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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.

Why We Must Stop ‘Bucketing’ Healthcare

Health insurance plans should be designed to spur the use of the highest-value pharmaceuticals as well as the highest-value care delivery services.

In some cases, plans do seek to ensure access to the highest-value care regardless of how it is delivered. Think for a moment about implantable devices, from drug-eluting coronary stents to replacement joints. Patients don’t have to pay for the stent outside of their insurance; it’s included in the total cost of their care because it’s less expensive to cure an individual’s heart or hip than it is to pay for the multiple episodes of care required by a lack of effective treatment.

Yet many plans are set up with “buckets” of money that don’t make sense and destroy value. For example, bucketing means there are plans that discourage the use of high-value blood pressure medications because the broader adoption of this therapy caused the plan to exceed its budget for medications – even though the therapy saved dramatically on the cost of hospital and disability care and the reduced incidence of heart attacks and strokes. (As a side note, these savings materialize much more quickly than many typically expect. Better use of blood control medications can reduce the incidence of strokes and heart attacks in as little as six months.)

There are also many specialty medications that are exceedingly expensive and tremendously effective. Their use can reduce the overall costs of care, but bucketing means the payment system often isn’t sure how to incorporate them. Examples include new medications for curing hepatitis C as well as “orphan drugs” for rare diseases, including unusual expressions of hemophilia, cystic fibrosis and Gaucher’s disease.

So what’s stopping providers from inciting the use of high-value medications? First, too few of the medications (or treatments of any sort) have good outcome data that shows results and costs over the full cycle of care. Second, few providers are set up to provide comprehensive, full-cycle care.

The way to get these high-value medications included in care is to eliminate the use of bucketing and instead look at the total cost of care for a patient’s medical circumstances. In the case of an infection like hepatitis C, that cycle of care would be from the time of diagnosis until the patient is cured. For conditions perceived as non-curable or lasting for an extended duration, it would typically be for a period of time or through a particular episode (e.g., an acute flare-up of Crohn’s).

This has been done for Gaucher’s disease, particularly in countries with nationalized healthcare, because the new drugs dramatically reduce the total cost of care. Untreated, the condition requires multiple, expensive and painful surgeries. For plans to encourage value-based care, they must similarly minimize fragmentation and instead consider the holistic needs of each medical condition. Only then can the industry truly improve health outcomes and reduce overall spending.

2015 Is Watershed for Healthcare Hacking

Predictions that 2015 would be a watershed year for stolen healthcare records are bearing out.

Health insurer Premera Blue Cross has disclosed that a cyber attack that commenced in May 2014 resulted in exposure of medical data and financial information of 11 million customers. Stolen records included claims data and clinical information, as well as financial account numbers, Social Security numbers, birth dates and other personal data. The Premera breach appears to involve a record number of victims.

Records for some 80 million people were stolen from the nation’s No. 2 insurer Anthem, and records for 4.5 million people were hacked from Community Health Systems, parent of 206 hospitals in 29 states, disclosed last summer. But the Anthem and CHS breaches involved the theft of personal data only, not medical records.

More: 7 steps to take if your healthcare records are in the wild

Personal and medical records are the building blocks for the worst forms of identity theft. With Premera, “hackers not only got the skeleton keys to lives, they got the key ring and the key chain,” says Adam Levin, chairman and co-founder of identity and data risk management consultancy, IDT911, which sponsors ThirdCertainty. “Members and employees whose data was exposed – especially their SSNs – will be forced to look over their shoulders for the rest of their lives.”

Seattleites hit hard

More than half of the victims — about 6 million Premera patrons – reside in Washington state, including employees of Amazon, Microsoft and Starbucks. These companies now are prime targets for spear phishing attacks. It doesn’t take much imagination for a criminal to use stolen data to create spoofed accounts to come across as a trusted colleague to send viral email and social media posts to fellow employees as a way to breach any of these corporate networks.

On a lower rung of criminal activity, a whole generation of scammers who’ve mastered fraudulent online transaction using stolen credit card account numbers are ready to move to the next level, observes Lisa Berry-Tayman, senior privacy and governance advisor at IDT911 Consulting.

“Criminals learn,” Berry-Tayman says. “The credit card thief steals the data, charges until the account is closed and the money is gone. To steal more money over a longer period of time, he or she must think bigger, and bigger is identity theft. Why just spend their money for a finite period of time when you can become them and spend their money for years and years?”

The healthcare industry has arisen as a target because it has moved aggressively to get rid of paper records and to collect, store and make use healthcare data in digital form. The goal: to boost productivity. Trouble is the healthcare industry, like many other industries, continues to make the digital push, including intensive use of the Internet cloud, without adequately accounting for security basics, security experts argue.

Healthcare data at riska three-part series: Why medical records are easy to hack, lucrative to sell

“Today’s Premera breach news once again demonstrates the failure of flawed, outdated assumptions, an over-reliance on guard-the-entry-point security and simplistic single-key encryption schemes,” says Richard Blech, CEO of encryption technology company Secure Channels. “This is a quaint and dangerous approach to a 21st century problem.”

Trent Telford, CEO of data security company Covata, agrees. “For many of these companies, data security has been an afterthought or something they did not deem necessary,” Telford says. “However, this breach again highlights how vulnerable the health care and insurance industries are to attacks. People are entrusting these organizations with their personal information, and it is the responsibility of corporations to take appropriate steps to ensure it is protected – this must include data encryption.”

Common culprits?

Premera is keeping details of how the breach was carried out close to the vest. The FBI and IT forensics specialist Mandiant, a division of FireEye, are investigating. A good guess is that Premera was the focus of a targeted attack, says Josh Cannell, malware intelligence analyst at Malwarebytes Labs.

“A vast majority of cyberattacks targeting enterprise networks originate by attackers gaining access to internal networks through social engineering techniques like phishing/spear phishing e-mails that closely resemble something employees are familiar with,” Cannell says. “Once attackers have an access point inside an enterprise network, they can then use privilege escalation techniques and install malware to maintain a presence on the network.”

Cannell says it’s plausible the same hacking collective hit Anthem and Premera. “Since the attack happened around the same time as the Anthem breach, and was targeting a similar organization, it seems reasonable to say the threat likely originated from the same actors,” Cannell says.

Why Can’t U.S. Health Care Costs Be Cut in Half?

Technological improvements in health care have given us the quality of life we enjoy today. But chronic conditions, end-of-life care, and an aging society will bankrupt the United States if it doesn’t make dramatic changes to its health care system. America — and many other countries — need an audacious goal to get off the unsustainable path.

What if the United States set itself the goal of cutting healthcare costs in half — without sacrificing quality, and in about a decade?

Sound undoable? In “Delivering World-Class Health Care, Affordably,” we argued that some Indian hospitals are delivering high-quality care at 5% to 10% of U.S. prices. Of course, the United States is not India, so its costs will always be higher. But even with all the constraints, cutting U.S. healthcare costs in half is not preposterous. After all, it’s been done in other industries, sometimes in less time (think computers or consumer electronics).

Or take the example of autos. When Karl Benz introduced the Mercedes Benz in 1876, each car was handmade from start to finish. Every customer was assumed to be unique and so was every car. Making autos was a craft, and very few people were skilled enough to put one together. Buyers visited the Benz factory and stayed for a week to test drive the car and fix any bugs before taking delivery. The net result: The craft approach produced only a few automobiles at extremely high cost for the very rich.

Enter Henry Ford, who revolutionized the industry with his manufacturing innovations, lowering the price of cars from $2,000 in 1908 to just $260 by 1925 — an 87% reduction! He didn’t do it by making cars shoddier or offshoring production to low-wage countries. His secret was mass production in a “focused factory,” using interchangeable parts, specialization, and the assembly line. (See this HBR article on attempts to apply the focused factory concept to health care.) By making only one type of car (Model T) in volume, he cut unit costs dramatically. Ford shifted the auto industry from craft to mass production, and the Japanese later took it a step further to lean production. At each step, costs fell sharply yet quality improved.

If we go back a hundred years, medicine had to be practiced in a craft mode since each patient was unique and our ability to diagnose diseases and treat them was rather limited. Knowledge and technology have advanced at a such a rapid pace that today that quite a number of medical conditions can be treated using a “process” approach. Yet, too much of U.S. health care is stuck in the craft mode. It is producing a Rolls Royce for each patient! Why can’t U.S. health care go vastly farther in streamlining operations, standardizing protocols, and rationalizing facilities to create focused hospitals for heart surgery, hernia repairs, cataract surgery, hip and knee replacements, organ transplants, or even cancer treatment — anything that’s not an emergency procedure and can be scheduled in advance?

Many U.S. health care providers are going down this road (see “Fixing Health Care on the Frontlines”). But the most innovative Indian hospitals are doing much more. Narayana Health in Bangalore, India, uses the focused-factory approach to perform open-heart surgeries for $3,000, versus $75,000 to $150,000 in the United States. The total number of open-heart surgeries performed in the United States is about 550,000 — six times India’s — but this volume is spread across too many hospitals. The same can be said of other procedures that might lend themselves to mass or lean production.

Aravind Eye Care in Madurai, India, performs cataract surgery in assembly-line fashion. Doctors focus their time on diagnosis and the most intricate aspects of surgery, while less-skilled paramedics take care of everything else. Care Hospitals in Hyderabad performs angioplasties with remarkable efficiency and efficacy. Lifespring focuses on uncomplicated maternity care for the urban poor. HCG Oncology performs advanced diagnoses and procedures in its Bangalore “center of excellence,” while its spoke facilities provide radiation and chemotherapy treatments. Onco-pathologists and medical physicists, who are scarce in India, sit in Bangalore and provide services remotely, using telecommunication links to patients at spoke hospitals. (See this HBR article on how to redesign knowledge work, including health care.)

Changing U.S. health care to achieve a 50% cost reduction will require patients, providers, insurers, and others to make major adjustments. But such changes happen routinely in other industries. With costs spiraling out of control, the day has come when the same must happen in health care.

Authors

Vijay Govindarajan collaborated with Ravi Ramamurti in writing this article which first appeared in the Harvard Business Review. Ravi Ramamurti is the D’Amore-McKim Distinguished Professor of International Business and Strategy, and the Director of the Center for Emerging Markets at Northeastern University.

India’s Secret to Low-Cost Health Care

A renowned Indian heart surgeon is currently building a 2,000-bed, internationally accredited “health city” in the Cayman Islands, a short flight from the U.S. Its services will include tertiary care procedures, such as open-heart surgery, angioplasty, knee or hip replacement, and neurosurgery for about 40% of U.S. prices. Patients will have the option of recuperating for a week or two in the Caymans before returning to the U.S.

At a time when health care costs in the United States threaten to bankrupt the federal government, U.S. hospitals would do well to take a leaf or two from the book of Indian doctors and hospitals that are treating problems of the eye, heart, and kidney all the way to maternity care, orthopedics, and cancer for less than 5% to 10% of U.S. costs by using practices commonly associated with mass production and lean production.

The nine Indian hospitals we studied are not cheap because their care is shoddy; in fact, most of them are accredited by the U.S.-based Joint Commission International or its Indian equivalent, the National Accreditation Board for Hospitals. Where available, data show that their medical outcomes are as good as or better than the average U.S. hospital.

The ultra-low-cost position of Indian hospitals may not seem surprising — after all, wages in India are significantly lower than in the U.S. However, the health care available in Indian hospitals is cheaper even when you adjust for wages: For example, even if Indian heart hospitals paid their doctors and staff U.S.-level salaries, their costs of open-heart surgery would still be one-fifth of those in the U.S.

When it comes to innovations in health care delivery, these Indian hospitals have surpassed the efforts of other top institutions around the world, as we discussed in our recent HBR article. Today, the U.S. spends $8,000 per capita on health care; if it adopted the practices of the Indian hospitals, the same results might be achievable for a whole lot less, saving the country hundreds of billions of dollars.

A key to this is that, faced with the constraints of extreme poverty and a severe shortage of resources, these Indian hospitals have had to operate more nimbly and creatively to serve the vast number of poor people in need of medical care in the subcontinent. And because Indians on average bear 60% to 70% of health care costs out of pocket, they must deliver value. Consequently, value-based competition is not a pipe dream but a reality in India.

Three major practices have allowed these Indian hospitals to cut costs while still improving their quality of care.

A Hub-and-Spoke Design

In order to reach the masses of people in need of care, Indian hospitals create hubs in major metro areas and open smaller clinics in more rural areas which feed patients to the main hospital, similar to the way that regional air routes feed passengers into major airline hubs.

This tightly coordinated web cuts costs by concentrating the most expensive equipment and expertise in the hub, rather than duplicating it in every village. It also creates specialists at the hubs who, while performing high volumes of focused procedures, develop the skills that will improve quality. By contrast, hospitals in the U.S. are spread out and uncoordinated, duplicating care in many places without high enough volume in any of them to provide the critical mass to make the procedures affordable. Similarly, an MRI machine might be used four to five times a day in the U.S. but 15 to 20 times a day in the Indian hospitals. As one CEO told us, “We have to make the equipment sweat!”

U.S. hospitals have been developing similar structures, but there are still too many hubs and not enough spokes. Moreover, when hospitals consolidate, the motive often is to increase market power vis-à-vis insurance companies, rather than to lower costs by creating a hub-and-spoke structure.

Task Shifting

The Indian hospitals transfer responsibility for routine tasks to lower-skilled workers, leaving expert doctors to handle only the most complicated procedures. Again, necessity is the mother of invention; since India is dealing with a chronic shortage of highly skilled doctors, hospitals have had to maximize the duties they perform. By focusing only on the most technical part of an operation, doctors at these hospitals have become incredibly productive — for example, performing up to five or six surgeries per hour instead of the one to two surgeries common in the U.S.

This innovation has also reduced costs. After shifting tasks from doctors to nurse practitioners and nurses, several hospitals have even created a lower tier of paramedic workers with two years’ training after high school to perform the most routine medical jobs. In one hospital, these workers comprise more than half of the workforce. Compare that to the U.S. system, where the first cost-cutting move is often to lay off support staff, shifting more mundane tasks such as billing and transcription onto doctors overqualified for those duties — precisely the wrong kind of task shifting.

Good, Old-Fashioned Frugality

There is a lot of waste in U.S. hospitals. You walk into a hospital in the U.S., and it looks like a five-star resort; half of the building has no relation to medical outcomes, and doctors are blissfully unaware of costs. By contrast, Indian hospitals are fanatical about wisely shepherding resources — for example, sterilizing and safely reusing many surgical products that are routinely discarded in the states after a single use. They have also developed local devices such as stents or intraocular lenses that cost one-tenth the price of imported devices.

These hospitals have also been innovative in compensating doctors. Instead of the fee-for-service model, which creates an incentive to perform unnecessary procedures and tests, doctors at some Indian hospitals are paid fixed salaries, regardless of how many tests they order. Other hospitals employ team-based compensation, which generates peer pressure to avoid unnecessary tests and procedures.

Innovation has flourished in the U.S. in the development of new pills, clinical procedures, devices, and medical equipment, but in the field of health care delivery, it appears to have been frozen in time. In too much of the U.S., system, health care is viewed as a craft and each patient as unique. But by applying principles of mass production and lean production to health care delivery, Indian doctors and hospitals may have discovered the best way to cut costs while still delivering high quality in health care.

Authors

Ravi Ramamurti collaborated with Vijay Govindarajan in writing this article which first appeared in the Harvard Business Review. Vijay Govindarajan is the Earl C. Daum 1924 Professor of International Business at the Tuck School of Business at Dartmouth College and a Distinguished Fellow at The Dartmouth Center For Healthcare Delivery Science.