2 min

The 2010 Affordable Care Act (ACA) deemed certain types of preventive services to be “essential health benefits” that should be free. Yet this potentially lifesaving care often results in unexpected patient bills sent by what a BenefitsPRO article calls “America’s ever-creative medical billing juggernaut.”

The article highlights several instances of patients receiving surprise (and often illegal) invoices:

• Additional bills of $1,000 for the radiologist’s reading fee and $236 for equipment and facility charges for “free” mammograms
  
• A $450 bill to biopsy a polyp found during a “free” colonoscopy
  
• A $111 “consultation” charge added to a no-cost preventive care visit because the patient responded positively to a question about “additional health concerns”

The medical establishment continues to erode the ACA’s guarantees of no-cost preventive care by exploiting gray areas of the law and redefining which aspects of a medical encounter it covers. When patients are blindsided by bills for care that should be free, it discourages them from seeking both preventive screenings and needed follow-up care, threatening their health and productivity in the workforce.

“The stories KFF Health News and NPR receive are likely just the tip of an iceberg. And while each bill might be relatively small compared with the stunning $10,000 hospital bills that have become all too familiar in the United States, the sorry consequences are manifold. Patients pay bills they do not owe, depriving them of cash they could use elsewhere. If they can’t pay, those bills might end up with debt-collection agencies and, ultimately, harm their credit score.”

Employers can combat these abuses with a modern health plan and exceptional concierge support from advocates who will defend members against such practices. This ensures members get all of the free preventive care they deserve without being charged for it, as well as help navigating a challenging healthcare system.

2 min

In the latest whitewashing of our ever-more costly healthcare system, hotel-like hospitals with “therapeutic art collections” and haute cuisine are touted as “better for healing.” The notion that “sickness is a journey” is often taken at facilities that invest more in luxury amenities than clinical quality.

Elisabeth Rosenthal, senior contributing editor at KFF Health News, shares her personal reflections on how rebranding illness as an adventure is harmful, irresponsible, and deceptive. Does anyone really equate their “cancer journey” to an Abercrombie & Kent safari? Calling patients “guests” and “customers” doesn’t change their struggle to get quality, affordable healthcare from hospitals facing tight budgets, staffing shortages, and professional burnout.

Sadly, “researchers at the National Bureau of Economic Research estimated that a hospital investing in amenities would increase demand by 38%, whereas a similar investment in clinical quality would lead to only a 13% increase.” Absent in this is what patients, employers, and society would really like to see hospitals and health systems compete aggressively on: the cost of care.

An honest analysis shows that luxury hospital “amenities have a cost, and they are not worth nearly what we’re paying for them as we’re billed for $100,000 joint replacements and $9,000 CT scans. Room charges in many hospitals can exceed $1,000 a night. And ‘facility fees’ for outpatient procedures and even office visits can reach hundreds of dollars, and simply don’t exist elsewhere.”

“For the amount that American patients (or their employers and insurers) pay for some luxury hospital journeys, they could sign up for a Virgin Galactic suborbital joy ride.”

Let’s Get Real.

Being sick is not an adventure. “A hospital’s function is to diagnose and to heal, at a price that sick people can afford.” “Instead of providing free coffee and a piano in a soaring, art-filled marble lobby, how about focusing on the very basic things that health systems in the U.S. should do, but…in many cases do not.”

Healthcare costs are projected to rise significantly in 2024, impacting employers and members alike. A modern health plan from Vitori Health delivers needed cost controls, quality care, and a remarkable member experience. Employers needing stable cash flow and predictable budgeting can find relief with Vitori Vantage, an industry-first, 3-year level premium health plan.

2 minMedical directors adjudicating claims are supposed to examine patient records, review coverage policies, and use their expertise to approve or deny claims. But at Cigna, they spend only 1.2 seconds on each case and instantly reject millions of claims without even opening the file.

This unfair review process, known as PXDX, is designed to boost profits by reducing claims processing costs, denying coverage, and avoiding payment of health care claims. The volume is staggering. According to a ProPublica exposé, “Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method.”

One former executive describes PXDX as “…a system built to deny claims.” Another, who helped conceive the program, questioned at the time whether such speedy denials satisfied the law or fell into a gray zone. “We sent the idea to legal, and they sent it back saying it was OK.”

It may be legal, but it’s certainly not ethical. The practice leaves patients with unexpected bills and encourages health care avoidance for services that should be covered by any decent employee health plan.

Ironically, Cigna has stated that its PXDX system does not prevent a patient from receiving care — it only decides when the insurer won’t pay: “Reviews occur after the service has been provided to the patient and does not result in any denials of care.”

Employers can circumvent this insanity by avoiding monopoly insurance carriers that prioritize profits over people. The ideal solution is a self-funded plan from a modern health plan plan administrator. Fair Market Payment™ (FMP), which is offered exclusively by Vitori Health, establishes fair and acceptable claim payments and eliminates provider friction that creates balance billing problems for plan members.

With a less costly, more compassionate health plan, employers can realize significant savings and reduce fiduciary risks while improving employee health and other benefits.

2 minA study published in the journal Radiology confirms what we already know — that there’s no rational explanation for wildly divergent costs for the same test at the same hospital or even between hospitals. And with every negotiation, it appears that hospitals hold the winning hand.

The vast difference between the lowest prices for common imaging services is astonishing. Likewise for the highest price, which on average can be nearly four times as much as the lowest. What’s worse is that these disparities exist not only between hospitals, insurers, and employers, but are found in different health plans offered by the same insurer.

The study shows that more expensive radiology services tend to have wider price variations. The most extreme example is a brain CT scan, whose prices ranged from $134 to $4,065 at the same hospital. How is it possible that the highest negotiated cost is over 30 times more than the lowest?

Even Ge Bai, Ph.D., a professor of accounting and health policy at Johns Hopkins University and one of the coauthors of the study, was surprised by its findings. In an interview with Fierce Healthcare, Bai noted that commercial health plans are “leaving money on the table” when negotiating with hospitals. This often contributes to higher out-of-pocket costs for insured patients and higher premiums for both employees and health plan sponsors.

According to Bai, “If insurance companies’ incentives had been perfectly aligned with employers, we would have observed little variation in negotiated rate for a given hospital across different health plans administered by the same insurance company.”

It’s clear that hospitals and insurance companies have zero allegiance to employers and continue to prioritize their profits over the needs of health plan sponsors and their members. Fair Market Payment™ is an immediate and effective solution for avoiding this price gouging variation and healthcare overspending.

2 minSaying things have “gone to the dogs” implies a worsened situation. However, a recent study by the Journal of the American Medical Association (JAMA) shows that dogs have a leg up and humans get the short end of the stick, paying more for commonly prescribed drugs used to treat both people and pets.

JAMA’s cross-sectional study compared 120 of the 200 most-prescribed generic human medications with unique active ingredients to the corresponding pet formulations to derive the human-to-pet price ratio. The average retail price (ARP) for humans was determined using GoodRx, with discounted prices obtained from Costco pharmacy. Pet prices were determined using online pet pharmacies such as Chewy.

The human ARP was a staggering 93.3% higher than the pet price; discounted prices were 64.2% higher. Researchers “found that prices of most medications were higher for humans than for pets. Even discounted prices for humans, a best-case scenario of out-of-pocket costs for patients without prescription drug coverage, were higher than pet prices for two-thirds of medications.”

Some results were even more significant. Check out the full study for citations relative to these results as well as several informative infographics.

• Phytonadione
  Oral vitamin K1
  Human | 5mg tablet | $70.51
  Veterinary | 50mg tablet | $0.61.4 (61.4¢)
• Levamisole
  Introduced in the 1960s as a veterinary anti-parasitic medication. When determined to be efficacious in treating human colon cancer, the human brand-name version (Janssen’s Ergamisol) was introduced.
  Human | 50mg tablet | $5
  Veterinary | 50mg tablet | $0.05 (5¢)

The researchers acknowledge that medication prices are dynamic and that there are “opaque rebates underlying discounted prices.” As a result, human prices are often not proportional to drug strength or fill quantity.

We concur with JAMA’s conclusion that “cash prices for generic medications should be transparent and accessible to people, for their own use and for their pets.” Paws up if you agree!

2 minThe landmark No Surprises Act became effective January 1, 2022 to protect consumers from surprise medical bills from out-of-network providers and facilities. Greedy industry stakeholders are fighting to remove these long overdue protections. Is anyone surprised? Read More about Health Care Industry Fights No Surprises Act. Are You Surprised?

< 1 minuteIs laughter really the best medicine? Sadly, it is mightily needed to offset these tragic “health care” experiences. While it’s easy to shake our heads at the absurdity of the American healthcare system, it’s hard to laugh at its outrageous and often heartbreaking impact on patients.

Can you imagine being charged to hold your newborn after delivery? Or repossessing a veteran’s prosthetic legs because he couldn’t afford the copay?

How about the woman who was charged $40 for crying during her doctor visit? In this and in another case, patients were charged for a “brief emotional/behavorial assessment.” This insidious and much abused billing code is often used to pad the bill. And while the charges are low and easily overlooked, they add up to millions of dollars in profits.

Under our dystopian healthcare system, Americans suffer from staggering medical debt and forego needed medications, mental health care, and life-saving surgeries they cannot afford.

Still laughing? We didn’t think so.

< 1 minuteBrand name inhaler manufacturers tinker with patents and use gimmicks the Food and Drug Administration (FDA) shouldn’t allow to thwart the availability of low-cost generic inhalers. And profits are so high that a tobacco manufacturer took over an asthma inhaler company to “diversity its portfolio.”

A research article in Health Affairs reveals that manufacturers recycle the same patents on multiple inhalers from different classes and shift old ingredients to new devices. Of the 62 inhalers for asthma and chronic obstructive pulmonary disease (COPD) approved by the FDA during the past 35 years, only one contained an active ingredient with a new mechanism of action. More than half of the patents issued were for the actual inhaler devices.

The researchers conclude that regulatory and patent reform is critical to ensure that patent protection bestowed on brand name inhaler manufacturers better reflects the true clinical benefits of new products. Until then, patients will continue to experience the dual medical and financial burdens of asthma and COPD.

2 minIn 2012, Emily Barker, a 19-year old student at the Art Institute of Chicago, fell four stories inside an improperly secured building. The accident led to paraplegia, a six-month hospital stay, countless operations, chronic pain, and a stack of bills and correspondence that inspired “Death by 7865 Paper Cuts.”

This installation-based work is a neat pile of 7,865 documents from 2012 to 2015 that includes bills for medical treatments, medical records, and care plans with their accompanying costs. Had all communications with the bureaucracy of the healthcare system to date been included, the pile would have fallen over.

In an interview with the Whitney Museum of American Art, Barker, who experienced spinal cord injury and uses a wheelchair, says the stack of papers over two feet tall “shows the medical industrial system and the healthcare industrial system and the pharmaceutical industrial system and how those all operate together when something tragic happens or an accident happens. You’re then faced with millions of dollars of medical bills and debt.”

Note the piece of paper on top of the pile: a partial bill from the day after the accident in excess of $144,000 for various surgical interventions on Barker’s spinal cord.

Barker says that she “racked up hundreds of thousands of dollars” for six months of hospitalization and “hit a million in the first year” of her recovery.

Barker is among the tens of millions of U.S. households whose credit reports include $88 billion in medical debt as of June 2021. Caught in a doom loop between medical providers and insurance companies, families and individuals struggle under crushing debt that often impacts their quality of life beyond the underlying medical concerns.

No longer able to paint, Emily Barker now lives and works in Los Angeles as a multimedia conceptual artist, designer, and activist. Her work confronts the blind spots in everyday dimensional and design standards that “leave out and patronize people who do not fit within these preconceived notions of normalcy.”

View Barker’s work to learn more.

2 minYou know things are bad when a pharmaceutical executive calls out the dysfunctional and deceptive industry practices that trigger skyrocketing drug costs for prescription medicines. But if drug companies are not the culprit, as asserted by Adam Gluck, Head of US Corporate Affairs at Sanofi, who is?

In a recent article, Gluck reveals that health insurance plans and pharmacy benefit managers (PBMs) mislead the public about their role in determining the price consumers pay at the pharmacy counter. In 2021, drug manufacturers funneled $350 billion in discounts and rebates into a black hole that has become revenue for these middlemen to spend however they choose.

None of this money finds its way to consumers to lower the price paid at the pharmacy counter. Out-of-pocket costs continue to rise as patients grapple with medical debt and potentially life-threatening situations when they’re unable to afford prescription drugs.

Patient-Centered Solutions

Gluck suggests three patient-centered solutions to address rising prescription drug costs.

• Transparency | Many states have enacted transparency requirements for drug manufacturers, but patients and policymakers are in the dark on where more than half of the money in the system goes or how it’s used. Transparency is needed for all stakeholders.
• Discounts and Rebates | Focus on patients! The government should require that the discounts and rebates paid by manufacturers be used to directly lower the costs of medicines for patients at the pharmacy counter.
• Fee Structure | Eliminate all fees that have no benefit or value to the patient, especially dubious charges for “services” such as providing data and administering rebates. In addition, any fees should be based on fair market value rather than a percentage of a drug’s list price.

Until such changes occur, employers should seek out pharmacy plans with transparent purchasing practices, ethical cost control mechanisms, and no conflicts of interest. Replacing traditional PBMs with a Medical Benefit Manager will reduce drug costs and pass 100% of all rebates to the employer.

Employers can consult this checklist to determine how well the structure of their PBM benefits members and not middlemen.