Thursday, October 27, 2005
A month ago a local prominent surgeon came to me to have a scope. I did his scope at a local hospital. He had a PPO insurance with a deductible amount and I waived the deductible amount he owed me. The hospital charged his insurance company close to $7,000. His deductible amount came to $1,500. He could have gone down the street to a private outpatient GI Lab and had the entire procedure for less than that amount.
He asked the hosptial administrator about this outrageous amount. The administrator stated that the hospital takes all insurances and treats the uninsured. It is a not-for-profit facility. For patients without insurance the hospital charges an amount 5 times higher than what Medicare or Medicaid pays. This inflated amount is what is charged to insured patients. This overinflated amount is charged to make up for the pittance received from Medicare, Medicaid and poorly paying insurance companies.
This madness has got to stop. You should look at: Anatomy of a Hospital Bill
Uninsured Patients Often Face Big Markups On Small Items; 'Rules Are Completely Crazy'By LUCETTE LAGNADO in THE WALL STREET JOURNALSeptember 21, 2004.
Also refer to: http://www.consejohelp.org/ Although this site addresses overcharging of the poor, it is clear that this practice is also hurting those who are insured. My patient was a prominent surgeon who brought many patients to the hospital and this is how well he was treated.
Why should such a hospital retain its not-for-profit status and get tax breaks?
Sunday, August 08, 2004
On August 6, 2004 newswires reported that Alabama attorney, Archie Lamb who is fresh from taking on HMOs, has his sights on the for-profit hospital industry. He alleges these hospitals generated hundreds of millions of dollars in profits by billing uninsured patients inflated prices. He has filed separate suits against HCA and other for-profit chains. The suits were filed in Florida and Nevada.
The suits allege the hospital operators violated state unfair-trade-practices laws by charging the uninsured three to four times more than what commercial insurance and Medicare patients paid for for the same services.
I have discussed these unethical for-profit tactics on this page for months.
The sad fact is that when these hospitals are not paid, they employ strong-arm collection tactics - garnishing wages, seizing homes and assets and seeking arrest warrants. The financial impact on patients is severe and some declare bankruptcy.
In the past, hospitals such as Rose Medical Center, an HCA facility would charge and demand high "sticker prices" - the hospital blamed it on obscure Medicare rules. I knew better as it was clear that Rose Medical was looking for profit. In addition, when you tell the uninsured upfront the high cost and demand it you will discourage the uninsured from coming to your hospital - this guarantees a steady stream of reliable paying customers. What for-profits hospitals enjoy next to excessive profits is a regular income stream. Of course, it doesn't hurt when your well-to-do patients do not see the unseemly poor patients in the bed next to them - don't they belong in the county hospital? Of course that is exactly what is going on in Denver. Most of the poor go to the Denver Health Center of the University system. That is a reason why the HCA hospitals provide so little care to the unisured in Colorado compared to these other systems.
Unfortunately for HCA and other for-profits hospitals, in February 2004 HHS Secretary Tommy Thompson clarified Medicare's rules. Hospitals could no longer blame obscure regulations for overcharging the uninsured and pursue tough collection policies.
I cheer Archie Lamb on in his efforts. Before this all I could do was to write about the subject. He can actually do something to stop these unethical practices.
Saturday, February 21, 2004
HHS Chief Scolds Hospitals For Treatment of Uninsured
By LUCETTE LAGNADO Feb 20, 2004 Staff Reporter of THE WALL STREET JOURNAL
In a blunt rebuke to the American hospital industry, the nation's top health regulator said hospitals can immediately slash the prices they charge to needy uninsured patients without fear of government reprisals.
In a letter last December, the nation's 4,800 hospitals told Health and Human Services Secretary Tommy Thompson that federal rules blocked them from cutting prices for the nation's nearly 44 million uninsured.
The group also claimed that Medicare policy required "aggressive efforts to collect from all patients," including the uninsured. The industry asked Mr. Thompson to alter or clarify government rules so the industry could help uninsured patients without risking punishment.
But in a toughly worded response to the American Hospital Association, Mr. Thompson said the hospitals had mischaracterized government policy and were simply "not correct" in arguing that complex federal rules left them no choice but to bill the uninsured full price, which is far more than the prices typically paid by insurers, HMOs and the government. He also noted that his agency provides hospitals with some $22 billion in subsidies to care for the uninsured.
"I strongly encourage you to work with AHA member hospitals to take action to assist the uninsured and underinsured," Mr. Thompson wrote to Richard Davidson, the trade group's president. In an accompanying document, HHS also denied that hospitals must use tough tactics to collect payment from the uninsured.
The documents, which were hand-delivered Thursday to the AHA, represent the government's long-awaited answer to the industry's argument that federal rules prevent discounted billing or special collection treatment for the uninsured. The Wall Street Journal has published a series of articles on hospital policies toward the uninsured over the past year.
In response to HHS, Rick Wade, the spokesman for the American Hospital Association, struck a conciliatory note. He said "there is a lot of clarification" in the Thompson letter, though "there could still be some tripwires." While the documents would help hospitals offer discounts to the indigent, the AHA said, there could be problems offering price cuts to the working poor, who may be significantly over the poverty level but still unable to afford health care. Mr. Wade added: "We never intended to blame the federal government. We simply said the regulatory morass was so thick that hospitals couldn't see their way clear to get past that."
Reaction from health-care advocates was gleeful. "This finally puts to rest the hospital's tired and inaccurate argument that the government made them charge uninsured and underinsured people these crazy inflated prices," said Elisabeth Benjamin, a Legal Aid Society attorney who has been at the forefront of efforts to reform the system.
Other industry observers believe that both the industry and the government were partly to blame. James R. Tallon Jr., president of the United Hospital Fund, a New York think tank, described Mr. Thompson's letter as a welcome "template," because while "there was ample room for criticism of hospitals' behavior," the hospitals were genuinely confused by the thicket of federal regulations. He added that the issue of the uninsured had "slipped off people's radar screens," and once it became clear that there was a problem, hospitals responded. "This is one of the classic cases where someone tells the story and lifts up the rock and what was underneath it was a lot of practices and a lot of suffering that were simply indefensible," Mr. Tallon said, referring to the Journal's articles.
Medical bills are now the second leading cause of personal bankruptcy, and the issue of what hospitals charge for services and what tactics they use to collect unpaid bills has emerged as an increasingly charged political and social issue. The HHS move, coming in an election year, could help the Bush administration counter Democratic challengers who have argued that the President hasn't done enough to help the poor and uninsured.
Hospitals have come under fire for billing the uninsured "full charges," in effect, list prices the hospitals maintain for every single item and procedure, even as they offer steep discounts to insurance companies and HMOs and those covered by Medicare and Medicaid.
Industry executives said the system was unfair but argued they had no choice but to abide by it. They said that a tangle of government rules forced them to bill everyone the same so-called "charges," severely restricting their ability to offer discounted rates to the uninsured.
In a document that accompanied Secretary Thompson's letter, government officials stressed that "nothing" should stop the industry from taking steps to offer discounts to the uninsured. They even offered a roadmap for hospitals in the form of a question-and-answer dialogue.
For example, the Q and A states: "Are hospitals required to take low-income patients to court or seize their homes or send claims out to a collection agency when those patients don't pay their hospital bills?" The answer: "No. Nothing in the Medicare instructions requires the hospital to seize a patient's home, take them to court, or use a collection agency." It adds that hospitals aren't required under the law "to engage in any specific level of collection effort for Medicare or non-Medicare patients."
In recent months, hospitals have been moving to change some of their practices. Two of the most influential state hospital associations, in New York and California, have both recently introduced guidelines that call on members to offer rate cuts to the low-income uninsured. And the AHA itself has urged members to adjust both their practices and their cultures to be more compassionate.
In addition to its impact on what the uninsured must pay, the HHS action could open the hospital industry's pricing practices to further scrutiny. In recent years, as hospitals have felt squeezed and pinched by managed care, they have allowed the list prices for their services to skyrocket, so that even simple procedures and short stays can cost thousands of dollars.
A congressional probe, led by the House subcommittee on oversight and investigations, is already examining the issue of hospital pricing, looking at the high rates the nation's 20 top hospital chains charge the uninsured.
Meanwhile, labor unions led by the Service Employees International Union, have organized campaigns in key cities, including New Haven, Conn., San Francisco and Chicago, to highlight price disparities that hurt the uninsured.
When I was on call at Rose Medical over the last 10 years, I saw numerous patients being turned away. Read the article for yourself:
Hospitals turn away ill, injured
Some question ER screenings that limit care for uninsured
June 29, 2003
Marsha Austin Denver Post Business Writer
Dr. Donald Lefkowits, emergency services director at Rose Medical Center, has treated patients who were turned away by the two public hospitals. Their 'solution seems so barbaric,' he says.
He'd already been turned out of two hospital emergency rooms that day, but Michael Angelo Martinez wasn't giving up as he pushed open the door to the third.
"This time they'll help me," the 38-year-old told himself as he walked toward the ER reception nurse at Rose Medical Center.
He was drooling because each swallow meant excruciating pain. His face muscles twitched. He slurred his words through the clenched teeth that still clung to his shattered jaw.
But he wasn't dying. And, according to federal law, he was stable, meaning he could walk out the door. And that's all doctors and nurses at Denver Health Medical Center and the University of Colorado Hospital needed to know before they suggested Martinez seek treatment elsewhere.
When Colorado's two largest public hospitals resorted to screening out anyone without an immediately life-threatening medical problem, administrators said it was because they could no longer afford the millions it cost to treat the uninsured who crowded emergency rooms with minor complaints.
So now, a nurse examines every would-be patient. Those without an emergency are told they must pay for their care or leave. The result is that uninsured people like Martinez go without medical attention or seek help elsewhere.
In the year since the screenings began, a steady stream of patients, most of them indigent or working poor, has filed into the emergency rooms of nearby private hospitals. And physicians who have treated such patients say the screenings are dangerous, possibly illegal and ethically impossible for them to stomach.
Those doctors also worry that as public hospitals nationwide struggle financially, more will find ways to turn away uninsured patients, and that new federal guidelines due out this summer could open the door for more aggressive screening by the nation's hospitals.
"This is a disturbing precedent," said Dr. Dennis Beck, president of CarePoint, the medical group serving HealthOne's five Denver emergency rooms, including Rose.
Since Denver Health started screening emergency-room patients in May 2002, an average of 110 patients of the 4,200 who sought care in the ER each month were referred elsewhere. At University, where screenings began in October, an average 176 patients of 3,655 seeking care each month were not treated.
That Martinez was turned away is no surprise. Patients with medical problems that require more than emergency care - broken bones, Hodgkin's disease, cancerous lumps, detached retinas - are routinely told to seek care elsewhere, said Dr. Norman Paradis, director of the department of emergency medicine at University Hospital.
"It really is, in my mind, unconscionable," Beck said. "What we do in the emergency room is put our head down and take care of people."
So far, federal officials have not challenged Denver hospitals' screening policies, in part because the hospitals are obeying regulations that require emergency-room staff to only briefly examine a patient and ensure the person is stable before sending him away, said Thomas Barker, senior policy adviser at the national Centers for Medicare and Medicaid Services.
In addition, University and Denver Health have followed rules set up in the Emergency Medical Transfer and Active Labor Act, or EMTALA, which says the hospital cannot inquire about a patient's ability to pay until it has determined whether the person has an emergency.
Because virtually no hospitals outside Colorado have pushed the limits of EMTALA, federal regulators have not aggressively scrutinized the practice, said Barker, a health care attorney involved in crafting the new federal guidelines. The guidelines, he said, would outline limited, clearly nonemergency cases where hospitals can block admission - such as someone wanting stitches removed or a prescription refilled.
Barker had strong words for Denver's hospitals and others considering adopting screening programs:
"I would be very, very careful. You are walking a very fine line, and you had better make sure you stay on the right side of the fence," he said.
When Martinez walked into the Rose ER on April 27, he told the nurse he'd already been to Denver Health, where a doctor confirmed he'd broken three ribs and fractured his jaw.
But the same doctor refused to treat him unless he had insurance or cash because he did not live in Denver County, he said.
"They told me to go back to New Mexico," said Martinez who had been visiting his girlfriend and her mother in a small town outside Santa Fe when he was attacked and beaten.
The Aurora resident rode a bus five hours north from Santa Fe to Denver to seek medical care.
He next looked for help at University Hospital, the only other full-service Denver hospital that receives tax money to treat the uninsured. But a nurse there told him the same thing: He'd have to pay before a doctor could fix his jaw.
And so he walked down the street to Rose.
The risk in turning away patients with broken bones, infections and other non-life-threatening but possibly serious medical conditions is that without proper care, those patients can unexpectedly go downhill fast, doctors say.
Even minor symptoms such as a headache can quickly turn deadly, said Dr. David Glaser, head of Exempla St. Joseph Hospital's emergency department.
"There are snakes in the grass hiding behind every minor complaint," Glaser said.
Glaser remembers treating a young woman who came into his ER complaining of nausea, vomiting, diarrhea and cramping. She was pregnant, and University had turned her away because a nurse said she just had irritated intestines. The woman turned out to be suffering from gastroenteritis, inflammation of the digestive tract that can cause severe cramping and dehydration. But Glaser was infuriated. It could have been much worse.
"To me it's a scary prospect that they have nurses weeding out the sick from the not sick. At some point, they are going to miss and miss big," he said.
Advocates of the screenings argue that treating every patient who walks through the door will bankrupt the public safety-net system, which is already overtaxed.
For the first time in recent history, the nation's academic medical centers will post a collective loss this year, Paradis said.
"Even the well-run hospitals are operating on razor-thin margins," Paradis said. "There's just not enough money to take care of everyone."
Denver Health Medical Center, the city's safety-net public hospital, lost $6.4 million in the first five months of this year and expects losses to grow because its uninsured caseload is far beyond what accountants predicted.
On Thursday, Denver Health approved more than $15 million in budget cuts that included layoffs, the closing of clinics and restrictions on what drugs will be bought and offered to patients.
"More and more people who never thought they'd be without health insurance are finding themselves on our doorstep as the economy continues to flounder," chief executive Patricia Gabow said.
Both Denver Health and University get federal money to offset the costs of caring for the uninsured, but it's not nearly enough, Paradis said.
During the year ended April 30, University's spending on uninsured patients increased 35 percent to $68.2 million. For the fiscal year ending in June, the federal government paid the hospital $29 million.
"We are just going to have to say some of these people are just too sick to be saved," Paradis said. "They've handed us a certain amount of money. We are trying to do the best we can with it. I think that this is a more reasonable solution than closing the ER."
When Dr. Donald Lefkowits saw Martinez, he was dehydrated and in obvious pain.
"This guy had been through the wringer," said Lefkowits, an ER physician of 20 years and director of emergency medical services at Rose. "He was really hurting."
Lefkowits got Martinez hooked up to an IV, gave him painkillers and paged the on-call oral surgeon.
"I kept thinking to myself, 'There was this thing they called the Hippocratic oath,"' Lefkowits said.
What University and Denver Health are doing may be legal, but it's highly unethical, said Dr. Robert Bitterman, a physician, attorney and head of the Department of Emergency Medicine at Carolinas Medical Center in Charlotte, N.C.
A national expert on EMTALA law, Bitterman has closely watched Denver hospitals' screening programs.
He said ethics and a fear of looking uncaring - not legal issues - have kept other hospitals from following Colorado's example.
"I know a bunch are talking about it, but so far no one has had the guts to do it," Bitterman said.
Lefkowits said he remembers a man who hobbled the two blocks from University to Rose with gout in his ankle and another who came to the ER at 2 a.m. with an excruciating earache.
"Was he going to die? No," Lefkowits said. "But could he sleep? No. Severe pain can be an emergency. This solution seems so barbaric. And how much are they saving?"
While it's not yet clear exactly how much University and Denver Health are saving, it is clear Rose and other private downtown hospitals are spending more to treat some of them.
Between April 2002 and April 2003, uncompensated care increased 22 percent at Exempla St. Joseph's Hospital and 24 percent at Centura St. Anthony Central Hospital. Rose corporate parent HealthOne would not release specific numbers, but doctors there say charity-care spending has substantially increased.
And the steady stream of patients makes it difficult for doctors at St. Anthony Central to keep staff and beds available for trauma patients, said Dr. Peter Vellman, emergency department director.
"It makes it tough when you run a Level 1 trauma center and you're cluttered with fallout from other hospitals," he said.
But so far the hospital isn't turning anyone away. Instead it's expanding capacity.
Vellman and some other doctors say they'd support the screenings if they knew patients were actually getting in to clinics.
"The people at University, when they hand them this list of clinics, they know very well there's little chance they're going to be able to get in there," Lefkowits said. "I don't know how they live with themselves."
Dr. Stephen Cantrill, director of Denver Health's emergency department, said he knows the solution is not perfect.
"My frustration is that the system is broken, and no one will fix it," he said. "What we have now is not the answer."
At UC-Davis Medical Center in California, where in the mid-1980s researchers conducted a pioneering study on emergency-room screening exams, nurses made follow-up calls to every patient they sent away.
The medical center worked out agreements with community clinics and neighboring hospitals to ensure patients got care, said Victoria Ritter, a nurse and director of the emergency department.
"We really had to stop the way of thinking that the purpose was to keep everybody out - that wasn't our purpose," she said. "If you've got that mentality, you've got problems."
The same practice is in place at UCLA Harbor Medical Center, which refers colds, back pain and other minor medical problems to its own clinics. Patients are guaranteed an appointment within 24 hours, said Dr. Bob Hockberger, head of the ER.
Denver Health is experimenting with a program that will guarantee patients at its 14 community health centers an appointment within 48 hours, rather than the previous six to eight weeks, said Terence Shea, director of community health nursing.
For Martinez, the whole experience was an eye-opener.
``I didn't see how these days, in the United States, anyone could be denied care," said Martinez, who is making payments to the doctor who fixed his jaw. ``I'm just happy I got referred to somebody. I felt like Neanderthal man."
Sunday, February 15, 2004
This month in New York after decades of overcharging the uninsured, hospitals in New York were among the first in the country to cut charges for uninsured patients. The hospital industry's use of ruthless collection tactics and its practice of billing America's 43.6 million uninsured at inflated retail rates has been the focus of many recent articles in the Wall Street Journal.
When I started working at Rose Medical Center in Denver over 10 years ago, I was able to provide care for some uninsured patients. The hospital accepted these patients without charging a dime. After the hospital was converted to a "for-profit" hospital by Columbia-HCA, my ability to provide care at Rose for the uninsured evaporated.
In my last year there I had to tell many uninsured that I would perform surgery at Medicaid rates BUT Rose Medical would not accept these rates. The hospital billing department told my patients that the charges were many times even what an excellent managed care company would pay. For example one patient needed a colon resection and was told the hospital bill would be $40,000 - 1/2 was due immediately and a quarter over the next two months. Minor surgery patients were told they would owe Rose Medical $4,000 and up. Since none of these uninsured patients had this money, they had to go elsewhere for their surgery. I pleaded with Rose Medical to reduce their charges to Medicaid level, but the hospital refused. This I felt was clearly unethical.
The Denver Post cited in 2002 that not all Denver hospitals were sharing the burden of caring for the uninsured equally. Most of these patients had to go to Denver General or the University hospital. The Columbia-HCA "for-profit" hospitals such as Rose Medical and others each made a profit. I wonder why? If you are not sharing in the burden of providing for the uninsured, you are likely seeing paying patients. Interestingly these hospitals provided a tiny amount of the uninsured care.
High hospital markups also contribute to hospital profits but this drives up health care costs. HCA/Rose Medical Center is among the 100 U.S. hospitals with the highest markups in their gross charges over costs. This list is published on www.calnurse.org. Rose is number 61 on the list with a markup of 583% over actual costs. For each $1,000 it costs to provide your care, Rose charges an extra $5,830. For-profit hospital systems such as Tenet and HCA dominate this list. Tenet is under investigation and HCA just settled the largest health care fraud case in U.S. history for $1.7 billion.
No wonder hospital profits are soaring. So are our health care costs. These kinds of hospital billing and pricing practices, especially by for-profit hospitals, call for greater public scrutiny and government oversight.
Monday, May 26, 2003
In the U.S., Board Certification is not mandatory to practice medicine. You do not have to be Board Certified to be a specialist. Your doctor may have failed the exams many times BUT he/she is still going to operate ON YOU!