Kevin Drum

The Great "Out-0f-Network" Scam Is Eating Patients Alive. And It's Supposed To.

| Mon Sep. 22, 2014 10:36 AM EDT

Over the weekend, Elizabeth Rosenthal gave us the latest installment in her series of rage-inducing stories about the American health care system. Like all the others in the series, it was all but ignored by the rest of the world. I guess everyone was too busy panicking over the White House fence jumper or figuring out ways to one-up each other in their withering scorn for Roger Goodell.

Or, like me, they've just given up even hoping that anyone will ever do anything about it. Saturday's installment was about a medical practice that infuriates me more than almost any other: the routine practice of creating artificial and insanely high "list prices" for procedures that bear no relation to reality and exist for only one reason: to occasionally take advantage of the people who are most vulnerable to abusive pricing. That includes the uninsured, who can least afford it, and those who are already on the gurney going into surgery, who are barely in any condition to fight back.

Rosenthal's latest piece is about the increasingly common practice of calling in "assistants" during surgical procedures who aren't covered by the patient's insurance and are therefore not subject to rates negotiated with the insurance company. This allows them to charge as much as they feel like, and then to harass patients with bill collectors forever unless they pay up. Here's a graphic that accompanied the article:

The stomach-turning part of this is that it's so obvious what's going on. Clearly, the muscle and skin graft in the first example can be done for about $2,000, which produces a decent income for the doctor. So what's the reason for the list price topping $150,000? There isn't one. It's solely so doctors can scam the occasional patient and make a fast buck. As long as it's not a Medicare or Medicaid procedure, and it's out-of-network, there are no rules. So why not?

Are these assistants pals of the primary surgeon who get called in occasionally as a wink-wink-nudge-nudge buck-raking favor for a friend? Does it happen more randomly than that? Who knows. But there's a limit to what patients can do. They're in prep for surgery, there are tubes in their arms, and they get handed a bunch of papers to sign. Who knows what they say? Are they going to check? Are they going to read all the fine print? No and no, even if they're aware that this kind of stuff can happen. Which most patients aren't. A few weeks later they get the bill and their jaw drops to the floor. It's the same thing that happens to uninsured patients who don't have the benefit of insurer-negotiated rates when they land in the ER.

And there's virtually no way to negotiate anyway. Have you ever tried to mark up a consent form? Have you ever tried to get a hospital to agree to an out-of-pocket max before an operation? Are you laughing hard enough yet? Insurance companies can do this, but ordinary schlubs like you and me can't.

This is a scam, plain and simple. So why does it continue? Let's allow James J. Donelon, the Republican insurance commissioner of Louisiana, to explain:

This has gotten really bad, and it’s wrong. But when you try to address it as a policy maker, you run into a hornet’s nest of financial interests.

And there you have it. It's a great racket that allows doctors to extort loads of money from those in the most pain and with the least ability to fight back. None of them want the gravy train to end, and that's your "financial interests" right there. It's shameless and venal and there's no excuse for it. And that's America's health care system.

In good conscience, I'm not even sure I can recommend that you read the whole piece. It will probably send your blood pressure skyrocketing and possibly send you to the ER, where you'll be pauperized by the very practice the article is about. You have been warned.

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Roger Goodell's Life Just Got a Whole Lot Worse This Weekend

| Sun Sep. 21, 2014 3:40 PM EDT

There's been a mountain of talk about the Ray Rice domestic violence case, but the evidence about exactly what happened and when it happened has remained stubbornly fuzzy. That changed this weekend. ESPN's blockbuster piece, like all stories of this nature, relies a lot on unnamed sources and therefore still isn't quite rock solid. Unnamed sources can have their own agendas, after all. But on the surface, anyway, it seems pretty damn close to rock solid. And it looks very, very bad for Roger Goodell, the Baltimore Ravens, and the NFL. Read it.

Friday Cat Blogging - 19 September 2014

| Fri Sep. 19, 2014 2:47 PM EDT

We have a very busy squirrel in our backyard. He is tireless in his quest to find pine cones and bury them in our garden. In fact, every time Marian goes out to do some gardening, she routinely digs up half a dozen pine cones. They're everywhere. But squirrels are squirrely little critters, and it's hard to catch them in the act. Yesterday, however, our local squirrel was zipping across our fence with a pine cone in its mouth, and stopped just long enough for me to acquire hard photographic evidence of his hardworking ways. If I were a squirrel, I'd spend my autumns just keeping an eye on this guy so that I could pilfer his treasure during winter.

In other news, certain of my family members were annoyed with my choice of catblogging photo last week. They wanted the picture of Mozart snoozing on my mother's car with his face reflected in the paint job. Well, patience is a virtue, and this week that's the picture you get. As for next week, who knows? Perhaps by then we'll no longer have a need for guest cats.

Quote of the Day: Nathan Deal Is Tired of Barack Obama's Treachery

| Fri Sep. 19, 2014 1:26 PM EDT

From Georgia Gov. Nathan Deal, apparently upset that his tax-fighting economic policies aren't yet producing a paradise on earth:

It’s ironic that in a year in which Republican governors are leading some of the states that are making the most progress, that they almost, without exception, are classified as having a bump in their unemployment rates. Whereas states that are under Democrat governors’ control, they are all showing that their unemployment rate has dropped. And I don’t know how you account for that. Maybe there is some influence here that we don’t know about.

Maybe! It might be that the Obama administration is cooking the books to make Republicans looks bad. Or maybe Democrats in Georgia are deliberately refusing work in order to spike the unemployment numbers. Or—and this is my suspicion—maybe computers have finally acquired human-level intelligence and they don't like Nathan Deal! If I were a computer, I sure wouldn't.

When I Was 5, I, Um -- What Were We Just Talking About?

| Fri Sep. 19, 2014 1:06 PM EDT

I remember approximately diddly-squat1 about my childhood. But why? Melissa Dahl explains the latest research to me today:

The way parents tend to talk to their sons is different from the way they talk to their daughters. Mothers tend to introduce more snippets of new information in conversations with their young daughters than they do with their young sons, research has shown. And moms tend to ask more questions about girls’ emotions; with boys, on the other hand, they spend more time talking about what they should do with those feelings.

This is at least partially a product of parents acting on gender expectations they may not even realize they have, and the results are potentially long-lasting, explained Azriel Grysman, a psychologist at Hamilton College who studies gender differences and memory. “The message that girls are getting is that talking about your feelings is part of describing an event,” Grysman said....“And it’s quite possible, over time, that those tendencies will help women establish more connections in their brains of different pieces of an event, which will lead to better memory long-term.”

So I can blame my crappy memory on my mother? Cool.

1This is a technical term used by neurologists and memory researchers.

Republicans Really, Really Want to Send Ground Troops Into Iraq

| Fri Sep. 19, 2014 10:44 AM EDT

I missed this NYT/CBS poll when it came out a couple of days ago, but a friend pointed it out to me this morning. I don't think much comment is necessary. It's pretty easy to see how the fight against ISIS is going to turn into a massive game of Munich-mongering and appeasement-baiting in short order. Yikes.

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Obama Signs Order to Take Away Your Antibiotics

| Fri Sep. 19, 2014 10:30 AM EDT

Here's the latest from the White House:

The Obama administration on Thursday announced measures to tackle the growing threat of antibiotic resistance, outlining a national strategy that includes incentives for the development of new drugs, tighter stewardship of existing ones, and improvements in tracking the use of antibiotics and the microbes that are resistant to them.

....John P. Holdren, the director of the White House Office of Science and Technology Policy, told reporters that the new strategy — established by an executive order that President Obama signed on Thursday — was intended to jolt the federal government into action to combat a health crisis that many experts say it has been slow to recognize.

I guess we can all see where this is going, right? It'll start with Alex Jones, maybe, and then Glenn Beck will catch the infection. Drudge will get it next, then Limbaugh, and finally the entire crew of Fox News will come down with it. The tyrant Obama is taking our amoxicillin away from us! Think of the children and their earaches!

Sadly, there's no treatment for this airborne virus. We just have to let it burn itself out. Maybe someday scientists will find a cure for vox bardus.

Don't Worry, the Crazy Is Coming Soon in the House Benghazi Hearing

| Thu Sep. 18, 2014 4:01 PM EDT

Yesterday's Benghazi hearing, chaired by Rep. Trey Gowdy (R–SC), was shockingly calm. Aside from a bit of gotcha over a 15-year-old report, there were no conspiracy theories, no hot buttons pressed, no shrieking clown shows. The extremely sober topic was whether the State Department has been successfully implementing the recommendations made by the Accountability Review Board shortly after the attacks. Everyone was on their best behavior, and even Ed Kilgore was impressed:

Now it's possible Gowdy will be taken to the woodshed by other Republicans (not to mention the conservative media that has made Benghazi! a sort of national security counterpart to Agenda 21), and come back snarling and ranting. But for the first time since September 11, 2012, the subject is being discussed by Republicans in an atmosphere that isn't reminiscent of a Tea Party street rally.

Go ahead and call me a stone partisan blinded by my own ill will toward Republicans, but come on. Gowdy doesn't need to be taken to the woodshed by anyone. This is just well-played theater from a guy who's a mite smarter than the usual tea party crackpot. He's gulling everyone into treating this like a serious investigation so that he'll have some credibility stored up when it comes time for the hundredth repetition of the stand-down myth or the latest insane parsing of the White House talking points. That's what this is all about.

I'll apologize if Gowdy manages to keep the tone of this hearing civil and judicious all the way to the end. But I'm not too worried about having to eat any crow here.

How to Discriminate Against Pre-Existing Conditions in Two Easy Tiers

| Thu Sep. 18, 2014 2:37 PM EDT

Via ProPublica, here's an editorial published yesterday in the American Journal of Managed Care:

For many years, most insurers had formularies that consisted of only 3 tiers: Tier 1 was for generic drugs (lowest co-pay), Tier 2 was for branded drugs that were designated “preferred” (higher co- pay), and Tier 3 was for “nonpreferred” branded drugs (highest co-pay)....Now, however, a number of insurers have split their all-generics tier into a bottom tier consisting of “preferred” generics, and a second tier consisting of “non-preferred” generics.

Hmmm. What's going on here? In some cases, this new non-preferred tier is reserved for higher-priced medicines. That's pretty easy to understand: insurers are trying to motivate their patients to choose cheaper drugs when they're available. That's the same reason copays are lower for generics compared to brand name drugs.

But it turns out that sometimes all the generic drugs for a particular disease are non-preferred and therefore have high copays. What are insurance companies trying to motivate in these cases? Charles Ornstein takes a guess:

The editorial comes several months after two advocacy groups filed a complaint with the Office of Civil Rights of the United States Department of Health and Human Services claiming that several Florida health plans sold in the Affordable Care Act marketplace discriminated against H.I.V. patients by charging them more for drugs.

Specifically, the complaint contended that the plans placed all of their H.I.V. medications, including generics, in their highest of five cost tiers, meaning that patients had to pay 40 percent of the cost after paying a deductible. The complaint is pending.

"It seems that the plans are trying to find this wiggle room to design their benefits to prevent people who have high health needs from enrolling," said Wayne Turner, a staff lawyer at the National Health Law Program, which filed the complaint alongside the AIDS Institute of Tampa, Fla.

If all your HIV drugs are expensive, then people with HIV will look for another plan. Technically, you're not discriminating against anyone with a pre-existing condition, but you're sure giving them a reason to shop around someplace else, aren't you?

At the moment, this practice appears to be confined to just a few insurers and a few classes of drugs. But if it catches on, it will prompt everyone to follow suit. After all, you can hardly afford to be the insurance company of choice for chronically sick people, can you? This is worth keeping an eye on.

IHOP Has Cut Back Its Menu By 30 Items

| Thu Sep. 18, 2014 12:11 PM EDT

Here's an interesting factoid: in 2008 we apparently reached Peak Menu. That year, the average menu contained 99.7 items. Then the housing bubble burst, we entered the Great Recession, and menus began to shrink. Today's menus feature a paltry 92.6 items.

Why is this? Cost is one reason: it's cheaper to support a smaller menu. But Roberto Ferdman writes that there's more to it:

The biggest impetus for all the menu shrinking going on is likely tied to a change in the country's food culture: Americans are becoming a bit more refined in their tastes.

"Historically, the size of menus grew significantly because there wasn't the food culture there is today," said [Maeve Webster, a senior director at Datassential]. "People weren't nearly as focused on the food, or willing to go out of their way to eat specific foods."

For that reason, as well as the fact that there were fewer restaurants then, there used to be a greater incentive for restaurants to serve as many food options as possible. That way, a customer could would choose a particular restaurant because it was near or convenient, rather than for a specific food craving (which probably wasn't all that outlandish anyway). But now, given the increasing demand for quality over quantity, a growing appetite for exotic foods and a willingness to seek out specialized cuisines, Americans are more likely to judge a restaurant if its offerings aren't specific enough.

"The rise of food culture, where consumers are both interested and willing to go to a restaurant that has the best Banh Mi sandwich, or the best burger, or the best trendy item of the moment, means that operators can now create much more focused menus," said Webster. "It also means that the larger the menu, the more consumers might worry all those things aren't going to be all that good."

Hmmm. Let me say, based on precisely no evidence, that I find this unlikely. Have American tastes really gotten more refined since 2008? Color me skeptical. And even if American palates are more discriminating, are we seriously suggesting that this has affected the menu length at IHOP, Tony Roma's, and Olive Garden—the three examples cited in the article? I hope this isn't just my inner elitist showing, but I don't normally associate those fine establishments with a "growing appetite for exotic foods and a willingness to seek out specialized cuisines."

So, anyway, put me down firmly in the cost-cutting camp. Long menus got too expensive to support, and when the Great Recession hit, casual dining chains needed to cut costs. They did this by lopping off dishes that were either expensive to prep or not very popular or both. Occam's Razor, my friends, Occam's Razor.