Thursday, October 2, 2014

Who’s to blame for unexpected doctor bills?

Patients are being stuck with huge and unexpected medical care bills in circumstances where they have no say in selecting the physician who is billing them, and no way for them to know in advance which services the physicians would render or what it would cost them, says the New York Times.
Mr. Peter Drier received a “surprise $117,000 medical bill from a doctor he didn’t know” for services relating to a 3-hour surgery for herniated disks, the Times reported.  “A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee,” the Times writes. “He was blindsided, though, by a bill of about $117,000 from an ‘assistant surgeon,’ a Queens-based neurosurgeon whom Mr. Drier did not recall meeting. ‘I thought I understood the risks,’ Mr. Drier, who lives in New York City, said later. ‘But this was just so wrong — I had no choice and no negotiating power.’"

And, it appears, Mr. Drier’s experience is just one example of what the Times calls “an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives.”

Then, earlier this week, the New York Times reported on patients being stuck with unanticipated out-of-pocket costs for services provided by emergency room doctors who do not accept insurance.  “Patients have no choice about which physician they see when they go to an emergency room,” reports the Times, “even if they have the presence of mind to visit a hospital that is in their insurance network. In the piles of forms that patients sign in those chaotic first moments is often an acknowledgment that they understand some providers may be out of network. But even the most basic visits with emergency room physicians and other doctors called in to consult are increasingly leaving patients with hefty bills: More and more, doctors who work in emergency rooms are private contractors who are out of network or do not accept any insurance plans.”

Some physicians will be inclined to blame insurance companies for these situations, arguing that low payments leave them no choice but to opt-out of taking insurance and to charge patients directly the full amount of what they consider to be a fair fee for their services.

But here is the problem with the “blame the insurer” mindset: insurance payments may or may not be too low (does anyone really think that any physician is worth $117,000 for assisting in a three hour procedure!), but even so, it’s no excuse for physicians to take advantage of vulnerable patients.

Advocates for “private contracting” with patients, balance billing (charging more than the insurer allows), and direct cash practices (physicians completely opting out of insurance and their negotiated rates) argue that these will bring free market competition to health care while making it possible for physicians to stay in business.  Fine—except in the cases profiled by the New York Times, there was no choice and no free market.

These were situations in which patients had no say in selecting the physician, and no say in what services the physicians provided.  They had no say in who their surgeon decided to bring into the operating room for assistance.  They had no say in what the doctors charged them or in what the insurance company paid.  They had no ability to “negotiate” rates in advance, and especially for the emergency room visits, no chance to shop around for a better deal.

No, these arrangements don’t sound to me like free market competition, but rather as exploitation of vulnerable patients.  Sticking the patient with the bill for services by a physician they did not choose, and had no way of knowing what the physician would charge, is the antithesis of patient empowerment and patient-centered care.  And quite likely, a violation of professional ethics—ACP’s ethics manual states that:

"An individual patient–physician relationship is formed on the basis of mutual agreement."

"Financial arrangements and expectations should be clearly established. Fees for physician services should accurately reflect the services provided."

AMA’s Council on Judicial and Ethical Affairs states that:

"…the term "surgical co-management" refers to the practice of allotting specific responsibilities of patient care to designated caregivers...The treating physicians are responsible for ensuring that the patient has consented not only to take part in the surgical co-management arrangement but also to the services that will be provided within the arrangement. In addition to disclosing medical facts to the patient, the patient should also be informed of other significant aspects of the surgical co-management arrangement such as the credentials of the other caregivers, the specific services each will provide, and the billing arrangement." 

ACP’s policy on “private contracting” legislation—a bill that would allow physicians to bill patients directly for more than the fee allowed by Medicare—states that physicians must disclose their professional fee for professional services covered by the private contract in advance of rendering such services, with beneficiaries being held harmless for any subsequent charge per service in excess of the agreed upon amount. Further, we state that:

“Since patients in emergency or urgent care situations are not in any position to shop around for another physician, we believe that the bill should clarify that private contracting arrangements should not apply at a time when emergency or urgent care is being rendered, even if the treating physician and patient had previously entered into a private contract.

“The legislation should include a prohibition on private contracting in cases where a physician is the ‘sole community provider’ for those professional services that would be covered by a private contract. This protection is critical, especially in under-served areas of the country, because patients should not be obligated to enter into a private contract with a physician for health care services if there are no other physicians in their community to provide such care…In addition to emergency and urgent care and sole community provider situations, there will be other instances where a patient has no reasonable choice of physician, such as when a physician is assigned to them in a hospital or other institutional setting. We recommend that the bill state that no private contract can be entered into in any situations in which the patient cannot exercise free choice of physician.”

While the situations described by the New York Times mainly involved surgeons, primary care physicians and internal medicine subspecialists must also consider at what point balance billing and private contracting cease to be an understandable and appropriate response to unacceptably low insurance company rates and instead become exploitative of patients who cannot afford to pay more.  The key considerations governing such private contracting arrangements must be that financial arrangements and expectations must be clearly established in advance of services being rendered,  that patients and physicians must mutually agree to the rates and the relationships involved, that patients accordingly must have a real choice of physician and must be informed in advance what they will be charged and agree to it, and that balance billing (charging more than the payer’s approved rates) should not apply in emergency or other situations where there is no real opportunity for such choice and mutual agreement.

As Mr. Drier told the Times "…this was just so wrong — I had no choice and no negotiating power” when stuck with the $117,000 bill from a physician he had not chosen.  It is shameful for some physicians to exploit patients when they had no choice and no negotiating power—and it is up to the medical profession to say so, clearly and forthrightly.

Today’s questions: what do you think of patients being stuck with big bills when they had no choice of doctor?  What should be the medical profession’s response? The government’s?


PCP said...

Bob, As usual you quote your liberal mouthpiece the NY Times, use the most egregious example and paint the profession in a bad light.
Where were you when a midwestern state medicaid program paid an internist the pitifully low rate of $14 for a level 3 office visit. Where was your ire?

That said internist stayed back well after his 'office hours' probably saved an ER trip and inconvenience for the patient, then left his office and got a hair cut for $15. Real story. More importantly, he was likely the best positioned person to see that patient at that time.
I wonder what multiple of $14 that stingy state medicaid program saved due to that?

There are excesses in both directions. In the primary care realm however, the one with which I am most familiar, it is the pure idiocy of insurers and policy makers (and pathrtically ineffective advocacy by those like ACP) in killing off office based primary care that is leading to the mushrooming of various cat and mouse insurance games, urgent cares, free standing ERs and a whole host of such things.
Pay and treat the honest hard working internists/PCPs appropriately so that seeing 80 or so patient encounters a week they can make a generous income, and pay office overhead, maintain independence and pay staff commensurate to their efforts and skills, and slowly many of these dark clouds will dissipate.
Sadly, I don't anticipate you nor the liberals in power to advocate for/make any meaningful changes that will be significantly impactful.

Harrison said...

I agree with PCP again.
Something must be wrong with the universe.

Really though. Perspective is important. It is easy to see that an asst who is charging $117,000 is likely fraudulent or an error of some kind. That will outrage newspaper readers and the spill over will be to crack down on legitimate businesses so that they are crippled by regulation and fear of regulators.


Jay Larson MD said...

Lack of choice is a common theme in our health care system. Physician placing profits before patient should review their ethics manual.

The practice of medicine is unsuited to be controlled by business principles and should be conducted as a profession. Most physicians, nurses, and other medical professionals have a belief system that assigns a higher priority to doing useful and needed work than to economic rewards. This ideology also focuses more on the quality and social benefits of work rather than its profitability.

Despite the inappropriateness of using a business model, the practice of medicine has become commercialized. Rather than the healthcare system existing for people, people have become revenue sources for the healthcare system. The commercialization of medicine has challenged the commitment of physicians to put the needs of patients ahead of personal gain, to deal with patients honestly, competently, and compassionately, and to avoid conflicts of interest. Healthcare has become a $2 trillion industry (16% of the Gross Domestic Product), largely influenced by the growth of private investor-owned businesses with a primary concern to maximize profits. In no other country are the organizations that provide medical care so driven by income and profit generation. Even nonprofit medical institutions act like their for-profit counterparts.

ryanjo said...

Reading the comments on Elizabeth Rosethal's article in the NY Times, it seems that many readers have the same experience with excessive charges. The common theme is that institutional care (ER, hospital) is at fault, no accountability, no personal contact. Yet policymakers are forcing our healthcare system in that direction, by continuing to overvalue procedures and specialties over primary care and small practice personalized medicine, and letting corporate for-profits dominate.

I posted my comment, hopefully the NY Times will allow readers to see it. No response from ACP or AMA though. Would have been nice to see condemnation from our physician leadership...silence sounds like collaboration.

Bob Doherty said...

A few observation in response to the comments on this post (and I do appreciate all of them, even the ones I disagree with!):

PCP--ACP is helping to lead the fight to reauthorize the Medicaid primary care pay parity, created by the ACA, that ensures that Medicaid programs pay no less than Medicare's rates for visits and immunizations by internists, family physicians, and pediatricians, and IM and PED subspecialists. This program, which ACP helped get into the ACA, will expire at the end of this year unless Congress reauthorizes it. Under this program, it is not legally permissible for a "midwestern state medicaid program to pay only $14 for a mid-level office visit--they must pay no less than the Medicare rates. So rather than maligning ACP advocacy, and inaccurately saying that we have said or done nothing about low Medicaid payments, why don't you support our efforts to get the Medicaid pay parity program program reauthorized? And give us credit when credit is due for getting Medicaid pay parity enacted in the first place?

As far as your drumbeat that our advocacy is killing office-based primary care, I don't think there is anything to be gained by my trying to persuade you otherwise. I do know for a fact though that the ACP members who volunteer their time to serve on ACP policy committees, the Board of Regents, the Board of Governors, and our councils, and who are active in our state chapters--many of whom are in office-based primary care practices--do not see things the way you do. They believe our policies, which are established by them, and our advocacy, have helped sustain and support office-based primary care at a time of increased competition. Many of the alternative payment models, like PCMHs, that you apparently reject have helped many office-based primary care practices not only survive but in some cases thrive. Our fight to get Medicare to pay for transitions of care management codes, and new chronic care management codes starting in January, will also be of substantial help to office-based primary care physicians.

To both PCP and Harrison, the instances portrayed in the NY Times were not, unfortunately, unusual, even though they were egregious. It is becoming a common practice in many parts of the country for surgeons to bring in an assistant, unknown to the patient, who then generates an outrageous bill. And as the NY Times also documented, more and more ER doctors are not accepting insurance, resulting in excessive out of pockets expenses to patients in situations where they clearly have no choice of physician. The medical profession will only hurt itself if it sticks its head in the sand by being silent on such practices.

Jay, I agree with all of your points on the commercialization of medicine.

And RyanJo, I am glad you submitted a comment to the NY Times. By my posting this blog, ACP is speaking out on the issue--since I am authorized, by ACP, to convey ACP policy through this blog. ACP is considering developing a more formal response, potentially with other organizations that share our concerns.

Unknown said...

"does anyone really think that any physician is worth $117,000 for assisting in a three hour procedure!"


That is a point that seems to be forgotten in this and other discussions. Like the many "villains" that we physicians criticize all the time (politicians, insurance companies, hospitals, etc.), when faced with an example that is clearly wrong, we start dragging in related but irrelevant topics, the usual "fill in the blank depending on the issue" rhetoric, and attempts to provide context where none is needed.

This charge for this procedure, whether it was known ahead of time or after the fact, whether it was from a solo physician or an large academic health center employee, whether it was for a rich patient or a poor patient, whether it was elective or emergent, whether it was private pay or insurance-paid, or whether it was an exceptional case or a trend, is simply wrong.

We should be more outraged than the newspapers, the regulators, or the general public because, like it or not, it reflects on all of us. Period.

Harrison said...

Is the primary orthopedic surgeon worth $133,000 for a 3 hour case?
Of course not.
But that is what doesn't make sense.
The anesthesiologist charges $4300 but the surgeons combine for a bill of over $250,000 together?

It is too outrageous to believe quite honestly.

Even if you cut it by an order of magnitude, it is still too high of a charge.
But if it is cut by two orders of magnitude, then it is reasonable, and perhaps a little low.
But not a lot low.

So it is hard to discuss seriously a case of over charging that is off by 100 times.
It simply cannot be true.

I live in a pretty expensive part of the country, and I promise nobody is generating bills like that -- unless it is a transcription error.

I know Ms Rosenthal in the NY Times has done some very credible work on medical bills.
But this just seems like it must be an error.

So what I can believe is not the number but the drive by referral.
Any bill of any amount coming from a doctor who had no known role in the case, well that is a scandal.

If that is a common practice, then it should be prosecuted as fraud.


PCP said...

Of course that bill of 117k is ridiculous. It is also probably unethical if accurate. There is no argument there.

What i am pointing out is that the NYTimes and company need to show the same incredulousness and ire when the abuse is on the other end. Any payer paying $14 for an office visit is abusive. I challenge anyone to find me any mainstream newspaper article that explores that side of the debate.

Likewise I challenge anyone to find me one that speaks about the primary care void created by such policy and the subsequent attempt by politicians to fill that said void with wasteful CHC/FQHCs/RHC/IHCs etc, that are paid 'cost based reimbursements' for medicare and medicaid patients which are at times an order of magnitude greater than
what a private practice doctor would be paid in that same location.

What of the abuse by CMS of private practitioners who have to make do with what they pay, but Hospitals get paid facility fees and higher rates for the exact same procedure. Isn't this driving private practitioners on the edge financially into hospital employment? Why the differential payments? Why does this not get the same attention.

There is a double standard. Only someone in total denial can argue with that.