourself to go there.
When you ask the CEO, you find a retreat into, "It is all very complicated and it would take me all day long to explain it."
In fact, we have to realize that the CEO works not for us, but for the shareholders who pressure the CEO and the 4,000 people who work for him to ensure that dividends keep going up. It is only fair for people with a significant investment to reap the reward they were promised.
In effect, the only pressure on costs is upwards. Those people who make under 50,000 a year are supporting those whose salaries are at least double that, and probably in multiples beyond that. But where is the line between a return on investment and gouging the consumer beyond tolerance? Does anyone actually address that?
Where could the pressure possibly come from to reduce the ever escalating costs? Apparently this all got started during the Vietnam years when the Pentagon spending got everyone used to the six hundred dollar toilet seat. Now, everyone from the brain surgeon on down to the orderlies is used to being really well paid, relative to the patients.
As far as I can tell, the drivers that ratchet costs ever upwards are not addressed in any of the legislative proposals for health care reform. Most likely, I would guess, that is because, if you want support from anyone in the health care industry, you have to promise to not talk about the multi million dollar salaries at the top end or the relatively well paid services that are ancillary to medical care at the lower end of the system.
Well, who wishes for anyone to do less well? I have sympathy for anyone who went to graduate school. My wife went through three programs. Is a librarian who has two-and-a-half Master's degrees worth less than a med tech with one? How many teachers does it take to equal an orthodontist?
Why debate such an issue? If we consider that many people in the middle class are supporting others who happen to work in the health care industry at many times their salary level, by being made to pay high rates, some sort of tilt to the playing field is being increased in a way that we are all apparently helpless to fully understand, much less control. Sometimes it feels like we are all just passengers on the Titanic, arguing over whether to rearrange deck chairs.
I am used to being an independent sort of person. Health care was something that I never needed until quite recently. I was lucky to enjoy just about bullet proof health until I got past 55. I think the most I ever spent was about fifty bucks, for having a rusty nail pulled out of my foot once. Now, as a diabetic, I am forced to look at it more closely.
As I look at it now, I don't see how the health care system in America is sustainable. I am rather suspicious that a single payer system isn't really feasible because I don't know how to suggest how an MBA who is in an administrative position should relate to such a state of affairs for really doing business.
But I think I am going to devote the months and years necessary to trying to figure it out. It may very well be the last thing I do. I think we all need to put on our thinking caps and take on responsibility for developing that graduate level of education that it seems to require in order to understand this stuff.
I certainly think we all need to increase our alacrity in bothering the people in the business offices and the leadership of these systems to explain themselves. That may be the only form of pressure that we can immediately put on the system to counter the pressure that causes costs to escalate.
We The People tend to be reluctant to march into the front office and ask questions that are "above our pay grade." This reluctance on our part to be assertive as citizens is what is keeping us all from moving towards reform at a better pace.
This is a guest blog by Stuart Heady. If you'd like to submit a piece for consideration as a guest blog, contact me by clicking on the Email Me link at the upper left-hand corner of the page.
July 22, 2011 at 10:01 AM in Guest Blogger, Healthcare | Permalink
Comments
Another service that seems to be overpriced is outpatient physical therapy. It is true that I never called them on it. I am covered by Medicare, and another insurance company for secondary expenses, not by the Lovelace plan.
Posted by: Joan Saks Berman | Jul 22, 2011 10:34:15 AM
What happened when you asked the lab what the charge would be? Was it really a Lovelace lab, or have they outsourced it to TriCore? Who was the bill from?
Posted by: Michelle meaders | Jul 22, 2011 11:50:41 AM
Don't forget that we get pressured by the doctors to "do everything possible" to keep ourselves (and our loved ones--BIG guilt trip there) going. I even get it from my vet, who tried to guilt-trip me into having surgery on my 12-year-old dog.
Seems to me a lot of people are being bamboozled into dying an expensive, prolonged death, that bankrupts them and leaves nothing for the ones they love to inherit.
Posted by: Ellen Wedum | Jul 22, 2011 12:33:12 PM
By now there have been more communications. It turns out that the Lovelace labs are more or less divided up into outpatient and hospital facilities. The very same test tubes tested by the very same methods are at a reasonably affordable rate at outpatient labs and at a rate that seems extraordinary to mere mortals at the hospital labs. The hospital rates pick up ER patients who can't pay, the cost of maintaining the building and a list of other costs.
One lab costs about a hundred dollars the other closer to 1600 for a simple blood test. The higher rate also reflects a recent price hike and an upgrade to a computer system which seems to have made it difficult to distinguish between classes of patients.
This affects a lot of people. The day I went in to the lab, there were at least 50 others standing in line. They didn't look like people who could afford to not think about costs. This issue must affect hundreds and maybe thousands of people.
I found that Lovelace was willing to do an audit on the bill to check the accuracy of the itemization, and then to work on adjusting the bill downwards.
I found myself having conversations with intelligent people who could understand the concern that high costs might actually prevent health care. I proposed that they charge for the service as if it had been done at an outpatient lab and they seemed to be willing to do that. We'll see when the final result arrives in the mail.
My sense of this is that insured or not insured, it is wise to be ready to make phone calls and get into conversations about why charges have been applied and what is going on. This usually necessitates finding people who are not in customer service, but who are educated professional finance officers who actually know what they are talking about.
If more people would do that, there would be more pressure downward on costs.
At present, one of the predominate pressures on costs is upward. With private sector providers like Lovelace, the more money they take in, the more the shareholders see a dividend. Incentives drive the system.
The question of whether this serves the purpose for which health care institutions were established, however is one that people who find themselves needing even minor healthcare have a right to ask and should.
Now I find myself looking for more information. The real truth is that, while people who began careers a couple of decades back in health care finance are really fine people, we all need to understand these systems better.
There is a website for professional finance people online, for the Healthcare Financial Management Association, HFMA. It may take quite a while to absorb what this profession's perspective is, but it is a good idea to be up on this and to be able to talk to professionals in a professional manner, using appropriate vocabulary.
Posted by: Stuart Heady | Jul 23, 2011 12:10:10 AM
You describe what is classic cost shifting, which is the basis of much pricing in health care. Losses on uninsured patients treated in the ER are paid by people getting their blood tested in the hospital, etc. Medicare patients used to be charged high prices to make up for much of this but as Medicare cuts and rule changes have happened, more cost shifting is used in other areas.
The silly thing is that we are already paying for the care of many uninsured or under-insured patients but most people don't know it. And we are often paying for these services at the highest level, as in ERs when the people should really be seeing ordinary doctors on a non-emergency basis. So we have a kind of universal health care system (although the coverage is not entirely universal) but instead of funding it outright and removing the profit makers, middle men and cost shifting, we have all the providers playing these games with pricing. Think of all the people paid high salaries just to game the system and keep up with the eternal rule changes made by government programs as well as insurance companies. What a waste.
We are the only "advanced" nation to rely on a system this senseless and inadequate, with some of the worst outcomes and the highest per capital costs. All so we can avoid the awful plague of ... wait for it ,,, SOCIALIZED MEDICINE! (Oh no!)
We had a chance to fix a lot of this with the health care reform legislation but of course the process was derailed by deep pocket players who make a living off the chaos. Don't forget the cowardly behavior of Obama in that mess and another one of those stupid "gangs" that created the final package, headed by one of the Senate's chief crooks, Sen. Max Baucus.
Unless there is an efficient single-payer system installed, this kind of gaming will only increase, especially with our president and Congress dead set on cutting spending on Medicare, Medicaid and other health services. This will create another round of insane cost shifting that doesn't really save any money-it just makes the vulnerable health care consumer the sucker in the game. Meanwhile more and more of the money in the system goes to ridiculously high executive salaries, outsourced services, Big Pharma and medical equipment provider boondoggles, and of course investor "profits." Even in an essentially non-profit system like Presbyterian, way too much money goes to high administrative costs while the number of staff members who actually provide health care services is cut and cut and cut. All so the rich and corporations don't have to be bothered with paying their fair share of taxes.
Thanks to the corporatist loyalties of our president and congressional leaders and others, I don't expect any of this to change for the better in my lifetime. In fact, as the massive baby boom population ages and more and more seek increased medical as well as long-term nursing type care, I expect things to get to the point of almost total chaos thanks to unsolved problems neglected for decades and the piecemeal and often corrupt health care system the politicos in this nation seem to prefer,
Posted by: barb | Jul 23, 2011 8:54:04 AM
I think Obama tied into this in a way that sets the stage for better progress as the future unfolds.
I know a state legislator in Arizona who is gay, a progressive, a Navajo and graduated from Harvard Law. Brilliant guy. He owns part of an air ambulance company and is no doubt keen to keep profits up.
It happens that I once got shipped from an ER in Chinle, near where we were living at the time, to Flagstaff by the same company. A 20 minute trip in clear air over flat desert and the billing on that was 28,620. I found out that the Bureau of Indian Affairs pays about 1200 bucks for the same trip. They just will not pay more. I hollered and my insurance at the time agreed to bargain it down - to 20,000.
I think there are several practical problems standing in the way of moving to a public system, away from the current private system.
1. There are too many people making too much money. I bet you that half of the people living in the suburbs are directly or indirectly paid by the high costs associated with the industry. It could be that if this were pulled away, the economy would be threatened. But, costs have got to be brought under control. These incredible billing amounts have got to quit skyrocketing. That will eventually bring the economy down and the health care system will crumble into dysfunction.
2. There are whole graduate schools that specialize in financial health care management. Hundreds of graduates each year earn a Masters in Businesss Administration with this specialty, or PhDs.
That represents a huge cohort within the population of those that talk to everyone in Washington and impress them with the complexity of the issues. It is an unseen and unheard component because these people prefer only to talk to other professionals in quiet, collegial settings.
3. Most people you talk to do not bother to do much to understand the system well enough to actually discuss the mechanics of how it works and how it could be changed. Most of us would rather let our insurance providers figure this out.
This is not a situation that will be influenced by hitting the streets.
Things will not change with whoever is in the White House or Congress. Things will only change when We The People take responsibility for informing ourselves and others about the practical issues that must be addressed if change is to occur.
I think with the current politics around this so full of emotionalism, the likelihood is that it will take years of dedicated effort, and decades.
Posted by: Stuart Heady | Jul 23, 2011 12:20:40 PM
Not that it would be perfect, nothing is, but what of the ideas of letting national service or even the military take over parts of medical service? Would like to see some input on this.
Posted by: LarryNM | Jul 23, 2011 2:54:24 PM
What I would like to see here or anywhere else, is some discussion by people who actually have serious knowledge about how the system works.
Some kind of nationalization seems ultimately likely, but if the same circumstance we are in now isn't to be replicated, how do the people who expect to be well paid as a result of gaining critical skills get paid?
At present it isn't clear. It is mostly clear that something, somewhere is going wrong and that there needs to be determination to right it. A lot of the discussion never gets beyond that.
Meanwhile, the big cities, people die in rather large numbers. Anybody want to be an old person, who can't work anymore who lives in a rat infested tenement in a big urban core where there are millions of others in the same boat who can't help?
Is that our future?
Posted by: Stuart Heady | Jul 24, 2011 1:54:20 PM
Health is wealth. So we are hoping that our government will not compromise. Some Doctors are just concern about the commercialization of medicines and patients suffered for it.
Posted by: unique hoodia | Jul 29, 2011 7:52:38 AM
"Sometimes a tiny thing opens up a great issue, makes it more easily seen" this is really true indeed. Health is the most unseen part but it has actually one thing that has the biggest budget. Our government should understand that people are not stupid, in fact very vigilant about it.
Posted by: Joint Advance | Jul 29, 2011 8:03:59 AM
