Summary: Health insurers beat down physicians in contract negotiations with fuzzy numbers, run-arounds, and other ruses associated with used-car lots, practice consultant Ron Howrigon told attendees here at the Medical Group Management Association (MGMA) 2015 Annual Conference,” writes Robert Lowes over at Medscape. “Howrigon should know. For 18 years, he worked in the managed care industry, running provider networks and negotiating contracts with medical practices. Now he coaches those same practices…. ‘When I worked on the payer side, we used to joke all the time that negotiating with physicians was like negotiating with somebody who brings a knife to a gunfight,’ said Howrigon, president and chief executive officer of Fulcrum Strategies in Raleigh, North Carolina. ‘You don’t win many of those, so be prepared.’ It is more important than ever for medical practices to forge good deals with private insurers, said Howrigon. The cost-cutting imperative of healthcare reform is making these companies more aggressive, ‘and when they get aggressive, they take it out on physicians.'” Among the tricks: “Our lady of perpetual negotiations” (three years for a contract), “two steps forward, three steps back,” or “negotiating on a treadmill,” or ” “You ask for something, my response is, ‘I have to check with corporate.'” For more, click here: Robert Lowes, MedScape.
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Summary: Yes, people are shopping for health care. Some are better at it than others, and some providers and payers (read: doctors/hospitals and insurers) are better than others about revealing information. We’re always interested to hear when people who haven’t encountered these truths come up against the real world. So when Sarah Kliff, the well-respected health care writer for Vox.com, wrote about her experience trying to get a better price for an MRI, I was really interested.
Summary: When our research and writing are cited as major sources of knowledge, we are both proud and humbled. So when we noticed we were getting a lot of traffic from a think-tank in Ohio, we scurried on over to their web page, to notice that we are being cited as an expert on the all-payer claims database phenomenon. This page, from the Health Policy Institute of Ohio, an Ohio research organization on health issues, lists resources for understanding the APCD: Our research is there in good company, along with research from the Network for Excellence in Health Innovation and the Robert Wood Johnson Foundation. (On this screenshot, my piece is listed first; the second one is NEHI and the third is the RWJF piece.)
Summary: We often tell people who are looking for health care prices to ask “How much will that cost? How much will that cost me?” But not all providers think that’s helpful — in fact, some think it’s “an exercise in futility.” We don’t fully agree, because sometimes you can know (“How much will an MRI of the lower back, CPT code 72148, cost?”) while sometimes you can’t (“I have a sore throat, how much will it cost?”) In the interest of improving communication, and representing the view from the provider’s office, we’re posting this, sent to us by Cecily Murray from Camino Ear, Nose and Throat in San Jose, Calif.
Summary: “You probably remember hearing the news a few weeks ago about a greedy hedge fund manager who acquired the rights to sell a life-saving medication just so he could raise the price of it by about 5,000%,” Dr. David Belk writes over at Huffington Post. “That was a pretty evil thing to do, and it showcased the sort of abuse drug companies can, and do engage in. Still, that was just one hedge fund manager, and maybe a few drug companies. What about your friendly neighborhood chain pharmacy? Would they ever try to gouge a customer that much?”
Summary: “Massachusetts has a problem: Even with all the work we have done, health care costs are outrageously high and unsustainable. On average, every Massachusetts resident spends 36 percent more on health care than the national average,” writes Dr. Howard Grant, president and chief executive officer of Lahey Health, in an op-ed piece in The Boston Globe. “Why? Too many of us choose to have our care delivered in the most expensive setting possible — academic medical centers and teaching hospitals — rather than at local community hospitals. Nationally only 16 percent of all Medicare hospitalizations occur in academic medical centers and teaching hospitals. In Massachusetts that number is 40 percent. The truth is, according to many state-funded studies, the quality of care provided at community hospitals is as good as, or in some cases better than, teaching hospitals. Here’s an example: Say you need a knee replacement. You could either choose to go to your local community hospital or you could go to one of Boston’s five academic medical centers to have that surgery. Many of us, without even taking a second to consider our options, will choose to have a common procedure done at what is perceived to be one of the best hospitals in the country, when equally exceptional care is available at community hospitals — closer to home — for a fraction of the cost. It’s because of decisions like this that the cost of health care in Massachusetts is higher than any other state in the nation.” Dr. Howard Grant, “Academic medical centers drive up costs in the health care marketplace,” The Boston Globe.
Summary: “Prices for many common medical procedures are higher in areas where physicians are concentrated into larger practice groups, according to a new study,” Michelle Andrews writes in Kaiser Health News. “The October Health Affairs study examined the average county prices paid by preferred provider insurance organizations in 2010. It focused on 15 high-volume, high-cost medical procedures across a variety of specialties, including vasectomy, laparoscopic appendectomy, colonoscopy with lesion removal, nasal septum repair, cataract removal and knee replacement. The prices studied reflected the negotiated prices between the PPOs and the physician groups, including payments made by both the plan and the patient. The average price ranged from $2,301 for a total knee replacement to $576 for a vasectomy. … In 12 of the 15 procedures, prices were 8 to 26 percent higher in counties with the highest average physician concentration compared to counties with the lowest average concentration, the study found. The three procedures where there was no significant relationship between physician competition and price were intensity-modulated radiation therapy, shoulder arthroscopy and kidney stone fragmentation. Although larger practices may have the resources to provide benefits to patients through better care coordination or access to new technologies, among other things, these practices’ greater market power may enable them to charge higher prices than smaller practices, the study authors said.” Michelle Andrews, Medical Prices Higher In Areas Where Large Doctor Groups Dominate, Study Finds,” Kaiser Health News. The original study in Health Affairs is here.
Summary: She got a foot MRI, for cash, at $450, and considers it a bargain. The story involves a young woman I know who needed an MRI to diagnose a complicated foot injury. Two X-rays about five days apart showed that it wasn’t broken, but it was swollen and painful (the foot in question had been run over by a car). So the doctor recommended an MRI just to be sure — there are a lot of bones in your foot, and if one is broken it’s better to know and fix it. A friend who’s an orthopedist also concurred that an MRI or CT scan was recommended, so the young woman decided it was not one of those unnecessary MRI experiences we hear about — that MRI’s are overused and often superfluous.
Summary: “I must admit that I chose to be uninsured,” C. wrote to me. “My work does not provide health insurance and I looked into nystateofhealth.ny.gov during the fall of 2014, excited to have real health care options. I am 33 years old, and could comfortably afford an insurance that was $160 per month. I punched in my info and looked at my options. Nothing was lower than $240. And I knew from my boyfriend that the quality of these low ball ‘bronze’ options was pretty pathetic — waiting lists for appointments, long waits once there, poor visit quality — and he paid $120 per month for his.”
(Editor’s note: I am posting this essay from a friend’s daughter using only her initial, C., to preserve her anonymity. I also removed the name of a radiology practice she used because there’s not a good way to reconstruct her experience and validate it for my readers. At the bottom is a list of resources with explanation that I sent to C., which had been sent to me by my friend Casey Quinlan, a communicator and patient advocate and the author of “Cancer for Christmas,” about her breast cancer experiences.)
Summary: “Specialists in infectious disease are protesting a gigantic overnight increase in the price of a 62-year-old drug that is the standard of care for treating a life-threatening parasitic infection,” writes Andrew Pollack in The New York Times. “The drug, called Daraprim, was acquired in August by Turing Pharmaceuticals, a start-up run by a former hedge fund manager. Turing immediately raised the price to $750 a tablet from $13.50, bringing the annual cost of treatment for some patients to hundreds of thousands of dollars. ‘What is it that they are doing differently that has led to this dramatic increase?’ said Dr. Judith Aberg, the chief of the division of infectious diseases at the Icahn School of Medicine at Mount Sinai. She said the price increase could force hospitals to use ‘alternative therapies that may not have the same efficacy.’ Turing’s price increase is not an isolated example. While most of the attention on pharmaceutical prices has been on new drugs for diseases like cancer, hepatitis C and high cholesterol, there is also growing concern about huge price increases on older drugs, some of them generic, that have long been mainstays of treatment.” Andrew Pollack, “A Huge Overnight Increase in a Drug’s Price Raises Protests,” The New York Times.