Year: 2014

How Much Does an MRI Cost In California: $255? $973.25? $2,925?

Aug 6, 2014• 74

By JEANNE PINDER

Early results from our California crowdsourcing project on MRI prices are in. Payments range from $255 to $2,925.15. MRI pricing is a complete mystery: What should you pay? Can you ask for a discount? We’ve been looking at health-care prices for three years, so if we say it’s a mystery, we can imagine what it looks like to you.

How much should you pay? Well, one person was told the price is $1,850, but if you pay up front, you can save almost $1,300.

The note on our form, shared by our community member: “I was told procedure would be 1850. I have a 7500 deductible. So I talked to the office mgr who said if I paid upfront and agreed not to report the procedure to Blue Cross, that it would be $580.”

On our Facebook page, one contributor wrote, “I was going to be billed $830 through my PPO for an MRI. The cash price? $500.”

This is the second part of our crowdsourcing project in California with KQED public radio in San Francisco and KPCC/Southern California Public Radio in Los Angeles. We have been asking people to share pricing information for MRI’s, especially of the back; last month we collected mammogram pricing.

A note: We are often asked in this crowdsourcing prototype project if we believe what we are being told by people who fill out our online form at the PriceCheck page. The answer: yes, we do. Though some of our community members have said their bills are confusing, or the coding they see on the bills doesn’t match what we’re collecting, we believe our contributors’ shares. We have seen wide variations in health-care pricing.

So: here are early results.

Lower-back MRI: $255? $602.85? $973.25? $1,660?

Eight identical MRI’s, and eight vastly different payments.

No. 1: We heard from one Kaiser member, who received an MRI of the lower back, without contrast or dye (CPT code 72148) at the Kaiser Antioch Medical Center on Sand Creek Road in Antioch, Calif. This person was charged $973.25 and paid $973.25; insurance paid nothing.Comment: “This price was the contracted amount through my insurance. Deductible had not been met so I was responsible for all charges. This does not include the two office visits required to obtain and analyze the results.”

No. 2: Same kind of MRI, code 72148, at Radnet Medical Imaging at 3440 California St. in San Francisco. This person was charged $1,660 and paid $1,660, out of HSA funds. (Note: Our ClearHealthCosts pricing survey included that Radnet location, and they did tell our survey agent that their cash price is $1,660.)

Early Exchange Outlook 2015

Aug 5, 2014• 25

By CECI CONNOLLY and CAITLIN SWEANY

States in more than half the nation have reported individual market premium rate requests for 2015, making this an opportune time to assess how the second year of the ACA’s new marketplaces is shaping up.

With rate filings in for 27 states plus the District of Columbia, the early word on 2015 appears to be expansion. At least 15 of the 28 jurisdictions in 2015 will offer new individual plans this year. Thirty-seven of the 176 health plan filings are new, according to analysis by PwC’s Health Research Institute (HRI).

Major national insurers such as UnitedHealth Group, as well as newbie Consumer Operated and Oriented Plans (Co-Ops), plan to add both products and states when exchange open enrollment begins in the fall. In Virginia, five new plan bids have been submitted to the state; Washington, Arkansas and Tennessee show three new plans each.

UnitedHealth’s CEO Stephen J. Helmsley estimates that UnitedHealth will sell on public exchanges in about two dozen states. In short, the ACA’s subsidized exchange markets represent growth opportunities for the health sector.

At the same time at least three non-profit health Co-Ops will move into additional markets. As of late April, Co-Ops operating in 23 states had 400,000 members, according to the National Alliance of State Health Co-Ops. Not every Co-Op drew big numbers, especially those in states such as Maryland, where the online marketplace never really got off the ground. And it’s far too early to say how many new entrants will be left standing as plans are forced to pay back $2 billion in federal loans over the next several years.

International Classification of Diseases Hampers the Use of Analytics to Improve Health Care

Aug 5, 2014• 3

By ANDY ORAM

The health care field is in the grip of a standard that drains resources while infusing little back in return. Stuck in a paradigm that was defined in 1893 and never revised with regard for the promise offered by modern information processing, ICD symbolizes many of the fetters that keep the health industries from acting more intelligently and efficiently.

We are not going to escape the morass of ICD any time soon. As the “I” indicates in the title, the standard is an international one and the pace of change moves too slowly to be clocked.

In a period when hospitals are gasping to keep their heads above the surface of the water and need to invest in such improvements as analytics and standardized data exchange, the government has weighed them down with costs reaching hundreds of thousands of dollars, even millions just to upgrade from version 9 to 10 of ICD. An absurd appeal to Congress pushed the deadline back another year, penalizing the many institutions that had faithfully made the investment. But the problems of ICD will not be fixed by version 10, nor by version 11–they are fundamental to the committee’s disregard for the information needs of health institutions.

Disease is a multi-faceted and somewhat subjective topic. Among the aspects the health care providers must consider are these:

Disease may take years to pin down. At each visit, a person may be entering the doctor’s office with multiple competing diagnoses. Furthermore, each encounter may shift the balance of probability toward some diagnoses and away from others.
Disease evolves, sometimes in predictable ways. For instance, Parkinson’s and multiple sclerosis lead to various motor and speech problems that change over the decades.
Diseases are interrelated. For instance, obesity may be a factor in such different complaints as Type 2 diabetes and knee pain.

All these things have subtle impacts on treatment and–in the pay-for-value systems we are trying to institute in health care–should affect reimbursements. For instance, if we could run a program that tracked the shifting and coalescing interpretations that eventually lead to a patient’s definitive diagnosis, we might make the process take place much faster for future patients. But all a doctor can do currently is list conditions in a form such as:

E66.0 – Obesity due to excess calories

E11 – Type 2 diabetes mellitus

M25.562 – Pain in left knee

The tragedy is that today’s data analytics allow so much more sophistication in representing the ins and outs of disease.Take the issues of interrelations, for instance.

These are easy to visualize as graphs, a subject I covered recently.

Innovation Isn’t A Pipe Dream, How Health Care Organizations Can Adopt Digital Health Technologies

Aug 4, 2014

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Startups announce new technologies to solve healthcare problems every week, but how much of these new technologies hit the public market and reach widespread adoption? Even more, how much technology gets adopted by key institutions that work directly with patients and deliver care? 6 out of 10 physicians reported that they did not use digital health technology for clinical purposes, including communication with patients and other providers and only 27% of physicians actively encourage their patients to use digital health applications, according to PriceWaterhouseCooper’s Top Health Industry Issues 2014 report. While many health systems are beginning to explore different avenues for innovation, some even creating internal departments to address innovation, many are still slow to adopt. As many as 36% of healthcare service organizations report that their organization has no mobile technology or innovation strategy.

Digital health startups, compared to traditional technology startups, have the additional burden of breaking into an established health care system before their solution can really gain traction. Whether it’s a hospital network, health plan provider or direct consumers, all of these groups want to see a product or service that has been validated. With so much activity in the digital health space, potential customers, especially large health systems, want to mitigate risk by purchasing a solution that has shown evidence of the benefits they claim to deliver.

Doctors Who Take Medicine Into Their Own Hands

Aug 1, 2014• 28

By RICHARD GUNDERMAN, MD

Many doctors are frustrated by pressures to practice a faster and more impersonal brand of medicine, but some are actually doing something about it. I recently spoke with one such doctor, Tom O’Connor, MD, who practices general internal medicine in central Connecticut. He and his partner, Paul Guardino, MD, believe they were the first US physicians to begin building a fully concierge medical practice the day they completed training. In the concierge model, their practice collects an annual fee of several thousand dollars from each patient, enabling better access, more personalized care, and even house calls.

But the real story about physicians such as O’Connor is not that they are opting for a different model of financing their practices. Instead it is the unmistakable sense of excitement with which they talk about the way they care for patients – an attitude that has become noticeably rarer in recent years. Says O’Connor, “I have been practicing medicine for nearly ten years this way, and I am happier than ever.” His enthusiasm stems largely from the fact that, unlike most physicians, he is not employed by a hospital or a large practice group. Instead, he works for himself. He is his own boss.

Of course, the idea of doctors running their own practice is not a new one. For much of the 20^th century, most physicians were self-employed, and many operated in solo practice. Today’s trend away from physician self-employment is driven by a number of factors, including increasingly complex and costly regulation of medical practice by government and insurance companies, the failure of medical schools and residencies to prepare physicians to manage their practices, and big financial incentives for hospitals and health systems to buy medical practices in order to capture patient referrals.

Enter a new breed of physician that includes O’Connor. He did not want someone else telling him who he could care for, what tests and medications he could order, or how long he could spend with each patient. In his practice, he and his partner – the doctors who actually see the patients every day – make such decisions themselves. He sees all his own patients, whether in the office, the nursing home, the hospital, or at home – wherever care needs to be provided. They do not go to walk-in clinics and they are not cared for by teams of hospitalists. O’Connor is their doctor in every context.

What the California Rate Increases Should Tell Us

Aug 1, 2014• 4

By ROBERT LAZEWSKI

The weighted average increase for plans being sold on the Obamacare California public exchange in 2015 will be 4%. So, that means Obamacare is working really well, right?

Well, wait a minute.

Let’s consider a few things:

This week the California insurance commissioner reported that the average unsubsidized 2014 rate increase carriers charged going into Obamacare was between 22% and 88%. That was a pretty healthy bump (I’ll call it a bump because “Rate Shock” didn’t happen) to get everyone into Obamacare in the first place. And remember, many of these consumers are now in narrow networks in California to boot.
California voters will go to the polls this fall to vote on Proposition 45. That ballot initiative would regulate health insurance rates in California for the first time––something the carriers are dead set against. Big rate increases on part of the carriers would do a lot to get that proposition passed and very low increases would do a lot toward defeating it. The state’s largest carriers have so far made $25 million in political contributions to defeat Prop 45.
The health plans competing in the Obamacare exchanges are limited to very small losses this year because of the Obamacare reinsurance program that runs through 2016. In effect, anymore underpricing the insurers put into their rates for 2015 is subsidized by the federal government. In fact, the Obama administration recently took the statutory caps off of how much they can pay the carriers to keep their bottom line whole.

So, let’s summarize.

The California insurance commissioner has said that consumers saw individual health insurance rate increases of 22% to 88% to get into Obamacare in the first place.

There is a highly contentious November ballot initiative facing the health plans they absolutely do not want to see passed, that would put the government in charge of their rate setting in future years, giving the carriers every incentive to low-ball the 2015 rates so voters don’t have any more incentive to vote for it.

Pseudo Innovation

Jul 31, 2014• 5

By DONALD LIGHT

Few people know that new prescription drugs have a 1 in 5 chance of causing serious reactions after they have been approved. That is why expert physicians recommend not taking new drugs for at least five years unless patients have first tried better-established options and need to. Faster reviews advocated by the industry-funded public regulators increase the risk of serious harm to 1 in 3. Yet most drugs they approve are found to have few offsetting clinical advantages over existing ones.

Systematic reviews of hospital charts by expert teams have found that even properly prescribed drugs (aside from misprescribing, overdosing, or self-prescribing) cause about 1.9 million hospitalizations a year. Another 840,000 hospitalized patients given drugs have serious adverse reactions for a total of 2.74 million. Further, the expert teams attributed as many deaths to the drugs as people who die from stroke. A policy review done at the Edmond J. Safra Center for Ethics at Harvard University concluded that prescription drugs are tied with stroke as the 4th leading cause of death in the United States. The European Commission estimates that adverse reactions from prescription drugs cause 200,000 deaths; so together, about 328,000 patients in the US and Europe die from prescription drugs each year. The FDA does not acknowledge these facts and instead gathers a small fraction of the cases.

Perhaps this is “the price of progress”? For example, about 170 million Americans take prescription drugs, and many benefit from them. For some, drugs keep them alive. If we suppose they all benefit, then 2.7 million people have a severe reactions, it’s only about 1.5 percent – the price of progress?

However, independent reviews over the past 35 years have found that only 11-15 percent of newly approved drugs have significant clinical advantages over existing, better-known drugs. While these contribute to the large medicine chest of effective drugs developed over the decades, the 85-89 percent with little or no clinical advantage flood the market. Of the additional $70 billion spent on drugs since 2000 in the U.S. (and another $70 billion abroad), about four-fifths has been spent on purchasing these minor new variations rather than on the really innovative drugs.

In a recent decade, independent reviewers concluded that only 8 percent of 946 new products were clinically superior, down from 11-15 percent in previous decades. (See Figure) Only 2 were breakthroughs and another 13 represented a real therapeutic advance.

Spokesmen for the pharmaceutical industry point out that therapeutically similar drugs have advantages. First, physicians need some choice within a therapeutic class because some patients do not respond well to a given drug. This is true, but after about three choices, there is little evidence to justify a 4th , 5th, or 6th in a class.

An AIDS-Free Future Requires More Than Medicine

Jul 31, 2014• 1

By RUTH MESSINGER

In 1985, during the height of the AIDS crisis in New York City, I was elected to the New York City Council. Time and again, I felt heartbroken as my friends and constituents lost their lives to a deadly disease without a cure. Too frequently, they suffered the effects of ignorance, fear and hate.

Now, nearly 30 years later, advances in biomedical treatment have been stunning in their power to achieve an AIDS-free future. But the truth is that prejudice and fear are as persistent as HIV. Medicine alone cannot deliver the future we seek. Even as we celebrate the scientific discoveries and treatments that dramatically reduce HIV transmission and death, we should not delude ourselves into thinking that a biomedical solution can overcome the devastating effects of bigotry. If, as the United Nations agency UNAIDS urges, we wish to get to zero—zero discrimination, zero new infections, and zero deaths—we must take an integrated approach that combines biomedical treatment and an enduring commitment to human rights.

Without a doubt, medicine is working. As of September 30, 2013, the United States’ program, PEPFAR, is currently supporting life-saving antiretroviral treatment for 6.7 million men, women, and children worldwide. This exceeds President Obama’s 2011 World AIDS Day goal of 6 million people on treatment—a four-fold increase (from 1.7 million in 2008) since he took office. But, unfortunately, the World Health Organization predicts that 50 million people will need treatment for HIV by 2030. This means we face a tremendous uphill climb and must somehow identify between $22 and $24 billion—a truly ambitious financial target.

Meet the First Aledade ACOs

Jul 31, 2014• 4

By FARZAD MOSTASHARI, MD

On June 18, we launched Aledade – a company built on our belief that independent primary care physicians are best positioned to lead the next revolution in health care delivery – boosting quality of care and bringing down costs. Over the past six weeks, we traveled across the country meeting doctors, discussing the future of independent primary care practice, and recruiting physician partners for our first wave of Accountable Care Organizations.

Meeting these doctors, from areas and backgrounds as diverse as the populations they serve has been a constant reminder of the reasons we founded this company. One physician, having spent decades serving the same community from the same office, lamented that in the past, he felt more involved – and more informed – about all aspects of his patients’ care. Today, he told us, fragmentation in care delivery had given him less insight into his patients’ health, and less influence in coordinating their treatment.

When we started Aledade, these were the type of doctors we wanted to empower.

Today, I am elated to announce that we have formally submitted applications to the Center for Medicare & Medicaid Services to form ACOs serving physicians in Delaware, Maryland, New York, and Arkansas for 2015. We expect this first wave of Aledade ACOs to serve tens of thousands of Medicare patients beginning January 2015.

The choice of four dissimilar states was intentional. We intend to establish a model that can be replicated across the country, and the diversity in our practices matches the diversity of our country. Each state has strengths to build on. Delaware- ‘the First State’ has been a leader in electronic health record implementation. Maryland and New York’s health reforms set the stage for alignment and collaboration with acute-care facilities. Arkansas’ tradition of independent primary care practice is strong. We’ll also be serving very different patient populations in each state – from practices that serve urban neighborhoods to those that treat folks in small towns and rural communities.

Ask Not What Your Government Can Do For You: JFK Speaks to Us About Health

Jul 31, 2014• 21

By VIK KHANNA and GENERAL HEALTHY

President Obama has spent a lot of time defending his health law, but he appears to us to be quite ill-equipped to actually talk about health. In fact, it’s the just about the only thing he doesn’t talk about. He’s talked insurance, web sites, and funneling even more money to medical care providers. He’s talked about deadlines. He’s talked about glitches. The shocking lack of official communication about what should be the central message of any drive to make Americans healthier should tell us something.

In point of fact, no American leader since John F. Kennedy has had the courage to implore us to work for our own better health. He wrote in 1961 in Sports Illustrated:

“Thus, in a very real and immediate sense, our growing softness, our increasing lack of physical fitness, is a menace to our security…if our bodies grow soft and inactive, if we fail to encourage physical development and prowess, we will undermine our capacity for thought, for work and for the use of those skills vital to an expanding and complex America. Thus, the physical fitness of our citizens is a vital prerequisite to America‘s realization of its full potential as a nation, and to the opportunity of each individual citizen to make full and fruitful use of his capacities.”

By JFK’s clear, powerful, and time-tested standard, we are a disaster. We have no leader on health. Nobody.

If the Forest Service has Smokey Bear and local law enforcement agencies have McGruff the Crime Dog, where is our fearless leader who makes doing healthy things cool, interesting, and desirable?

Doing healthy things is not cool, and until it becomes cooler than doing unhealthy things, we are delivering to ourselves and our kids a future of misery and entrapment in a medical care system that regards us and them as widgets in its revenue cycle.

Ask any kid on any playground who’s their role model for living a healthy life, who’s teaching them the value of eating smartly, exercising, and managing their stressors, and you’ll get a blank stare For example, standard medical advice is that electronic gaming is bad and is a major contributor to inactivity and declining health in our children. But, gaming is here to stay, and we don’t see how professional finger-wagging gets kids to make better choices. Who’s their enlightened leader to tell them that getting up and getting fit will make them even better gamers? Nobody. Leaders meet their followers where their “heads” are and craft messages that connect and inspire action.