Category: Patients

Ambulance bill rip-off: There’s always a public option

published date
December 1st, 2017 by

A Kaiser Health News story on sky-high ambulance bills caught my attention; I have a long-standing interest in out-of-network billing and a more recent experience of taking a pricey ambulance trip myself.

Taken for a ride? Ambulances stick patients with surprise bills, is not a new story. To sum it up: it’s not unusual for a patient to get a bill for thousands of dollars and then to be stuck with a big part of the charge, even if that patient is insured. That’s because many ambulance companies can make more money by being out-of-network. Unlike physicians and hospitals, ambulance companies don’t lose patients by being out of network and refusing to offer discounts. After all, if you need an ambulance you wouldn’t have time to shop around, and it doesn’t affect repeat business either.

The article cites an example of a Fallon ambulance in Chestnut Hill, MA, one town away from where I live. A patient was transported to Brigham and Women’s hospital four miles away and charged $3,660, which the article points out is $915 per mile. The insurer paid about half and half was the responsibility of the patient.

In my own case I was crossing the street in a crosswalk and was struck by a car making a left turn. My bill from Fallon was $3,427.50 for a one-mile ride, so at least on a per mile basis it was much higher than the Chestnut Hill example.

But to be fair, the bill comprises a base fee of $3,350 for an advanced life support ambulance plus $77.50 per mile. That works out to exactly the same rate as what the suburbanite paid ($3,350+4x$77.50=$3,660) and demonstrates that Fallon is not mainly charging for mileage, it’s charging for the equipment and personnel being ready to show up on a moment’s notice.

Much of the ire is directed at the ambulance company for price gouging and the insurance company for leaving patients hanging. There are calls to regulate prices and otherwise tighten the rules, and I’m sympathetic.

But notice this point a little further down:

” If the injury had happened just a mile away inside Boston city limits, he could have ridden a city ambulance, which would have charged $1,490, according to Boston EMS, a sum that his insurer probably would have covered in full.”

When you call 911 to report a fire or a crime in Chestnut Hill and anywhere else near Boston, fire fighters and police officers are dispatched at no charge. It doesn’t matter what insurance you have –or whether you have insurance– it’s a service provided by the local government as part of its budget. Police and fire fighters responded to my crash, too, but they aren’t sending a bill.

Cities and towns could do the same with ambulances if they want. Some, like Boston, do. Public ambulances can still bill insurance and individual patients, but they’re less likely to antagonize patients and insurers with outrageous bills.

So while we think of policy solutions for ambulance bill rip-offs, let’s not forget that there are public options and lots of hybrid solutions, too.


By healthcare business consultant David E. Williams, president of Health Business Group.

Hospice: Another sad sector of the opioid crisis

published date
August 30th, 2017 by
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Help yourself?

A person addicted to drugs might do anything to get their hands on the next dose. Whether that means ‘borrowing’ painkillers from a relative who had their wisdom teeth extracted, breaking into cars to grab small bills and coins, or stealing their mother’s jewelry –all things I’ve seen myself– there are no real limits. So I was saddened but not surprised to read Dying At Home In An Opioid Crisis: Hospices Grapple With Stolen Meds, which highlights the trouble dying patients face in keeping hold of their painkillers.

The Kaiser Health News examples are only anecdotal, but the combination of high quantities of opioids and homebound patients unable to fend for themselves is an ideal setting for diversion. The problem is two-fold: theft of drugs while the patient is alive, and diversion once the patient passes away. Since many patients die within days or weeks of beginning hospice, the second problem is a major one.

The examples offered in the article are heartbreaking:

  • In Mobile, Ala., a hospice nurse found a man at home in tears, holding his abdomen, complaining of pain at the top of a 10-point scale. The patient was dying of cancer, and his neighbors were stealing his opioid painkillers, day after day.

  • In Monroe, Mich., parents kept “losing” medications for a child dying at home of brain cancer, including a bottle of the painkiller methadone.

  • In Clinton, Mo., a woman at home on hospice began vomiting from anxiety from a tense family conflict: Her son had to physically fight off her daughter, who was stealing her medications. Her son implored the hospice to move his mom to a nursing home to escape the situation.

Some hospices are trying to do something about the problem, but it’s not easy. After all, their primary goal is to ease the pain of dying patients. It’s not really their job to keep track of and control everyone else. Some of the ideas being tried include:

  • Screening families for a history of drug addiction
  • Limiting the amount of meds delivered at any one time
  • Drafting agreements with families about consequences for drugs that disappear
  • Encouraging the destruction and disposal of drugs after the patient dies

None of these approaches is likely to succeed on its own. The country will have to address the broader opioid crisis in order to bring this part of it under control. However, there are a couple additional steps that could be taken now:

  • A few states let hospice employees destroy drugs once a patient dies. That should be expanded nationwide and made mandatory. There is no conflict here with the patient’s needs
  • Some patients, who would otherwise be eligible for home hospice, should be moved to facilities such as nursing homes, where controls can be tighter. (Much as I hate to argue against home care this needs to be part of the discussion)

By healthcare business consultant David E. Williams, president of Health Business Group.

Advances in care management: podcast interview with AxisPoint CEO Dr. Ron Geraty

published date
August 10th, 2017 by
Ron Geraty
Dr. Ron Geraty, CEO of AxisPoint Health

AxisPoint Health is part of the new breed of care management companies, leveraging new data sources and digital techniques that go beyond the traditional paradigm of nurse call centers focused on a handful of common chronic conditions. Industry veteran, Dr. Ron Geraty (former CEO of Alere) took the reins of the company a couple years back.

In this podcast interview, Ron and I discuss the evolution of care management, the role of digital, and what the future will bring.

  1. (0:11) What’s the current state of care management in the US?
  2. (2:27) How is care management being done differently across populations: commercial, Medicare, Medicaid, dual eligibles?
  3. (5:36) Care management traditionally focuses on 5 common chronic conditions. Has it made a significant difference in those areas?
  4. (8:26) What attracted you to AxisPoint? How is it different from other population health management companies?
  5. (13:08) Who are the customers? Who is drawn to your approach and why?
  6. (15:26) You work with the most vulnerable populations. Do you attempt to influence the social and behavioral determinants of health?
  7. (19:18) What’s at stake for AxisPoint in the debate about healthcare in Washington, DC, especially since you are serving populations that have been a major focus of the ACA?
  8. (22:33) How will digital tools be leveraged for vulnerable populations? Will you still have feet on the street?

By healthcare business consultant David E. Williams, president of Health Business Group.

Urgent care clinics just for cancer patients

published date
May 2nd, 2017 by

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It’s tough being a cancer patient. The illness is serious and sometimes fatal, treatments can have serious side effects, and the fatigue and stress can be overwhelming. It gets worse when patients end up in the emergency room where they are exposed to people who may be contagious and encounter medical staff who may not know how to address the special needs of an oncology patient.

So I was heartened to read about urgent care centers specifically for cancer patients. Centers like the one at University of Texas Southwestern Medical Center in Dallas cater to the requirements of cancer patients. They provide same-day appointments, are open early and late, and coordinate with the rest of the patient’s oncology care givers. It’s a good example of patient-centered care.

Of course there are some strong economic incentives as well (hospitals aren’t doing this for their health, so to speak). Cancer patients are lucrative for hospitals –that’s one reason you hear so much advertising for cancer care. And hospitals are wise to treat their best customers well to encourage loyalty. In the value-based care era, we can also expect pressure for hospitals to improve outcomes, control costs and improve the patient experience of care. Urgent care cancer centers contribute to addressing all these goals.

It does raise the question of why only cancer patients get their own urgent care while the rest of the population has to put up with all the challenges and downsides of the regular healthcare system. Perhaps other parts of the healthcare system can learn from these urgent care centers and emulate them more broadly.

———-

By healthcare business consultant David E. Williams, president of Health Business Group.

USPSTF adopts my reasoning on PSA screening for prostate cancer

published date
April 13th, 2017 by
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Which way on PSA?

I oppose over-testing and over-treatment, so I really had to think hard five years ago when I turned 45 and my doctor offered PSA screening for prostate caner. The US Preventive Services Task Force (USPSTF) had just come out against PSA screening, concluding that the harms outweighed the benefits.

Nonetheless (Why I decided to get a PSA screening test for prostate cancer), I did go forward. As I wrote:

I know that PSA is a very imperfect indicator. I definitely want to avoid the stress and possible discomfort of having a biopsy. I’m worried about false positive and false negative biopsy results. And I don’t relish the significant potential for incontinence, impotence, or bowel problems from treatment.

But at this stage of my life I am willing to accept a significant risk of morbidity in exchange for a small reduction in mortality risk, which is my impression of what my choice to have the PSA test means. In 10 or 20 years I probably won’t feel that way. And I hope there will be better detection, follow-up and treatment options by then.

I’m also confident in my ability to make informed choices with my physicians along the way. The PSA test itself was done as part of routine blood work and there was no additional risk from that. My doctor and I agreed that if the PSA is elevated we’ll discuss what to do next. At that stage I’ll also have the chance to do more research and get more opinions if necessary. I’m not automatically going to get into a cascade of follow-up and treatment.

Now the USPSTF appears to be coming around to my way of thinking. In particular, they note that more men are choosing “active surveillance,” i.e., keeping a close watch rather than jumping straight to aggressive treatment.

The choice about whether to undergo PSA testing and what to do once results are in is a great opportunity for shared decision making. And this is what should be encourage.

By healthcare business consultant David E. Williams, president of Health Business Group.