Tag Archives: ER

Health Insurer Trickery Straps ER Patients

Millions of emergency room patients could face financial ruin — even if they deliberately seek care at hospitals covered by their insurers.

That’s the disturbing finding of a new study published in the New England Journal of Medicine. Conducted by two Yale professors, the study shows that one in five ER visits involve doctors who are not in the same insurance network as their hospitals. The patients treated by those out-of-network physicians are forced to pay for a portion of their care out-of-pocket. The average out-of-network ER charge is $600.

A bill that size spells disaster for many patients. About half of Americans wouldn’t be able to cover a surprise $400 bill without selling something or borrowing money.

It’s a travesty that, in the midst of medical emergencies, people who specifically head to hospitals covered by their insurance plans are still getting hit with huge bills. Unfortunately, these out-of-network ER charges are just the latest tactic that health insurers have devised to shift costs onto patients.

See also: Key Misconceptions on Health Insurance  

The contracts that hospitals establish with health insurers typically don’t cover ER doctors. Those physicians have to negotiate with insurers directly. Many insurers decide ER physicians’ fees are too high and cut them out of coverage networks.

Patients hardly ever suspect that the ER doctors at in-network hospitals could be out-of-network. Take Candice Butcher, a Salem, Va., mom who rushed her two-year-old son Logan to the ER after he cut his head on a dining room chair. Candice made sure to take her son to a hospital covered by her insurance. And Logan’s treatment — cleaning and suturing the wound — was relatively straightforward. So she was stunned when she got the news: Her out-of-network ER doctor was charging her $750.

Or consider Craig Hopper, who got hit with a $937 bill by his Austin, Texas, hospital for ER treatment for a sports injury. “It never occurred to me that the first line of defense … could be out of the network,” says his wife, Jennifer. “In-network means we just get the building? I thought the doctor came with the ER.”

The Hoppers are in a particularly unfriendly state. Fully half of the Texas hospitals covered by the state’s main private insurers have zero — yes, zero — in-network ER physicians, according to work from the Center for Public Policy Priorities. Emergency patients all are getting hit with huge, unexpected bills. “There’s little consumers can do to prevent it and protect themselves” says Stacey Pogue, an analyst at the CPPP.

This out-of-network trickery is largely a response to Obamacare’s crippling mandates on insurers. The outgoing president’s signature legislative accomplishment straps coverage providers with invasive, costly regulations, squeezing bottom lines and forcing insurers to cut expenses and boost revenues anyway they can.

The obvious insurer response is to ratchet up premiums. The average premium for plans available on the Obamacare exchanges in 2017 jumped 22% over the 2016 rates.

But insurers also have resorted to subtler tactics.

That includes raising deductibles, the amount that customers have to spend out-of-pocket before benefits kick in. The average health insurance deductible for individual plans shot up 42% in Obamacare’s first year — and that figure continues to climb. Today, the average deductible for the “bronze” plans in the exchanges — the cheapest possible coverage — is a whopping $6,000 for individuals and $12,000 for families.

See also: The Basic Problem for Health Insurance  

Insurers also are restricting their official networks — limiting the doctors and hospitals that their customers can use. This strategy enhances insurer bargaining power in negotiations with healthcare providers, but it hurts patients by denying them access to convenient care. People get stuck traveling long distances to unfamiliar caregivers for vital treatments. McKinsey calculates that about four in 10 exchange plans exclude more than 70% of hospitals in the plan’s coverage area, and a further three in 10 plans exclude at least 30% of hospitals.

Insurers are feeling the squeeze under Obamacare, and they’re resorting to devious tactics to cut costs. Too often, that straps patients with staggering, unforeseeable medical bills. That should all change when Obamacare is repealed and replaced — which is why lawmakers must move with all due haste in the new year.

5 Reasons Doctors Are ‘Non-Standard’

Non-standard physicians and surgeons are practicing doctors who have had claims frequency or severity issues or board actions or have been previously or are currently on probation. It can often be difficult for non-standard physicians to find affordable malpractice insurance coverage because they are considered a higher risk by insurance companies. Typically, a doctor remains in the non-standard market for about five years, provided once they enter the non-standard market they have kept themselves clean. In this post, we examine the top five reasons doctors become non-standard physicians.

#1 Claims – The common reasons for claims filed against physicians include: poor communication, poor bedside manner, erroneous documentation and failure, delay or change in diagnosis. To reduce the likelihood of lawsuits and claims, physicians might take just a few minutes of extra time to answer all questions and address all concerns. Patients and their families will walk away feeling as though they had all the information, even if a bad outcome occurred. They will be much less likely to seek the counsel of an attorney. Click here to read our blog post Top 5 Reasons Doctors Get Sued.

#2 Lack of informed consent – Informed consent should occur with every patient encounter. Patients must be informed on the details of their options, especially when care involves an invasive or new, cutting-edge procedure. Top breaches in informed consent that lead a doctor to the non-standard market include the use of non-FDA approved medications, and new or innovative procedures. Physicians should engage with a risk management consultant to learn best practices and get risk management advice specific to a particular practice specialty, especially those that are considered high-risk.

#3 Substance abuse issues – While physicians are about as likely to abuse alcohol or illegal drugs as any member of the general public, they are more likely to misuse prescription drugs. The motivation for this often initially includes the relief of stress or pain or to stay alert when suffering from sleep deprivation. Physicians often work strange hours and long shifts, especially in the ER. The cycle often begins by using medication to stay awake and alert to manage the stress and the hours. These stresses combined with easy access to medications can lead to substance abuse issues.

#4 High-risk practice profile – Physicians in a practice with higher claim ratios automatically fall into the category of “high risk.” Examples of high-risk specialties include: bariatric surgery, OB/GYN, neurosurgery, plastic surgery and pain management. These specialties are either composed of high-risk and invasive procedures such as in the case of surgeons or they are prescribing medications that are new or dangerous, such as with weight-loss or pain-management clinics. Physicians in these practices will most likely have to remain in the non-standard market throughout their entire careers.

#5 Poor record keeping – Following a bad outcome or an adverse event, the first thing that the patient’s attorney will request is a copy of medical records. These will be scrutinized. Any incorrect or conflicting information contained within the medical record will prove problematic for the physician’s case. Accurate and thorough record keeping proves especially challenging for older physicians, who may have been away from practice for some time and re-enter wanting to pick up where they left off. Or perhaps they are just resistant to change. Medical clinics are now using electronic medical records (EMR), which provides a more streamlined and accurate system of record keeping; they even have informed consent forms built right in. From a risk management perspective, EMR is highly encouraged.

Bottom Line – Physicians should consult a clinical risk management expert for help in developing strategies to decrease the risk of becoming a non-standard physician. Thorough protocols covering documentation, informed consent and communication will all prove invaluable in risk reduction. It’s also important that doctors are honest about their personal bandwidth when it comes to patient load capacity, stamina for extended work hours, overall physical and emotional health and stresses that may be coming from personal circumstances. These factors are important to consider and if not tended to can lead to events that have a long and lasting impact on a doctor’s ability to practice medicine.

How End of Life Is the Real Healthcare Crisis

To contend with ever-escalating healthcare costs, Americans will need to come to grips with the cost of end-of-life care. Right now, it’s my reality. I am seeing, first hand, rampant and seemingly uncontrollable costs of sustaining life in a system that lacks any semblance of common sense.

My mother is 90 years old and, other than some spending on five healthy sons, has expended very limited healthcare dollars in her lifetime. That is, until now. Suffering mild dementia, she is a resident in a very pleasant assisted-living facility on Long Island. The facility takes good care of her creature comforts, but, medically, she appears to be a case study in why we are all facing a cost crisis. Two of my brothers are medical professionals, and we have a concerned, knowledgeable, family that oversees her care, but we are not with her all the time to manage treatment, and that’s where things break down.

At the first sign of an issue, the facility phones an ambulance and ships her off to the nearest emergency room — three times in the past few months. The first was because of the flu. She weathered the illness but, because of scarcity of resources, was bedridden for a week. As a result, she needed more than a month of inpatient rehabilitation to restore her ambulatory skills. I am guessing that this episode cost in excess of $50,000. The doctor believes that the next two episodes – which occurred in the past 10 days – relate to an allergic reaction, and he has been trying to rule out possible culprits. He took her off Prilosec, and soon thereafter she complained of chest pains, which turned out to be indigestion. So the hospital sent her home. She burned through about $3,000 in costs to figure that one out. Then, after some tinkering with her medication, her blood pressure spiked to 200/113. This has resulted in another in-patient stay. We are planning to keep her moving to avoid another costly rehabilitation; so, for this one, Medicare and her supplemental insurance will probably spend less than $20,000.

The medical expenses she has experienced could have easily been reduced. The problem is that our Medicare system pays for services rendered and not for care management. Care management would have resulted in a much better outcome for my mother, for our family and for U.S. taxpayers.

I am convinced that the Affordable Care Act is not the answer to solve the healthcare crisis, which can only be fixed if we change the way we deliver care at the end of life. And those who lobby for Medicare for all can consider my mother’s experiences. That’s certainly not the answer.

Electronic Health Records Hurt Care

Patient care as we know and expect it will diminish because of electronic health records (EHR) requirements. Society will suffer a slow degradation of artful interactive provider attention in deference to “data-field” medicine.

I am not simply referring to the very real and challenging issues in the technical application of EHR systems. Rather, I point out a more serious and insidious future threat to the actual human aura in medical practice.

There exists an unintended but real incentive for doctors and clinicians to consider task-completion as clicking through the data interface rather than interacting with and treating the patient. Legal requirements, reimbursements and potential penalties force EHR to top priority. In turn, clinicians as EHR users become more aware of and anticipate the truncated, template-driven and limited means of expressing case events via electronic reports. Therefore, their interaction with patients may be truncated.

I know this sounds callous and insulting to all good medical providers. To them, I say no insult is intended, and the fault of this perverse incentive is not theirs. They might honestly assess their experience and the actions of peers and associates within their practices given the advent of EHR. To providers, I ask: What about EHR might be sucking the creative life out of your optimal vision for the practice of your specialty?

My most stark encounter with this reality comes from a chance discussion with a longtime friend. She is a nurse practitioner who, for decades, has treated both ER and family-practice patients. As family friends, we never talk shop, and this particular conversation was not solicited by me. I politely asked, “How’s it going?” and got a surprising, soul-baring burst of frustration.

She expressed disdain. She prides herself as a master of triage, symptom investigation, on-the-spot research and communication with involved family members, and she desires to take the wide approach to patient situations as a service to them and to the doctors or specialists who may eventually carry the case, but electronic records don’t allow the narratives or collective points of data she would prefer. As such, her value is diminished, and the patient ultimately gets poor attention.

As she described her situation, I began to understand the rigid decision-tree “intelligence” in narrowing prompts for information based on how case records are initiated. She has persevered and found cumbersome work-around methods (such as editing previous fields to change next options, etc.) to combine or add issues or thoughts to a record beyond the template’s desired straight line of thought. Unfortunately, she explained, taking extra time to do anything is neither advisable nor encouraged because of the volume of patients requiring care.

Quick Tip: The Want for Data Should Not Put the Cart Before the Horse

As a foreshadowing about healthcare in general, consider what the supreme focus on automation and data collection has done to workers’ compensation. I have written extensively about the advent of electronic claim systems, over decades, reducing the adjusting job from that of an intelligent, intuitive personal-interactive specialist to the current task-level data entry clerk. We are now well into the post-paper-file generation of claim adjusters who know their job only as data-interface. Will medical clinicians meet the same fate when our current generation of providers, like my friend, move on? Will future clinicians, knowing only electronic records, assume that the decision tree of the EHR interface supersedes intuitive medicine?

Let’s hope not. Unfortunately, a simple Google search for “problems with EHR” will not sit well with anyone who embarks on some research in this area.

In claim adjusting, as in medicine, we need to intelligently feed the hunger for data but rail against a perverse desire to let automation increase case volumes or assume the template is sacrosanct. I am certainly not against all the good that electronic medical records bring to the party. However, we must first let practitioners do their jobs, not let “data screen medicine” dumb down patient care.

Perhaps provider-run coalitions should dictate standards for ever-improving EHR frameworks and interfaces so their highest-quality, real-time nimble intelligence can be best captured in all patient events. I know at least one nurse practitioner who has a lot to say on that subject.