Friday, December 02, 2011

The "non-two-tier" story saga continues

Thanks to Jack Sullivan over at CommonWealth Magazine, we now have an new chapter to add to the story of the referral of a patient by one hospital to its higher priced affiliate.  In particular, we get to add the insensitivity of the insurance company to that of the provider network.  We can now understand more fully the nature of the problem faced by this patient.

Remember the background.  A patient was told that he could not get his prostate surgery done quickly enough at the lower-priced hospital, but could get it done at the higher-priced one, by the same surgeon.  It was not until afterward that he realized that his two-tier insurance company would charge him more for the service.  He was never told it was the same health care provider system.

I am not surprised by the comment from the provider network, even though it is totally off-point, as the care received by the patient would have been exactly the same at either hospital:

[A] spokesman for Partners Healthcare dismissed questions about a potential conflict of interest and said all care decisions are based on the health of the patient.

But here's the reaction from the largest insurer in the state:

[Patients] have to wrestle with the fact it’s going to cost more money if they choose a higher-tier hospital.... The copays are designed to incent a thought process around quality and cost. Members still get a choice but it costs them more out-of-pocket. It costs the health care system less.

If a patient is not told that the choice is going to cost more money, shouldn't the integrated provider network refund the difference in the co-pay?  But, better yet, shouldn't someone have told the patient that there was a financial consequence in the decision being made?  But, even better, shouldn't the provider system have figured out how to deliver the service at the lower priced hospital?

Here's another unanswered question:  Do Faulkner and the Brigham receive the same technical fee for this surgery?  I am guessing not, in that they are in different tiers.  So, net of the higher copay, did Blue Cross still pay more for the surgery than it would have had it been at the Faulkner?  If so, does it care about that?


Anonymous said...

Mr. Copp from Partners and Mrs. Murray from BCBS seem to be missing the point on both conflict of interest and on 'choice', so I will have to make my comment on your previous post more explicit:

If, in fact, Faulkner systematically and consistently fills up its 16 OR's with routine cases so there is an unacceptably long waiting period for newly diagnosed cancers, then in actuality there IS no lower tier option for cancer patients in this network who need semi-urgent surgery. They will all be forced into the higher tier by virtue of OR availability.

Therefore, any representation that this is a functioning two-tier system for all insurees is, by appearances, fraudulent. There is a 'choice' in name only. BCBS becomes complicit in this situation by failing to ensure that the insurance product it markets as a two-tier system is, in fact, a two-tier system for all its insurees.

It would seem the Massachusetts insurance commissioner should review this situation to look for evidence of a pattern.

nonlocal MD

Barry Carol said...

Looking at it from afar, the insurance company couldn’t know which hospital was going to do the surgery until it receives the claim after the surgery is completed. The surgeon, like many doctors, probably doesn’t consider it part of his job to know or care about costs or co-pay differentials. Tiered network insurance plans are still a relatively small percentage of the commercial market for most insurers and less than 10% of BCBSMA’s business, I believe. Since this was a procedure that was scheduled in advance, there could have been more coordination between the surgeon, his billing manager and the patient. Presumably, there is a record somewhere within the surgeon’s practice of the patient’s insurance company and insurance plan – HMO, PPO, tiered network, etc. The hospital, for its part, probably didn’t know just what insurance the patient had until he arrived at the admitting office on the day of the procedure.

My take is that it’s the doctor’s decision that (1) surgery is required and (2) it’s important to do it sooner rather than later. If not the surgeon himself, someone in his practice should know and care about cost and be sensitive to the patient’s coinsurance exposure. The surgeon should also be prepared to explain exactly why waiting an extra two weeks to do the procedure at the less expensive hospital would be unwise and how much risk is there that the patient’s condition will worsen in that time. If time really was critical, as the Commonwealth article noted, the surgeon probably could have done more to get his patient on Faulkner's schedule sooner.

@dankennedy_nu said...

From Twitter:

Even if that patient had been told about the difference in cost, he really didn't have a choice, did he?

@dankennedy_nu said...

The whole idea of sick, scared people being told to go shopping for the best medical deal is ridiculous.

@DoctorBokhari said...

Straight forward deception technique on part of multiple pointless within the system.

Barry Carol said...

It could be that Partners accepts lower reimbursement rates at Faulkner than at the Brigham regardless of what insurance the patient has because its costs are structurally lower at the community hospital than at the AMC. As nonlocal notes, the patient may not have had a choice in this case even though Faulkner has 16 operating rooms unless the surgeon could use his influence to either squeeze him in or bump someone else needing an elective or non-urgent procedure. Presumably, true emergency cases could be done quickly at either hospital.

I also don’t think it’s too much to ask of patients that have a tiered network insurance product and to communicate that fact to any provider recommending a hospital based procedure either inpatient or outpatient. The same is true for expensive imaging. Non-hospital owned facilities are virtually certain to be much less expensive.

e-Patient Dave said...

This got way longer than I expected, because this turns out to be an excellent case in point. Lots to see here, lots to learn.

Hi, Dan Kennedy - it's terrific to see you here.

Re "the very idea of sick, scared patients being told to go shopping ... is ridiculous": Having been one of those patients five years ago, and having personally met a lot of them since, I can say that indeed many just want to be taken care of ("tell me what to do,") and many others of us ABSOLUTELY want to know what ALL THE OPTIONS are.

And in my opinion it's predatory for a provider to capitalize on the scared (intentionally or not) by making it hard to KNOW what all the options are.

This is one of the great advantages of an online patient community. When I was diagnosed as almost dead, and my primary (at Beth Israel Deaconess) offered me the URL, within two hours of my first post to that patient listserv I had learned of the best treatment option and even the names & numbers of docs who offer it.

One of those oncs was at the BID - I was smart to have become a patient there years earlier - but 3 out of 4 patients are never told that treatment exists.

Ability to withhold that information from people who need it, so they must decide (sick and scared) without information they would have wanted, is an indication of immense power and, intentionally or not, an abusive effect of that power.

Increasingly I see that breaking through the power of the medical establishment (which saved my life - I love its best parts) will be to put power (largely INFORMATION) in the hands of consumers. And not just at the moment where they're scared to death - do it as a matter of course.

Thus, withholding information about costs and options (even at other hospitals!!) is sinful, to me.

Yes, I mean it's sinful for one healthcare system not to tell a patient about other options that could benefit the patient.

For my disease (kidney cancer), I assert that it's sinful for a hospital that knows about high-dosage interleukin-2 to not tell a kidney cancer patient that it has a small but real chance of permanent response (the ONLY shot at a cure), and it's available down the road (or in another state), but not here. IL-2 is not for everyone (dangerous treatment that usually doesn't work), but I can't see any moral justification for not telling the patient the option exists.


Patient communities have no problem telling each other that. Most hospitals don't do it. Draw your own conclusions about whether hospital priorities are aligned with patient priorities.

And that means BIDMC, too. Any system. This isn't about any one system.

On a related note, scared people who know an informed peer often do turn to them, as well as their professionals, for advice. The patient is not necessarily the one to go shopping.

But I don't expect today's healthcare systems - which are massive big-finance operations - to solve this on their own. That's why I advocate for more, stronger, and smarter patient communities.

e-Patient Dave said...

B.S. BS to the system that did this (knowingly or not), and BS to Blue Cross for acting like they have nothing to do with this.

The patient family says: “We were told that we didn’t have time to wait. We didn’t think we had any other options.”

The health system says “We are seeing a health care environment that is evolving with different insurance products being introduced. Perhaps what is needed is a health care dialogue to better understand these products." Oh? Is it all about the insurance products now?? I'd say perhaps that hospital needs a "dialogue" to help patients better understand the treatment options!

We have truly gone into hell if what we need in this situation is a better understanding of the needs of the money system.

And on a different dimension, I thank Mr. Copp for the clearest example I've seen in print of paternalism: “All decisions are based on the health of the patient.”

So, Mr. Copp, who gets to know what all the options are, and who gets to decide what’s in my best interest?

Sorry, that’s a flat-out #fail, as they say on Twitter. That's old-school, and as the Foundation for Informed Medical Decision Making and the Dartmouth Institute have documented for decades, physicians tend to guess wrong about what their patients want.

This lack of transparency about costs and options will generate increasing screams of protest as more of us becomem self-pay – as I am, now that I’m on $10,000 deductible insurance. Give ME the options – all of them. Let ME decide. It’s my money and my body. The issue is NOT that we need to better understand insurance, it's that insurance and providers need to better understand us.

e-Patient Dave said...

One more item, replying to myself:

I said -

"Patient communities have no problem telling each other [all the options]. Most hospitals don't do it. Draw your own conclusions about whether hospital priorities are aligned with patient priorities."

I'll add: I'm really tired of insurance companies (including my own, the New Hampshire high-risk plan, NHHP) that say it's really one of their business to be involved in such decisions.

I recently had my four year follow-up scan at BIDMC. The insurance company sent me an insane "explanation" of benefits, which I scanned & posted on my blog. It listed 15 line items, and for every one of them the "procedure" was described as "Hospital." I called and asked what I was being charged for and the agent said they don't know and it doesn't matter: "We have to accept whatever the hospital sends us."

It seems increasingly clear to me, as a patient with an ordinary career in business, that rising costs are simply not a problem to some insurance companies, because they're cost-plus businesses: "Gosh, costs went up again. Nothing we can do about it."

I say, to both the hospitals and the insurers: you are both pricing yourselves out of our lives. I've already begun shopping around for a better deal on my next CT scan and associated lab work. And since the industry evidently doesn't know how to stop costing more, it's predictable that more and more of us will be leaving you - ESPECIALLY if none of you feel it's your responsibility to help us find the options we like best.

There are exceptions, of course - providers who do help, who are genuinely committed to improving quality AND reducing costs. I'm talking about the ones who say "Hey, there's nothing we can do about it" and "You just need to understand the insurance better."

Anonymous said...

I know very nice hospitals in Thailand and Brazil, and very successful pharmaceutical companies in India and Mexico. They are not so demur about quality metrics and pricing schedules. If I have only a few weeks to live, I'll be on a plane to the tropics tomorrow, rather than on the phone with my obstructionist insurance company (who could buy a developing country, by the way) or pacing cold grey Longwood Avenue in Boston for an answer to how much my care will cost, begging for full disclosure of the risks (rates of infection, performance data on providers) and benefits from doctors who make moral claims that they are not in the business of knowing the business of healthcare. It will probably take that long to get incomplete copies of my medical records!

Why would we expect candor from a system built to provide profit but not patient-centered honesty? No matter how high my deductible, there will be a breath-taking bill at my door because the provider and insurer negotiated a rate with everyone but me.

What American healthcare needs is a heavy dose of that competition we (say we) hold so dear.

Bring it on, southern hemisphere. A hammock and warm sunset would prove a lower stress backdrop for palliative care, too.

Sheila said...

There is so much corruption in insurance and I'm not the least bit surprised of this outcome in this case mentioned here. They should stop treating patients like second class citizens and tell it like it is. This patient getting the same care, same surgeon should not have been charged more for the exacts same procedure. What is this world coming to any way. The medical field is full of this kind of nonsense and it happens all the time. When will they learn to start treating patients the way in which they wish to be treated. Enough said.

Mike Langlois, LICSW said...

I'd like to expand this discussion to chronic care in addition to acute. And the example I'd like to raise is mental health, which often gets overlooked.

The fact that the patients I see who suffer from depression manage to make an appointment with me at all given common symptoms of hopelessness, fatigue, distractability and/or irritation is impressive. The idea that such patients have the fortitude, tenacity and optimism to "go shopping" as Dan Kennedy says is pretty ludicrous, if not downright sadistic.

e-Patient Dave said...

Agreed, Mike - I want to be clear that when I think about such issues, I include in my thinking everyone who might be assisting or advocating for the patient. It's a separate kind of cruelty, IMO, when patients of diminished capacity - whether for reasons of mental illness, stressed/scared, being a toddler or elder, or anything - don't have access to such support.