e-Patient Dave

Democratizing Healthcare

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“Chaos, behind a veil of secrecy”: Show me the cash flow

April 2016 update
April 2017 update

Original post here was June 2013. Or, jump to the Nov 2015 update below.

Latest in my series Let patients help, cost-cutting edition

I’ve blogged several times about the greatest truth I’ve learned about the business of medicine. It’s the title of a 2006 Health Affairs article by Princeton economist Uwe Reinhardt: The Pricing of US Hospital Services: Chaos, Behind a Veil of Secrecy.

The cost chart at right shows what’s happened since Reinhardt’s paper appeared, in the middle of the chart. It’s what you’d expect if slush is flowing around with nobody watching.

Today I was reminded that it ain’t just hospitals. :-)
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Last week I got my annual checkup. There were two separate problems in my hospital’s appointment system, so I ended up leaving too late to get the simple lab work my doctor had ordered; I said I’d get it done at a local lab.

Today I visited AnyLabTestNow, a chain with a local office. I called ahead, and for walk-in self-pay, it’s $49 for the chemistry panel I needed (Calcium, CO2, etc) and $49 for the cholesterol, total $98. And a $10 off coupon, on the site! Just $88.

Or not.

[Read more…]

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The reality of shopping for health insurance

Graph of the numbers

I keep hearing disparaging things about what lousy consumers patients are – unable to understand how things work, unable to understand the options. Well, as I often say in my speeches, in any other industry you go out of business if consumers don’t understand you – because customers ditch you. But in medicine we consumers can’t easily do that. Heck, we can hardly get our hands on information in the first place.

Case in point: when I shopped for health insurance in 2011, I found out just how slanted the table is when companies offer insurance and consumers buy it. Here’s the true story of the information I was given.

1. Cancer? You can’t play in our market – go away.

First, Blue Cross of New Hampshire asked if I’d ever had various things. When I said cancer, they went from cordial & friendly to cold and “go away.” It was rude, frankly.

But at least I could get at the high risk pool. Some states won’t let people like me get ANY insurance without a six month waiting period. (Up yours, states. And up yours, regulators in those states.)

2. Here are your options. Figure it out yourself.

[Read more…]

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An encounter with the Swiss medical system

See the comments at the end!

I had a wholly satisfying encounter tonight with the Swiss medical system. It started, as you might imagine, with a worry: I appeared to have a deep vein thrombosis (clot, aka DVT), which in the worst cases can be fatal. I was processed promptly, with good news, at a good price.

Chief complaint: swelling, redness and pain in the foot

Last week while traveling I developed what seemed to be gout: a painfully swollen big toe joint. Long story short, five days and a long overseas flight later the symptoms had shifted and I wondered if it could now be a DVT. My doctor, with images and discussion via Skype & email but unable to physically examine me, said yes, I should go have it checked out.

Great: nothing like looking for medical services in a strange city, I mean strange country. Where to go? What’s this going to cost this uninsured foreigner? How long will I wait?

My trip host and the hotel desk agreed I should go to the walk-in clinic at the railroad station, across the street. Ginny and I gathered our things, and 15 minutes later we’d found the clinic and were waiting in line, with one person ahead of us. I checked in, and ten minutes later was called into an exam room.

Outcome:

[Read more…]

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The Big Ugly continues: “Hospital charges bring a backlash”

Here’s the next episode in what I’m starting to call “The Big Ugly” – a wave of suffering that will happen as the medical industry contracts, and everyone tries to find ways to maintain their income. Unfortunately when an industry shrinks, everyone can’t maintain the same income. As anyone knows who’s seen an industry die (like mine, typesetting; or steel in America, or what Detroit went through), it’s painful. Good people get hurt, and organizations fight for survival.

Medicine’s certainly not going to die – we need it – but the Institute of Medicine says (see links below) we have massive overspending, and when the overspending shrinks, that too will hurt.

Today’s Boston Globe has the newest item: Hospital charges bring a backlash:

Patients, angered by surprise surcharges that hospitals tack on bills for doctor visits, are increasingly challenging these fees — sometimes even refusing to pay.

Hospitals say the charges cover their overhead, but the fees are sometimes added to the bill even when patients are treated in offices miles away from the medical centers. …

The Globe published a story in January about a patient charged $1,525 in operating room and facility fees for a minor skin procedure. Yeah, the doctor charged $354 for her services, and the hospital (Lahey Clinic) added $1525 of overhead. Another patient is quoted as sounding like (amazingly) an empowered consumer:

“I am willing to spend my money for my doctor — I am getting expert care,’’ said the New Hampshire resident. “I am not willing to pay $500 to sit in a waiting room.’’

Watch for more stories of overhead charges, and more, as organizations gasp for air, and ask consumers to bear the burden. See other stories in the links below, like the chain that put its E.R. docs on quota.

What to do: [Read more…]

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Let Patients Help, Cost-Cutting Edition: “Chaos behind a veil of secrecy”

One blog I read regularly is “Not Running A Hospital” by Paul Levy, formerly CEO of my hospital, Beth Israel Deaconess. Today’s post is A Tale of Two Blues, in which an MIT professor colleague recounts the insane, infuriating situation with his insurance company. His tale:

The last couple of months have been very heavy duty bad medical stuff for me.  Horrendous. So, I’ve been able to see the dysfunctional medical insurance system in action.   Do you understand how Blue Cross/Blue Shield actually works?  Out of, oh, maybe 80 transactions over 2 months — they managed to get one, as in the number 1, correct.  The rest are mistakes, mis-billings, computer errors, everything one can imagine.  And the only reason I can ever figure it out is because I am dogged and know something.  I can’t even begin to imagine the bone-head database that lurks behind all of it, along with inept programming, but whatever it is, the people running the place (sorry if I tread on toes) — up to and including all the executives, are simply, sorry to say, totally bonkers.  And they are just middlemen. They aren’t providing services, just managing to extract rents. Badly.

P.S. BTW, my running statistics on them, is that out of 540 transactions with them over the past 1.8 years, they have gotten two, as in the number 2, correct.   Not a good batting average. Why are they so inept?

As regular readers know, this general subject (not BC/BS of MA) has been one of my pet peeves lately, especially since I so often hear “Our costs are high because patients are irresponsible lazy slugs.” I summarized the past year’s posts in a comment there; I’m pasting it in here:

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A quick preliminary response, Paul:

As I think you know, Paul, this is something I’ve been blogging about for the past year. [Read more…]

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Collapse couldn’t happen in law, and it can’t happen in medicine. Right?

If you care (or worry) about the crunch-time that’s beginning in medicine, read this post last Tuesday on the Harvard Business Review blog:

Creative Destruction Visits the Legal Profession

It has strong echoes of what I wrote last month in As the crunch hits, will the best survive? That post talked about how much pain there’s likely to be as we try to solve the $750 billion of unnecessary spending in US medicine.  Until now I wasn’t aware of how much the legal profession has been hit by changing realities. Items from the HBR post:

  • “In the ten years or so since running that course, the assumptions underpinning a lot of the business models at law firms have come unraveled. Just as we argued, a lot of the lower-end, but profitable, work is now being done by cheaper providers or has been automated”
  • “Legal budgets have come under intense scrutiny as the Great Recession’s aftermath grinds on.”
  • “And — gasp — lawyers are now realizing that if nobody is looking after the business end of things — ahem — in other words, being strategic, the entire operation can come to a crashing halt. Witness the spectacular bankruptcy of once high-flying Dewey & LeBoeuf.”

Yeah, the bankruptcy of a once-high-flying law firm. More:

  • “The problems started to become urgent when young lawyers, armed with freshly minted degrees, either couldn’t get legal jobs or, worse yet, couldn’t get jobs at all.” Only 55% percent of 2011 graduates had a law-related job nine months after graduation.

Imagine if only 55% of med school graduates could find a job. Can’t happen, right?

That’s at the low end. And at the top?