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Insurers to end no-fee programs for COVID-19 treatment on Oct. 1; CRAIN’S DETROIT BUSINESS

With the current COVID-19 surge not expected to peak until mid-October, treatments for the deadly virus are set to cost much more for those infected.

Michigan’s large health insurers—including Blue Cross Blue Shield of Michigan and Priority Health—are sunsetting their programs that waived all costs to patients treated for COVID-19.

The waiving of cost-sharing for patients expires on Sept. 30 for the two insurers.

More than 2 million Americans have checked into hospitals to get treated for severe cases of COVID-19 and many, thanks to insurers and government programs, have received no bills in the mail.

The cost for treating COVID-19 varies greatly, depending on severity. But after Oct. 1, Michiganders who contract COVID-19 and seek treatment will face co-pays and treatment bills.

Nationally, COVID-19 treatments performed in an outpatient setting cost an average between $500 and $1,000, according to a February report from the Blue Cross Blue Shield Association.

Insured individuals generally cover 30 percent of medical bills out of pocket, meaning those patients would be charged roughly $150 to $300.

However, costs rise exponentially for COVID-19 patients hospitalized or placed in the intensive care unit.

Total costs on average for treating patients hospitalized with COVID-19 is $22,500 to $45,000, according to the Blue Cross study. That mean patients could see bills as high as $13,500.

For patients requiring treatment in the ICU, total costs average $56,250 to $112,500. Patients could see bills as high $33,750 for COVID-19 ICU treatments.

The move is part returning to regular course of business for the insurers and part pushing the costs on to those the virus preys on—the unvaccinated.

Hospitalizations are doubling every 10 days in the state—there were more than 700 hospitalized with COVID-19 in Michigan on Aug. 8, according to state data—and the majority of those are unvaccinated.

“The vaccines have proven to be extremely effective at preventing the transmission of COVID-19 and severe illness or death,” Grand Rapids-based Priority Health said in a statement to Crain’s. “We will continue to offer the vaccine at $0 to all members, as we believe getting vaccinated is the most effective way for our members to keep themselves, their families, and their community safe.”

U.S. health officials on Wednesday recommended all Americans get COVID-19 booster shots to shore up their protection amid the surging delta variant of the coronavirus and evidence that the vaccines’ effectiveness is falling. The doses could begin the week of Sept. 20.

Employers weigh insurance surcharges for unvaccinated workers

Charging unvaccinated workers with higher insurance premiums could help employers fully vaccinate their workforces and mitigate the health and financial risks of employees contracting COVID-19.

About 10% of employers have offered cash and prizes to persuade workers to get immunized, but those tactics may have outlived their usefulness. Private and public employers increasingly are imposing mandates instead that require workers to be vaccinated or, in some cases, to submit to regular COVID-19 testing as a substitute.

Early in the nationwide vaccination campaign, employers were comfortable staying on the sidelines but now more understand their crucial role in brining the pandemic to a close, said Wade Symons, a partner and leader of Mercer’s regulatory resources group. “It is important for employers to be sending the right messages about vaccination and getting behind these efforts,” he said.

Around 65% of workers say their employers encouraged them to get vaccinated, and 72% say they trust their companies to provide reliable information about the vaccines, according to a Kaiser Family Foundation COVID-19 Vaccine Monitor report published in June.

Now some companies are weighing the advantages and disadvantages of increasing health plan premiums on employees who refuse the vaccine and don’t qualify for medical or religious exemptions.

“Employers feel like that may be justified, similar to a surcharge for those that use tobacco, because of the potential for unvaccinated employees to cost more from a medical claims perspective,” Symons said.

While most businesses still want vaccination to remain a choice for workers, 20 to 30 large employers are investigating the possibility of premium surcharges for unvaccinated employees, Symons said. Companies want to shield themselves from the medical costs of hospitalizing COVID-19 patients and create safe workplaces for all employees.

In the healthcare sector, more than 96% of physicians and 83% of nurses are vaccinated, according to American Medical Association and American Nurses Association surveys. So far, more than 1,500 hospitals have implemented employee vaccination mandates.

Higher health insurance premiums for unvaccinated people could provoke a backlash from employees who don’t want the vaccine, however, said Adam Block, assistant professor of Public Health at New York Medical College and founder of Charm Economics.

Employers that want to avoid surcharges could instead offer wellness credits that reduce health insurance premiums for workers who get inoculated, as some companies do for employees who get annual flu shots, Block said.

Companies considering premium surcharges also must be mindful of federal laws governing health insurance and employee benefits, Block said.

While the Affordable Care Act prohibits insurers from charging higher premiums to unvaccinated people, employers are still able to encourage vaccination through penalties and mandates.

However, Equal Employment Opportunity Commission rules restrict employers promoting vaccinations from instituting incentives or surcharges so large that they is considered coercive, Block said.

Under the Americans with Disability Act, employers are required to provide reasonable accommodations for employees aren’t vaccinated against COVID-19 due to a disability. The Civil Rights Act mandates that accommodations must also be made for employees who do not comply based on a sincerely held religious beliefs.

Typically, employers can modify health insurance premiums to offer tax-free incentives or penalties to employees as part of a workplace wellness program, said Bob Neiman, a principal at Much Shelist’s Healthcare Law Group.

Full FDA approval of the Pfizer-BioNTech, Moderna and Johnson & Johnson vaccines would strengthen the grounds for vaccine mandates and insurance surcharges, Symons said. That’s despite the fact that the U.S. Department of Justice issued an opinion stating that employers are not prohibited from imposing vaccination requirements even though the vaccines are only available under an emergency use authorization.

Because employers are interested in increasing vaccination levels soon, they are likely to begin rolling out surcharges next month, giving employees time to get vaccinated, Symons said.

“Healthcare providers more than employers in other sectors have struggled with the concept of vaccine mandates because they’ve been concerned that if they mandate the vaccines, they might have 20% of their nurses quit and then they couldn’t care for their patients,” Neiman said.

But healthcare workers resistant to the vaccine may prefer getting the shots or paying the penalities if the alternative is finding a new job during a pandemic, Neiman said. Still, employers should consider the risks of implementing incentives and disincentives based on the vaccination rates of their individual workforces and their geographical areas, he said.

Health insurance companies on their own are unlikely to modify premiums or benefits to add vaccination-related surcharges or incentives, said Paul Keckley, managing editor of The Keckley Report. Instead, they will set premiums based on community vaccination rates to anticipate where COVID-19 costs will be higher, he said.

By:  MARI DEVEREAUX   Modern Healthcare  August 13, 2021 04:59 PM

Report: Only 5% of hospitals fully compliant with controversial price transparency rule

by Robert King | Jul 19, 2021 11:24am FIERCRE HELTHCARE

A new analysis found only 5.6% of hospitals were fully compliant with a major price transparency rule, with most failures centered on not posting payer-negotiated prices.

The analysis released Friday by the group PatientRightsAdvocate.org is the latest evidence of widespread noncompliance with the rule, which went into effect back in January.

“These findings align with previous research indicating that hospitals are undermining the rule with incomplete information, burdensome access restrictions, code to block prices from being displayed on search engines and tools to obfuscate access to mobile app developers and to patients,” the analysis said.

Another problem has been price estimator tools that don’t enable meaningful accessible comparison of discounted cash prices, researchers said.

The group examined a random sample of 500 hospital websites out of the roughly 6,000 facilities subjected to the rule’s requirements.

Only 5.6% of the websites were compliant with all the rule’s requirements. It found that 471 facilities did not post a complete machine-readable file of standard charges.

RELATED: Only 1 in 10 patients know hospitals are now required to post their prices online, survey finds

A large majority (80.6%) of hospitals did not publish payer-specific negotiated charges that were clearly associated with each payer and plan, a controversial requirement of the rule. It found that 258 hospitals (51.6%) didn’t publish any negotiated rates at all and 198 hospitals (39.6%) didn’t publish any discounted cash prices.

The rule required hospitals to also publish 300 shoppable healthcare services in a list or an estimator tool. The group found that 96 hospitals presented them in a “consumer-friendly display for customary charges. However, a significant number of these hospitals presented incomplete data fields and were therefore noncompliant.

There were 378 hospitals that posted a price estimator tool. However, the tools were inconsistent and limited researchers’ ability to determine if the tool was compliant with the rule.

The analysis is the latest finding that many hospitals are not complying with the new rule. A study published last month found that 83 out of 100 randomly sampled hospitals were not compliant with the regulation.

The Centers for Medicare & Medicaid Services has sent out warnings to some hospitals for noncompliance. There is a $300-per-day penalty for hospitals for each day they aren’t fully following the regulation.

But the analysis posits that the penalty is nowhere near enough.

“Scaling the penalty to $300 per hospital per bed per day and robustly enforcing the rule will result in a meaningful financial incentive for hospitals to comply, while providing proportional fairness to smaller and rural hospitals,” the group said.

PatientRightsAdvocate.org also wants CMS to scrap the requirement for a price estimator tool and instead require hospitals to provide “guaranteed price quotes.”

A new analysis found only 5.6% of hospitals were fully compliant with a major price transparency rule, with most failures centered on not posting payer-negotiated prices.

The analysis released Friday by the group PatientRightsAdvocate.org is the latest evidence of widespread noncompliance with the rule, which went into effect back in January.

“These findings align with previous research indicating that hospitals are undermining the rule with incomplete information, burdensome access restrictions, code to block prices from being displayed on search engines and tools to obfuscate access to mobile app developers and to patients,” the analysis said.

Another problem has been price estimator tools that don’t enable meaningful accessible comparison of discounted cash prices, researchers said.

The group examined a random sample of 500 hospital websites out of the roughly 6,000 facilities subjected to the rule’s requirements.

Only 5.6% of the websites were compliant with all the rule’s requirements. It found that 471 facilities did not post a complete machine-readable file of standard charges.

RELATED: Only 1 in 10 patients know hospitals are now required to post their prices online, survey finds

A large majority (80.6%) of hospitals did not publish payer-specific negotiated charges that were clearly associated with each payer and plan, a controversial requirement of the rule. It found that 258 hospitals (51.6%) didn’t publish any negotiated rates at all and 198 hospitals (39.6%) didn’t publish any discounted cash prices.

The rule required hospitals to also publish 300 shoppable healthcare services in a list or an estimator tool. The group found that 96 hospitals presented them in a “consumer-friendly display for customary charges. However, a significant number of these hospitals presented incomplete data fields and were therefore noncompliant.

There were 378 hospitals that posted a price estimator tool. However, the tools were inconsistent and limited researchers’ ability to determine if the tool was compliant with the rule.

The analysis is the latest finding that many hospitals are not complying with the new rule. A study published last month found that 83 out of 100 randomly sampled hospitals were not compliant with the regulation.

The Centers for Medicare & Medicaid Services has sent out warnings to some hospitals for noncompliance. There is a $300-per-day penalty for hospitals for each day they aren’t fully following the regulation.

But the analysis posits that the penalty is nowhere near enough.

“Scaling the penalty to $300 per hospital per bed per day and robustly enforcing the rule will result in a meaningful financial incentive for hospitals to comply, while providing proportional fairness to smaller and rural hospitals,” the group said.

PatientRightsAdvocate.org also wants CMS to scrap the requirement for a price estimator tool and instead require hospitals to provide “guaranteed price quotes.”

Federal Speech Rulings May Embolden Health Care Workers to Call Out Safety Issues By Harris Meyer JULY 9, 2021

Karen Jo Young wrote a letter to her local newspaper criticizing executives at the hospital where she worked as an activities coordinator, arguing that their actions led to staffing shortages and other patient safety problems.

Hours after her letter was published in September 2017, officials at Maine Coast Memorial Hospital in Ellsworth, Maine, fired her, citing a policy that no employee may give information to the news media without the direct involvement of the media office.

But a federal appellate court recently said Young’s firing violated the law and ordered that she be reinstated. The court’s decision could mean that hospitals and other employers will need to revise their policies barring workers from talking to the news media and posting on social media.

Those media policies have been a bitter source of conflict at hospitals over the past year, as physiciansnurses and other health care workers around the country have been fired or disciplined for publicly speaking or posting about what they saw as dangerously inadequate covid-19 safety precautions. These fights also reflect growing tension between health care workers, including physicians, and the increasingly large, profit-oriented companies that employ them.

On May 26, the 1st U.S. Circuit Court of Appeals unanimously upheld a National Labor Relations Board decision issued last year that the hospital, now known as Northern Light Maine Coast Hospital, violated federal labor law by firing Young for engaging in protected “concerted activity.” The NLRB defines it as guaranteeing the right to act with co-workers to address work-related issues, such as circulating petitions for better hours or speaking up about safety issues. It also affirmed the board’s finding that the hospital’s media policy barring contact between employees and the media was illegal.

“It’s great news because I know all hospitals prefer we don’t speak with the media,” said Cokie Giles, president of the Maine State Nurses Association, a union. “We are careful about what we say and how we say it because we don’t want to bring the hammer down on us.”

The 1st Circuit opinion is noteworthy because it’s one of only a few such employee speech rulings under the National Labor Relations Act ever issued by a federal appellate court, and the first in nearly 20 years, said Frank LoMonte, a University of Florida law professor who heads the Brechner Center for Freedom of Information.

The 1st Circuit and NLRB rulings should force hospitals to “pull out their handbook and make sure it doesn’t gag employees from speaking,” he said. “If you are fired for violating a ‘don’t talk to the media’ policy, you should be able to get your job back.”

The American Hospital Association and the Federation of American Hospitals declined to comment for this article.

While the 1st Circuit’s opinion is binding only in four Northeastern states plus Puerto Rico, the NLRB decision carries the force of law nationwide. The case applies to both unionized and non-unionized employees, legal experts say.

In March, the NLRB similarly ordered automaker Tesla to revise its policy barring employees from speaking with the media without written permission.

Hospitals and health care organizations often have policies requiring employees to clear any public comments about the workplace with the organization’s media office. Many also have policies restricting what employees can say on Facebook and other social media.

Hospitals say requiring employees to go through their media office prevents the spread of inaccurate information that could damage the public’s confidence. In Young’s case, the hospital argued that her letter contained false and disparaging statements. But the 1st Circuit panel agreed with the NLRB that her letter was “not abusive” and that its only false statement was not her fault.

Health care organizations have undisputed legal authority to prohibit employees from disclosing confidential patient information or proprietary business information, legal experts say.

But the 1st Circuit panel made clear that an employer cannot bar an employee from engaging in “concerted actions” — such as outreach to the news media — “in furtherance of a group concern.” That’s true even if the employee acted on her own, as Young did in writing her letter. The key in her case was that she “acted in support of what had already been established as a group concern,” the court said.

“I think employers with a blanket ban on talking to the media need to relook at their policies,” said Eric Meyer, a partner at FisherBroyles in Philadelphia who often represents companies on employment law matters. “If you go to the media and say, ‘There are unsafe working conditions impacting me and my colleagues,’ that’s protected concerted activity.”

Chad Hansen, Young’s attorney in a separate federal lawsuit alleging discrimination based on a disability against the hospital, said she has not yet been reinstated to her job. Young would not comment.

The hospital’s parent company, Northern Light Health, said only that its news media policy — which was amended after Young’s firing — meets the NLRB and 1st Circuit requirements and will not be further changed. The new policy created an exception allowing employees to speak to the news media related to concerted activities protected by federal law.

Speech rights under the National Labor Relations Act are particularly important for employees of private companies. Although the Constitution protects people who work for public hospitals and other government employers with its guarantee of unrestricted speech, employees at private companies do not have a First Amendment right to speak publicly about workplace issues.

“I hope this case keeps alive the right of health care workers to speak out about something that’s dangerous,” said Dr. Ming Lin, an emergency physician who lost his job last year at PeaceHealth St. Joseph Medical Center in Bellingham, Washington, after publicly criticizing the hospital’s pandemic preparedness.

Lin, who was employed by TeamHealth, which provides emergency physician services at the hospital, lost his assignment at PeaceHealth in March 2020 soon after saying on social media and in interviews with news reporters that PeaceHealth was not taking urgent enough steps to protect staff members from covid. He had worked at the hospital for 17 years.

In an April 2020 YouTube interview, PeaceHealth’s chief operating officer, Richard DeCarlo, said Lin was removed from the hospital’s ER schedule because he “continued to post misinformation, which was resulting in people being afraid and being scared to come to the hospital.” DeCarlo also alleged that Lin, who was out of town for part of the time he was posting, refused to communicate with his supervisors in Bellingham about the situation. PeaceHealth declined to comment for this article.

PeaceHealth’s social media policy at that time stated that the company does not prohibit employees from engaging in federally protected concerted activity and that they “are free to communicate their opinions.” TeamHealth’s social media policy, dated July 15, 2020, states the company reserves the right to take disciplinary action in response to behavior that adversely affects the company.

Lin, who’s now working for the Indian Health Service in South Dakota, has sued PeaceHealth, TeamHealth and DeCarlo in state court in Washington claiming wrongful termination in violation of public policy, breach of contract and defamation.

Dr. Jennifer Bryan, board chair of the Mississippi State Medical Association, who publicly defended two Mississippi physicians fired for posting about the inadequacy of their hospitals’ covid safety policies, said she faced pressure from her hospital for speaking to the news media without approval.

The medical association pushed its members to talk to the media about the science of covid, while employers insisted doctors’ messages had to be approved by the media office. That reflected a conflict, she said, between medical professionals primarily concerned about public health and executives of for-profit systems who were seeking to shield their corporate image.

Bryan predicted the court ruling and NLRB decision will be helpful. “Physicians have to be able to stand up and speak out for what they believe affects the safety and well-being of patients,” she said. “Otherwise, there are no checks and balances.”

U.S. Proposes Raising Penalty for Hospitals That Don’t Publish Prices

The Biden administration on Monday proposed sharply higher penalties for larger hospitals that don’t make their prices public.

The Centers for Medicare and Medicaid Services, the federal agency responsible for enforcing rules requiring hospitals publish their prices, is seeking to raise penalties as high as $2 million a year for large hospitals that fail to make prices public. Large hospitals are those with more than 30 beds.

The proposed penalty is a sharp increase from the $109,500 maximum per year per hospital under existing rules. For hospitals with 30 or fewer beds, penalties remain the same.

The proposal comes after many hospitals failed to publish their prices as required by federal rules that took effect this year, undercutting policy makers’ goal of boosting competition and choice through transparent pricing.

As of Monday, data from price-transparency startup Turquoise Health Co. shows no usable pricing data from 32% of 4,885 acute care, children’s or rural primary-care hospitals.

The company’s database includes another 10% of these hospitals with prices that fall short of requirements.

“With today’s proposed rule, we are simply showing hospitals through stiffer penalties: Concealing the costs of services and procedures will not be tolerated by this administration,” Health and Human Services Secretary Xavier Becerra said.

Drug Prices Are One Focus of Biden’s Push to Boost Competition

WASHINGTON—President Biden’s executive order to promote business competition lays out a series of steps to lower prices for prescription drugs, including taking legal action against companies that cooperate to keep generic medicines off the market and allowing states and Indian tribes to import drugs from Canada.

The administration also is calling for measures to increase the use of generic drugs and other medicines known as biosimilars, which are essentially generic versions of expensive biological drugs already on the market.

Most of the ideas have been urged in the past, primarily by Democrats but also by the Trump administration. Growing bipartisan support for lowering drug prices could give the current push a greater likelihood of success.

What isn’t in the executive order, however, is any mention of giving the federal Medicare agency the power to directly negotiate prices with drug companies. That approach, favored by many Democratic lawmakers, would potentially be more far-reaching than any of the measures in the presidential order.

“Negotiation of prices is the biggest and best solution” to lowering drug prices, said Diana Zuckerman, president of the National Center for Health Research, a nonprofit organization in Washington. The federal Medicare agency is generally barred by law from such direct negotiation for many prescription medicines, a ban many Democrats in Congress have urged be lifted.

While Republicans generally have been less supportive of such a step, “there is pressure from all sides” for legislative change as the public increasingly seeks solutions to high drug prices, Dr. Zuckerman said.

The recent federal approval of the Alzheimer’s drug Aduhelm from Biogen Inc. put a spotlight on concerns about rising drug costs. The company said the medication would have a U.S. list price of about $56,000 a year for the average patient. Amid concerns about the drug’s effectiveness and cost, the Food and Drug Administration this week narrowed the potential pool of patients in new prescribing instructions.

The drug-industry trade association PhRMA didn’t respond to requests for comment on the administration’s executive order.

In his order on Friday, Mr. Biden noted that the FDA hasn’t issued the necessary rules for high-priced hearing aids to be sold over-the-counter in drugstores. He called on the FDA’s parent agency, the Department of Health and Human Services, to issue proposed rules within 120 days to allow such sales. The administration said the four largest makers of hearing aids control 84% of the market, with the devices costing an average of $5,000 and up for a pair. As a consequence, the administration said, only about 14% of the 48 million Americans who have lost hearing are using the devices.

Mr. Biden also urged the government to curtail what are called “pay for delay” deals between brand-name drugmakers and generic companies. These are contractual arrangements in which generic companies receive compensation for keeping their lower-cost drugs off the market.

“The big picture is that the number of such pay-for-delay settlements has gone down,” said Michael Carrier, a Rutgers University law professor and leading authority on these deals. “In the few cases that make it all the way to the courts, for the most part courts are seeing the delay” and taking action, he added.

A 2013 U.S. Supreme Court decision has cut into such arrangements, Mr. Carrier said. And a Fifth Circuit U.S. Court of Appeals decision this year largely supported a Federal Trade Commission action against such an alleged arrangement. “But my sense is that it’s still going on,” Mr. Carrier said.

The administration’s order also pushes for allowing the importation of less expensive drugs from Canada, a measure that has had considerable support, including from the Trump administration.

“This is a very reasonable thing to do,” Dr. Zuckerman said. “I don’t think Canada likes it, because they’re afraid they may run out of drugs.” She points out that the Canadian market is far smaller than that in the U.S., making the likelihood slim that such a step would have a major impact on U.S. prices.

When the Trump administration proposed such a step in December 2019, a spokesman for the Canadian health ministry, Thierry Belair, predicted any such measure would have only minimal effect on the U.S. market.

PUBLISHED BY THE WALL STREET JOURNAL ON JULY 10, 2021

Effort to Decipher Hospital Prices Yields Key Finding: Don’t Try It at Home

Most of the 20 common medical procedures I attempted to compare were among those 70. But a few, from lists of top outpatient procedures provided by the Health Care Cost Institute, were not. I decided to use the more comprehensive, less friendly spreadsheets for my comparisons, since they contained all 20 of the procedures I’d chosen.

Each carried a five-digit medical code known as a CPT, a term trademarked by the American Medical Association that stands for “current procedural terminology.” The transparency rule requires hospitals to include billing codes, because they supposedly provide a basis for price comparison, or in the rule’s jargony language, “an adequate cross-walk between hospitals for their items and services.”

Much to my chagrin, I soon discovered they don’t provide an adequate crosswalk even within one hospital.

My first inkling of the insuperable complexity came when I noticed that Sutter’s Alta Bates Summit Medical Center in Oakland listed the same outpatient procedure with the same CPT code three times, thousands of rows apart, with entirely different prices. CPT 64483 is the designated code for injection of anesthetics or steroids into a spinal nerve root with the use of imaging, which relieves pain in the lower back, legs and feet caused by sciatica or herniated discs. The spreadsheet showed a maximum negotiated price of $1,912 in row 12,718, $3,650.85 in row 19,014 and $5,475.80 in row 19,559 (let your eyes glaze over for just a few seconds, so you know what it feels like). The reason for the triple listing is tied to Medicare billing guidelines, Sutter later told me. I’ll spare you the details.

My head really began to hurt when I decided to double-check some of the prices I had pulled from the big spreadsheets against the same items on the shorter shoppables sheets. Kaiser’s prices were generally consistent across the two, but for Alta Bates, there were large discrepancies.

The highest negotiated price for removing a breast lesion, for example, was $6,156 on the big sheet and $23,069 on the shorter one. The difference seems largely attributable to the estimated cost of additional services, some rather nonspecific, that Sutter lists on the smaller sheet as accompaniments to the procedure: anesthesia, EKG/ECG, imaging, laboratory, perioperative, pharmacy and supplies.

But why not include them in both spreadsheets? And what do the two dramatically divergent prices actually encompass?

“How many bills they really represent and what they mean is difficult to interpret,” said Dr. Merrit Quarum, CEO of Portland, Oregon-based WellRithms, which helps employers negotiate fair prices with hospitals. “It depends on the timing, it depends on the context, which you don’t know.”

In some cases, Sutter said, its shoppables spreadsheets show charges not only for ancillary services typically rendered on the day of the procedure, but also for related procedures that may precede or follow it by days or weeks.

The listings for Kaiser’s ancillary services do not always match Sutter’s, which further clouds the comparison. The problematic fact of the matter is that hospitals performing the same procedures bundle their bills differently, use different medications, estimate varying amounts of time in the operating room, and utilize more or less advanced technology. And physician charges are not even included in the posted prices, at least in California.

All of which makes it almost impossible for mere mortals to anticipate the total cost of their medical procedures, let alone compare prices among hospitals. Even if they could, it might be of limited value, since independent imaging centers and surgery centers, which are increasingly common — and generally less expensive — aren’t required to report their prices.

The bottom line, I’m afraid, is that despite my efforts I don’t have anything particularly insightful to reveal about how Kaiser’s prices compare with Sutter’s. The prices I examined were as transparent to me as hieroglyphics, and I’m pretty sure that hospital executives — who unsuccessfully sued to stop implementation of the price transparency rule — are not losing any sleep over that fact.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

For Surprise Medical Bills, It’s the Beginning of the End

On Thursday, federal officials are expected to begin completing the particulars of how that legislative plan will translate to action, by publishing the first major regulation interpreting it. The law establishes a system for calculating a benchmark payment and a way for insurers and health providers to appeal to a neutral arbiter when they feel that amount is not appropriate.

The rule expected Thursday is not the last that will need to be published before the end of the year, but it will most likely settle several contentious issues.

Among the more important and contested provisions is a detailed definition of the “fair” price that arbiters should consider as a baseline for deciding how much the insurance plan typically owes the hospital or doctor. This will be a key figure because it will determine how much the patients owe — they are still responsible for paying the out-of-network doctor their normal co-payment or deductible amount — and what reimbursement the provider will net.

Other thorny issues being addressed in the Thursday rule include how providers must inform patients that they do not participate in their insurance network, along with the framework for a new federal complaint system. The notification rules in the law represent a new form of transparency — doctors and hospitals will need to warn patients if any of their care isn’t covered by insurance.

The complaint system will manage submissions from patients who believe their hospital or doctor is sending bills that are illegal under the new law. The law provides $500 million in funding for that new system, and gives the federal government authority to assess fines as high as $10,000 per billing violation.

Some consumer advocates worry that providers may continue billing patients in violation of the law without stringent enforcement, and will be on the lookout for rules that robustly enforce the new protections.

Subsequent rounds of regulation will provide more detail about how the arbitration process will work, and what factors the neutral arbiter can or can’t consider in deciding the right price for a medical service. Another rule is expected to deal specifically with air ambulances, which are regulated under the new law and tend to generate some of the most expensive surprise medical bills.

Sarah Kliff is an investigative reporter for The New York Times. Her reporting focuses on the American health care system and how it works for patients.

 

Margot Sanger-Katz is a domestic correspondent and writes about health care for The Upshot. She was previously a reporter at National Journal and The Concord Monitor and an editor at Legal Affairs and the Yale Alumni Magazine.

A Consumer Guide to Understanding Healthcare Price Transparency: What a Healthcare Consumer Needs to Know to Navigate the Pricing Maze

 

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College Tuition Sparked A Mental Health Crisis. Then The Hefty Hospital Bill Arrived…Published By Kaiser health news

Despite a lifelong struggle with panic attacks, Divya Singh made a brave move across the world last fall from her home in Mumbai, India. She enrolled at Hofstra University in Hempstead, N.Y., to study physics and explore an interest in stand-up comedy in Manhattan.

Arriving in the midst of the pandemic and isolated in her dorm room, Singh’s anxiety ballooned when her family had trouble coming up with the money for a $16,000 tuition installment. Hofstra warned her she would have to vacate the dorm after the term ended if she was not paid up. At one point, she ran into obstacles transferring money onto her campus meal card.

“I’m a literally broke college student that didn’t have money for food,” she recalls. “At that moment of panic, I didn’t want to do anything or leave my bed.”

In late October, she called the campus counseling center hotline and met with a psychologist. “All I wanted was someone to listen to me and validate the fact that I wasn’t going crazy,” Singh says.

Instead, when she mentioned suicidal thoughts, the psychologist insisted on a psychiatric evaluation. Singh was taken by ambulance to Long Island Jewish Medical Center in New Hyde Park, N.Y., and kept for a week on a psychiatric ward at nearby Zucker Hillside Hospital. Both institutions are part of the Northwell Health system.

The experience — lots of time alone and a few therapy sessions — was of minimal benefit psychologically, Singh says. She emerged facing the same tuition debt as before.

And then another bill came.

The Patient: Divya Singh, a 20-year-old student at Hofstra University.

Medical Service: Seven-day inpatient psychiatric stay at Zucker Hillside Hospital in Glen Oaks, N.Y.

Service Provider: Northwell Health, a large nonprofit hospital system in New York City and Long Island.

Total Bill: Northwell charged $50,282, which Singh’s insurer, Aetna, reduced to $17,066 under its contract with Northwell. The plan required Singh to pay $3,413.20 of that.

What Gives: Singh had purchased her Aetna insurance plan through Hofstra, paying $1,107 for the fall term. Aetna markets the plan specifically for students. Under its terms, students can be on the hook for up to $7,350 of the costs of medical care during a year, according to plan documents. Singh’s Northwell bill of around $3,413 reflects the plan’s requirement that she pay for 20% of the costs of her hospital stay.

Although such coinsurance requirements are common in American health plans, they can be financially overwhelming for students with no income and families whose finances are already under the extreme stress of high tuition. Singh’s Hofstra bill for the academic year, including room and board and ancillary fees, totaled $68,275.

As a result, Singh found herself beset by a double whammy of bills from two of the costliest kinds of institutions in America — colleges and hospitals — both with prices that inexorably rise faster than inflation.

For hospitals, there is supposed to be a relief valve. The Internal Revenue Service requires all nonprofit hospitals to have a financial assistance policy that lowers or eliminates bills for people without the financial resources to pay them. Such financial assistance — commonly known as charity care — is a condition for any hospital that wants to maintain its tax-exempt status; that status shields the facility from having to pay property taxes on its often expansive campus.

Northwell’s financial assistance policy limits the hospital from charging more than $150 for individuals who earn $12,880 a year or less. It offers discounts on a sliding scale for individuals earning up to $64,400 a year, although people with savings or other “available assets” above $10,000 might get less or not qualify.

The IRS requires hospitals to “widely publicize” the availability of financial assistance, inform all patients about how they can obtain it and include “a conspicuous written notice” on billing statements.

While the bill Northwell sent Singh includes a reference to “financial difficulties” and a phone number to call, it did not explicitly state that the hospital might reduce or waive the bill. Instead, the letter obliquely said “we can assist you in making budget payment arrangements” — a phrase that conjures installment payments rather than debt relief.

Resolution: In a written statement, Northwell said that although “all eligible patients are offered generous financial payment options … it is not required that providers list the options on the bill.” Northwell stated: “If a patient calls the number provided and expresses financial hardship, the patient is assisted with a financial need application.” However, Northwell lamented, “unfortunately, many patients do not call.”

Indeed, a KHN investigation in 2019 found that, nationwide, 45% of nonprofit hospital organizations were routinely sending medical bills to patients whose incomes were low enough to qualify for charity care. Those bills, which totaled $2.7 billion, were most likely an undercount since they included only the debt hospitals had given up trying to collect.

Singh says the worker who took down her insurance information during her hospital stay never explained that Northwell might reduce her portion of the charge. The student adds that she didn’t realize that was a possibility from the language in the bill they sent.

Northwell said in a statement that after KHN contacted it about Singh’s case, Northwell dispatched a caseworker to contact her. Singh says the caseworker helped Singh enroll in Medicaid, the state-federal health insurance program for low-income people. Foreign students are not generally eligible for Medicaid, but in New York they can get coverage for emergency services. With the addition of Medicaid’s coverage, Singh should end up paying nothing if the stay is retroactively approved, Northwell said.

At the same time the caseworker was helping her, Singh received a “final reminder” letter from Northwell about her bill. That letter also mentioned Northwell’s financial assistance, but only within the context of people who completely lack health insurance.

“Send payment or contact us within 21 days to avoid further collection activity,” the letter said.

The Takeaway: Despite stricter requirements from the Affordable Care Act and the IRS to make nonprofit hospitals proactively educate patients about the various forms of financial relief they offer, the onus still remains on patients. If you have trouble paying a bill, call the hospital and ask for a copy of its financial assistance policy and the application to request your bill be discounted or excused.

Be aware that hospitals generally require proof of your financial circumstances — such as pay stubs or unemployment checks. Even if you have health insurance that covers much of your medical bill, you may still be eligible to have your bill lowered or get on a government insurance program like Medicaid.

You can also find documentation online: All nonprofit hospitals are required to post financial assistance policies on their websites. They must provide summaries written in plain language and versions translated into foreign languages spoken by significant portions of their communities. Be aware that financial assistance is distinct from paying your full debt off in installments, which is what hospitals sometimes first propose.

Although the IRS rules don’t govern for-profit hospitals, many of those also offer concessions for people with proven financial hardship. The criteria patients need to meet to get charity care — and how generous the hospital is likely to be — vary among institutions, but many give breaks to families with middle-class incomes. Northwell’s policy, for instance, extends to families of four earning as much as $132,500 a year.

Singh’s family has paid off her fall tuition and half of her spring tuition so far. She still owes $16,565.

Singh says the back and forth over her hospital bill continues to cause anxiety.

“The treatment I got in the hospital, after I’ve gotten out, it hasn’t helped,” she says. “I have nightmares about that place.” The biggest benefit of her week there, she says, was bonding with the other patients “because they were also miserable with the way they were being treated.”


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