February 2014

Calling All Shoppers for Health Care

by socheata on February 19, 2014

I recently went to my local ophthalmologist in order to obtain a new eye glasses and contact lens prescription. Even though I’ve had Coke-bottle glasses since I was 9 years old, I have no other health complications. I never imagined that my plain vanilla eye exam would rack up a $600 bill for a procedure that I should have opted for at Costco costing around $100.

What I thought of as a routine eye exam brought me face to face with the inefficiencies of the health care market that we as patients with insurance are often blind to. However, with the rise of high deductible plans that put more of the burden of health care costs on individuals, we’re going to have to start acting more like consumers.

A few weeks after my visit, I received the bill for the eye exam. I have a high deductible plan so my insurance only paid about a third of my bill — leaving me with a hefty balance of $400. I called my insurance company to find out what accounted for this.

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Photo credit: Sage78 | Dreamstime.com


They informed me that the doctor categorized the eye exam as a medical procedure — diagnosis: myopia and dry eye. “Dry eye?” I asked, “I don’t remember coming in for dry eye.” I scanned my memory and then it came to me. The doctor after examining my eyes told me that they looked a “little dry” and every once in a while, I could put a hot wet towel over them. That was it. Those remarks justified the billing as a medical procedure.

The office also added an extra $45 because I was considered a new patient even though I had already been there two times. Evidently, every two years at this office, they act like they’ve never seen you before.

Needless to say, I was incensed.

Here’s what I think happened:

Seeing that I had private insurance, the medical billers probably assumed that my insurance would pay the whole bill, no matter what they coded. So they were incentivized to lay it on thick. They probably didn’t count on the fact that I had a high deductible plan and that the rest of the balance would be kicked back to me.

But to be honest with you, I can’t blame my ophthalmologists’ office. The circumstances that led to my $600 bill for a routine eye exam is a systemic problem, not one that has to do with my doctors in particular. I think that because of the low reimbursement for Medicaid and Medicare patients, coupled with the high cost of malpractice insurance in this country and the high overhead costs for hospitals and clinics, providers have to game the medical billing system in order to stay in business.

We as patients have to learn to be smarter. For the first time there are new tools available that can actually help us actually shop around. Can you imagine going to a car dealership and purchasing a car without looking at the sticker price? No. And now these companies can help you do the same with health care.

Check out Castlight Health, “Healthcare Blue Book.com, ClearCost Health, and Change Healthcare.

What these companies promise, that has never before been available in the health care market, is price transparency. We have yet to see if this new marketplace can substantially lower health care costs overall. But as more and more patients like me are left “holding the bill,” I can’t help but imagine that it will.

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Where There Is No Doctor

by socheata on February 19, 2014

If you’re a parent, you’ve probably been through this too many times to count.

Your child comes to you in the middle of the night, complaining of pain in her ear. Her temperature is rising and she can’t get to sleep. Other than giving your daughter children’s Tylenol there isn’t much that you can do.

You know that in the morning, you’ll call the pediatrician’s office to tell them that your daughter has another ear infection. All you really need is the prescription for the antibiotics, but the doctor will insist that he examine your daughter’s ear himself. If you can get an appointment the next day (and that’s a big “if”), you’ll wait in the reception area for an hour with a cranky child, the doctor will look at here ear for about 10 seconds and then declare, “Yep, she’s got an ear infection.” He’ll write a prescription and hopefully 12-24 hours later, you’ll have the antibiotics you knew you needed last night.

What if there was a way to spare that half day you had to take off work, not to mention the sleepless night you had to put your daughter through?

Ear infections, urinary tract infections and bronchitis fall under the category of “precision medicine,” according to Clayton Christensen, the author of The Innovator’s Prescription. These are the kind of conditions that are the most common drivers of physician visits and they are also clear to diagnosis and treat.

With the shortage of primary care doctors in America soon to hit us, we as patients and consumers will need to rely less on doctors to diagnosis some of these common conditions.

When it comes to primary care, we’re about to see long waits for visits and even shorter visits to boot. There are a number of factors that are making this so: the Baby Boomers aging, the Affordable Care Act will mandate that all Americans have some kind of health care coverage, and a disproportionate percentage of medical students are opting for lucrative specialties instead of primary care. (The Affordable Care Act does give a 10 percent boost to Medicare payments for primary care and incentives to boost the number of primary care docs, though.)

But access to primary care is so important to preventing conditions before they become chronic and costly. If we’re going to lower health care costs overall, we need more primary care, not less.

The answer is for some of the responsibility of diagnosing and treating these “precision medicine” conditions to fall to non-doctors.

In some cases that could be a nurse practitioner at a retail clinic like MinuteClinic. In other cases, it could be the parent who uses a home health device to diagnose an ear infection, send the images to a doctor, and then pick up the prescription at a pharmacy. A device just like that called CellScope could be on the market next year.

Here’s a run-down of other promising technologies that could empower patients to take charge of their health:

  • Alivecor is one of the first of these devices to be approved by the FDA. It’s an “iPhone ECG” that sends data directly to your cardiologist.
  • ScanduScout, called a “real-life ‘Star Trek’ tricorder,” uses sensors, which after being placed on your forehead will take your vital signs, including your heart rate, respiratory rate, and blood pressure in 10 seconds.
  • My personal favorite is Opternative. (Especially if you read my last post.) They promise to develop the world’s first online eye exam for $20.

Doctors and the American Medical Association will fight these changes, no less. Not only will these technologies disrupt their business model, but they also hate the idea of relying on patient-gathered data. This is an understandable objection given our American tradition of litigation. But if the alternative is weeks and weeks of wait for a primary care visit, no care could be more harmful. Not to mention the fact that doctors make misdiagnoses all the time. Medical error is the third leading cause of death in America if you believe this study.

The irony is that many of these new technologies will be available in the developing world before they’re available here because there are fewer regulations and entrenched interests to contend with. Places like India acknowledge that they have a problem with health care access, which is something that some of our politicians are in denial about.

The FDA is going to have catch up with technology, doctors are going to have to practice letting go, the tort system is going to have to be reformed, and patients are going to step up if we’re going to solve this health care crisis.

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When it comes to health care, some politicians want us to believe that we can have it both ways — we can reduce health care costs and increase quality at the same time. They’re right about the fact that there’s an enormous amount of waste in our health care system (some estimate as high as 30 percent of our health care spending). But the idea that Americans are going to be able to avoid making some trade-offs in order to save our health care system is misleading, even dangerous.

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There are initiatives underfoot that could create the kind of wizardry that would lower costs while increasing quality, but frankly, the jury is still out on each of these:


Electronic health records — As part of the 2009 stimulus package, Congress allocated approximately $26 billion to help hospitals and clinics adopt electronic health records. The idea is that because our health system is so fragmented, patients don’t receive coordinated care. They receive unnecessary tests and procedures because doctors are talking to each other. The problem is that the health savings haven’t been realized yet.

ACOs — Obamacare set up nationwide pilot projects of Accountable Care Organizations. The organizations allow hospitals to serve Medicare patients through a payment and care delivery model tied to quality metrics and overall reductions in health care costs. Sounds great, but the questions is: “Does it significantly lower costs?” After the first year of the pilot program, one-third of hospitals will drop out because they didn’t realize cost savings. It’s expensive to keep two different types of accounting systems in one health system. And ACOs could push more hospitals to consolidate, allowing them to charge whatever they want.

New technology — Many new medical devices that hospitals use to sell themselves as cutting-edge barely improve quality and drive up costs. One example is the da Vinci robotic surgery system. It costs $1.5 million plus a $100,000/year service contract. Recent studies have shown that it’s not much better than laproscopic surgery and has even been implicated in a number of deaths on the surgery table. But because patients and doctors love the newest whiz-bang gadget, the product is in about one-fourth of all hospitals.

In order to fix this health care crisis, we are going to have to make some trade-offs. Many people, especially those who get their insurance through their employer, will have to pay more out of pocket. Though nobody likes to pay more, hopefully over time, this will lead us to make healthier life choices and spend smarter for our health care. And we’ll probably have to stick to a tighter network of providers. Doctors — especially specialists — will probably be paid less. Given the fact that doctors in the U.S. are paid more than almost in any other industrialized country, I think they’ll still be able to manage. Drug companies will probably less profitable. Given that they run among the highest profit margins of any industry in the world, they have room to lower prices and still be viable.

These are the new dynamics of health care in America. When the alternative is mortgaging our grandchildren’s future, I think the sacrifice is worth it.

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