Health Access WeBlog

The latest Health Wonk Review highlights our comments about Rush Limbaugh’s short stay at a Hawaii hospital. His endorsement of its quality provided a moment to spotlight the success of the Aloha state’s thirty-year old health reforms, especially in the area of ensuring employer-based health coverage.

As policymakers consider the fate of health reform, it's worth considering what is the alternative that the opponents propose.

Let's start with Rush Limbaugh, from his his first day back on the radio, his response to such commentary.

He noted he is uninsured—by choice. And that he is concerned about the waste and barriers to coverage by insurance companies—and he may have been overcharged—all issues addressed in the health reform bills. Rush said:

I'm not gonna get health insurance. I'm not going to inflate my bill by 35%. This cost me 30% less than had insurance been involved here. There was not one bureaucrat determining whether or not I was gonna get treatment. There wasn't a death panel here.

He seems to be referring that a lot of insurance premium dollars go to costs beyond patient care. That’s why the health reform bills set minimum medical loss ratios—the industry’s term for the money that is “lost” to care, rather than administration, marketing, and profit.

He also seems concerned about insurance bureaucrats denying care. The health reforms also include independent medical review—a component of a patient’s bill of rights package that has been passed in many states but stalled at the national level until now—so that if an insurer does deny coverage for medically necessary care, patients have the ability to get a third party to review, and possibly overturn, the decision.

His solution to insurance industry abuses is to not get insurance. As a multi-millionaire, Limbaugh had the ability to pay, as he said, just using a credit card.

But for the rest of us, health coverage is not just a good idea, it is essential. It's not an option to be on the hook for thousands (or possibly tens or hundreds of thousands of dollars) if we get sick.

How much did he pay for his short stay? He indicates it’s around the price of a car.

In the first place, you don't need to make $33 million a year or $50 million to afford what happened. I'll put it to you this way. My expenses were less than the cheapest car that you will go out and buy today other than one of these little bubble smart cars. It was five figures less than the average car. Yet for some reason it's immoral for people to have to pay for that. I don't have insurance. "I'm sure he has insurance." No. I pay cash for it and it was less than the price of a car. And just as is the case with a car you could finance your health care coverage. You don't have to come up with the whole lump sum, hospitals, doctors, work with you on this.

As someone who is uninsured, self-pay patient, Limbaugh probably gets charged on average of three times what insurers and public programs pay, for exactly the same service.

That’s because hospitals have a “chargemaster,” or sticker price, for their services that are inflated well beyond the actual cost of providing care. Insurers and public programs, with their market power, have the ability to negotiate the rate down. The uninsured, without that bargaining power, are stuck with the inflated rate.

The cruel irony of our health care system is those with the least are charged the most. In California, the average hospital charge is four times what most insurers pay. I’ve worked with patients who a 3-hour visit to the ER cost $12K; a one-night stay for an appendectomy cost $26K; and people who have racked up six figures in debt. These are the kinds of numbers that force regular middle-income people—however responsible they are—into collections and bankruptcy.

There have been class-action lawsuits about these unfair billing practices, and California and a few other states now cap how much hospitals can charge uninsured within certain incomes. (We have a website, www.hospitalbillhelp.org, to help Californians struggling with high hospital bills.) The Senate health reform places some oversight over hospital pricing policies, which has been a longtime interest of Senator Grassley.

But the ultimate way to prevent this practice of overcharging is to get people into group coverage, where they have the purchasing power to negotiate the best rate. Coverage provides a way for people to share in the risk and cost of health care: even if you are healthy today, you have financial security when (not if) those chest pains, or another ailment, comes upon you, you don’t have the additional shock of a huge bill. And that’s the heart of health reform.

So Rush’s alternative to health reform seems radical: he's not just against health insurance reform, but against health insurance. For most people who can’t absorb a five or six-figure trip to the hospital, that’s a prescription for financial ruin—or worse.

A lot of people say, "Rush, you're really running a risk here of sounding out of touch when you talk about how you can pay for this.”

Yep. Before we agree with those opposing health reform, we should understand what their proposal is.

Labels: Hospitals, Insurers, YearOfReform

posted by Anthony Wright | Permalink | 7:45 PM

As we have written previously, the manager's amendment to the Senate bill that was adopted earlier today makes a number of changes to the Senate bill.

Our California Senator Barbara Boxer, as well as Senator Dianne Feinstein, won a significant improvement for California as well as six or seven other states, including Idaho, North Carolina and Michigan.

It is easy to figure out that Nebraska (and Hawaii) got something in the Medicaid provisions because those two states are mentioned by name.

We guessed that California met the following: "If the State is not a low DSH State described in (5) (B) and has spent more than 99.90 percent of the DSH allotments for the State on average for the period of fiscal years 2004 through 2008, as of September 30, 2009, the applicable percentage is 35 percent."

What is that and why do we care? DSH or Disproportionate Share Hospital funding is a key part of Medicaid funding for hospitals. In some states, DSH helps to make up for low Medicaid reimbursement rates. In other states, including California, DSH helps to cover the cost of care by hospitals for the uninsured as well as improving low Medicaid rates.

DSH is a big deal in California both because we are 51st in Medicaid reimbursement and because we have such a high proportion of uninsured.

So what did our Senators win for us? The earlier version of the Senate bill cut DSH funding in half once the rate of uninsurance drops. The new version would cut DSH funding by only 35%.

This moves the Senate bill much closer to the House version in terms of the DSH cut, at least for California, Idaho, North Carolina, Michigan and several other states.

Labels: Hospitals, Legislation, MediCal, YearOfReform

posted by Beth Capell | Permalink | 8:04 AM

This story’s a shocker – a sad, tragic shocker. Again, it’s from the Central Valley. Again, the money-maker in our health care system comes across as the bad guy.

The Sacramento Bee’s Sam Stanton reports on a heinous billing mistake that sent the parents of a deceased 23-year-old Sacramento college student into a devastating emotional tailspin. You’ll have to read it to believe it.

Less than two weeks after their son was brutally beaten to death in his dorm room, the bill from UC Davis Medical Center arrived. Addressed “Dear Patient,” it was the sort of “Dear John” letter the hospital sends to indigent patients who go to the emergency room because they don’t have insurance.

Trouble is, the family had insurance – and had just lost their son.

When you read the story you’ll be horrified at the letter’s clinical, uncaring language – not to mention its message.

The dollar-amount of the bill raises questions as well. For a 5-minute (unsuccessful) attempt at resuscitating the young man, UCDavis charged $29,186.50.

Even if this was a mistake, patients get horrendously huge hospital bills every day in California. There were some protections that were put in place in 2006, that are detailed at our newest website, www.HospitalBillHelp.org, that provides some step-by-step assistance to families in this predicament.

But the story makes you wonder about our health system in general. And when you think about what the UCDavis medical system represents – that it’s really part of California’s public universities – questions about accessibility, accountability and morals arise, too.

We need health reforms where families don't face such financial pain, especially at the same time that they are going through such stress and grief that led them to the hospital in the first place.

Labels: Affordability, Hospitals, YearOfReform

posted by Cynthia Craft | Permalink | 9:17 PM

In the last hours of the legislative session, literally between 5:30AM and 6AM Saturday September 12, the California Legislature passed AB1383 by Assemblyman Dave Jones which will create a hospital provider fee that will be used to fund children’s coverage and to improve Medi-Cal reimbursement to hospitals (now 51st in the nation). It passed the Senate 24-5 and the Assembly 52-22 as a fee measure. In the Senate, the vote was party-line, in the Assembly a few Republicans voted in support.

Because the Senate Republicans were blockading all two-thirds vote measures on the last day of the legislative session over un-related budget matters, the bill has been amended to eliminate the urgency clause and to go into effect January 1, 2010 so that it no longer required a two-thirds vote. The amendment also eliminated the appropriation that would have funded the work of the Department of Health Care Services in implementing the measure.

The amendments also included some seemingly minor tweaks to the formula or model that were needed to bring it into compliance with federal requirements for the provider fee.

At this moment, we do not know whether the elimination of the urgency clause means half-year money for the fiscal year 2009-10 or full-year money. Provider fees take months to implement in any case.

Whether it is six months worth of better funding for hospitals and children’s coverage or a full year, Health Access is supportive of the measure.

More importantly, we do not know how the Schwarzenegger Administration will respond to the revised measure. So there is work to do to persuade the Governor to sign the bill.

Labels: Hospitals, Legislation, SCHIPHealthyFamilies

posted by Beth Capell | Permalink | 9:54 AM

With California's large and growing uninsured & underinsured population, we at Health Access are really pleased to unveil a new website--http://www.HospitalBillHelp.org--to help California patients know their consumer rights and financial options to deal with the biggest bill they get in their entire life. Here's the release that announces the new resource:

New Consumer Protection Website
Informs Consumers against Underinsurance and Overcharging
By Hospitals and Health Providers

HospitalBillHelp.org provides help for growing number of uninsured and underinsured in CA;
informs consumers about their rights and financial options, including under new, first-in-nation fair pricing law

On Wednesday August 12th leading consumer protection groups in California announced the launch of HospitalBillHelp.org, a new consumer information website that helps patients deal with hospital and other medical bills, including inflated charges, “junk” insurance, and aggressive collections practices. The new site is part of a collaborative effort called the California Health Initiative on Overcharging and Underinsurance (IOU), led by Health Access and including Consumers Union, Western Center on Law and Poverty, ACORN, CALPIRG, Congress of California Seniors, and other consumer and community groups.

Visitors to HospitalBillHelp.org will find many resources informing them about their consumer rights and financial options in dealing with hospital, including under California’s first-in-the-nation Hospital Fair Pricing Act, a 2006 law authored by Assemblywoman Wilma Chan and sponsored by Health Access California, which limits the common practice of charging uninsured and underinsured patients more for care than everybody else pays.

Typically, hospitals and doctors overcharge self-pay patients three to four times what insurance companies and government programs pay for exactly the same procedures. The Hospital Fair Pricing Act, effective since January 2007, limits the amount that most uninsured and underinsured patients have to pay to the amount that a public insurer would pay for the same care. In most cases, this will be the Medicare price, which is 65-85% less than the inflated price. The Hospital Fair Pricing Act also requires hospitals to adequately inform patients about their charity care and discount policies.

However, despite clear rules outlined in the Hospital Fair Pricing Act, many California hospitals are still failing to inform uninsured and underinsured patients about their right to a fair price.

"In our current health system, self-pay patients lack bargaining power, and are asked to pay more than anybody else for needed care. HospitalBillHelp.org is a new and unique one-stop shop for the nearly 10 million Californians who are either uninsured or underinsured. HospitalBillHelp.org lets Californians know what their consumer rights and financial options are, so that individual patients get what insurers already get: a fair price for hospital care, " said Anthony Wright, Executive Director of Health Access. "If you have a large hospital bill and need help paying it, or if you need hospital care and can't afford it, this website can help you."

Medical debt is a growing problem for low- and middle-income consumers, especially those who are self employed or between jobs. Some go without health coverage and others purchase “junk” or “catastrophic” insurance plans with extreme gaps in coverage. Both scenarios put consumers at tremendous risk of overwhelming medical debt or delay receiving treatment when needed.

The case of Laura Burwell of Chico, CA is demonstrative of the way in which deceptive “junk” insurance policies and the failure of hospitals to inform patients of their options can have traumatic consequences. Laura thought she was buying comprehensive coverage when she purchased health insurance with a $281 monthly premium, a $500 deductible and $50,000 in hospital coverage. She didn't realize that her hospital coverage was capped at $3,000 a day, until a rattlesnake bite landed her in the Intensive Care Unit and with a $73,000 hospital bill.

"There I was thinking I was covered for $50,000," Burwell said, “but my insurance only paid $3,000 and then I was responsible for the rest.”

Fortunately for Laura, she was protected by California ’s Hospital Fair Pricing Act, which prohibits hospitals from charging underinsured and uninsured patients more than Medicare would pay for the same care. In her case, that meant her final bill was reduced to $7,300, one-tenth the original bill. Laura hopes HospitalBillHelp.org will help other consumers faced with high hospital bills.

"The hospital never told me I was entitled to a discount. I had to do a lot of research on my own before I even found out about the Fair Pricing Act. This new website is going to make it a lot easier for Californians to get a fair price for hospital care,” she said.

The site also provides a wide variety of tools, features, resources and information to help consumers better understand their legal rights and financial options, including links to public health insurance options and applications, information on how to get discounted health care and even an Underinsurance Calculator to figure out whether you count as underinsured under any of the definitions commonly used.

“In May 2009, Consumer Reports published an article describing seven signs that a health insurance plan might be ‘junk’ insurance. Consumers can use HospitalBillHelp.org and use the site’s resources to discover loopholes in their own insurance plans, or as a helpful guide when purchasing new plans,” said Laurie Sobel, senior attorney with Consumers Union. “The site provides important information to help consumers make informed decisions when purchasing health insurance and steps to take to ensure that hospitals recognize their rights as stipulated under California ’s fair pricing law.”

When visiting HospitalBillHelp.org consumers can also research ways to get a discount on an existing bill, who to call for help and instructions on what to do when a hospital doesn’t follow the law. Furthermore, the site features a directory to help patients locate the closest and most affordable hospitals where they may be eligible for discounted care, regardless of their income.

"Western Center has long advocated for the needs of low-income uninsured people who are saddled with unaffordable hospital bills,” said Jen Flory, attorney with the Western Center on Law & Poverty. “We're pleased to have a website that breaks down into plain English the complex programs that are available to help and provide information to those who might qualify."

Other useful resources available on the site include information and steps on troubleshooting other common hospital and insurance billing problems, such as getting an independent medical review if an insurance company denies an individual coverage, and finding information on the prohibition against balance billing of HMO patients for out of network Emergency Room visits.

While the site serves as an important resource for consumers, including providing steps and information on how Californians can take advantage of our state's strong consumer protection laws, the major problems in our health care system require broad federal health reform, like that proposed in H.R.3200, and further steps to ensure that self-paying patients and consumers are sufficiently protected against overcharging by health providers, like AB1503(Lieu), and inadequate private health insurance policies, like AB786(Jones).

"Whether it is overcharging, underinsurance, or care that is just plain unaffordable, the need for health reform is urgent. This website helps inform consumers about their rights and options, but they are limited. If anything, our work on HospitalBillHelp.org only reaffirmed our urgency for comprehensive health reform, like that which President Obama has proposed." said Anthony Wright of Health Access California. "And California can continue to take the lead with specific reforms pending in the state legislature, by passing AB1503(Lieu) to prevent overcharging by emergency room doctors, and AB786(Jones) to prevent people being trapped in plans that leave them with unlimited financial risk."

Labels: Hospitals, Legislation, Underinsurance

posted by Anthony Wright | Permalink | 1:50 PM

Today the Board of Equalization acted, on a 3-2 vote, to require that non-profit hospitals report to it in July and September of this year about whether those hospitals are complying with the basic requirements of California law with respect to non-profit tax status as well as AB774, on hospital overcharging. The Board expect to put out a report in February of next year (2010).

The hospitals opposed this and attempted to delay the vote until another year, another decade, maybe another century.

However, Board Members Betty Yee, who proposed the motion, former Assemblymember Judy Chu, and Controller John Chiang prevailed. While the motion to conduct a stakeholder process passed a few months ago 5-0, this time Board Members Bill Leonard and Michelle Steel both voted no. Although the Board of Equalization is technically non-partisan, the vote was along party lines.

Under California law, including a decades-old court case named Rideout, after a hospital of that name, nonprofit hospitals are generally expected to have revenues in excess of expenditures of less than 10% (otherwise known as profits). However, non-profit hospitals may accrue greater “surplus” revenues if they use those “surplus” revenues for debt retirement, facility expansion or reserve for operating contingencies.

For those of you who are not tax geeks, here is an example: a few years ago Sutter Tracy had revenues in excess of expenditures of 24%. Pretty healthy return for a “non-profit”. It is this sort of thing that made the BOE think perhaps they should take a look and request information about what “non-profit” hospitals were spending their surplus revenues on.

The information request also requires hospitals to provide their charity care and discount payment policies as well as the number of liens and amount collected from liens. They are also looking at joint ventures and executive compensation and for personal inurement, since there is some lingering notion that those who are in charge of non-profits should not be among the wealthiest in our society.

The BOE also asked for corporate organization charts: we have seen a few of these over the years: we call them octopus charts because of how convoluted they are. All too often, remarkably enough, the land-use intensive, less profitable elements of the health system are held by the non-profit while the lucrative elements are held by for-profit affiliates or subsidiaries. Again, this is the sort of thing that has piqued the interest not only of the Board of Equalization but also of the U.S. Senate Finance Committee where under current chair Max Baucus (D-Montana) and former chair Chuck Grassley (R-Iowa) the committee has pressed the Internal Revenue Service to revise the reporting requirements for non-profit hospitals.

None of the data that the Board of Equalization required for its efforts is available from any other source: all of the financial reporting that is done to the Office of Statewide Health Planning and Development (OSHPD) is done on a facility basis while the BOE looks at taxable units. A hospital system can have 20 or 30 hospitals but it may have only two or three taxable units depending on its corporate structure (hence the need for the corporate organization chart).

In the relatively near future, we will have better information on whether “non-profit” hospitals are really non-profits—or whether they are behaving more like their for-profit counterparts.

If you want to look at the questionnaire, it is at http://www.boe.ca.gov/meetings/pdf/Item_P3b1_Nonprofit_Hospitals_041509.pdf

Labels: Hospitals

posted by Beth Capell | Permalink | 7:45 PM

In California, about 10% of hospitals are for-profit while over two-thirds are non-profit entities.

Non-profit hospitals, like other non-profits, pay no property tax and no corporate income and they even get a special deal on unemployment insurance taxes. For-profit, private hospitals pay property taxes, corporate income taxes, unemployment insurance taxes, the Employment Training Tax and other taxes just like any other business. Yet, in the words of Bill Leonard, a conservative Republican member of the Board of Equalization, “when I drive past a hospital, I can’t tell the difference” between a non-profit hospital and a for-profit hospital.

Last week the Board of Equalization met and considered a proposal by Board Member Betty Yee to obtain information from non-profit hospitals regarding what in tax lingo is called the “welfare exemption”, meaning their non-profit tax status. Ms. Yee has been working on this for some time: last year she proposed requiring non-profit hospitals to spend 5% of revenue on charity care in return for their non-profit tax status. That proposal was not favorably received by the Board. Last week, Ms. Yee had a better day.

The California Hospital Association challenged the authority of the Board to collect the desired information and CHA also said that some of the information was duplicative and some information was impossible to provide.

The attorney for the Board and all five members of the Board of Equalization, including the representative of State Controller John Chiang, were unequivocal in asserting their right to collect the information they deemed necessary in order to determine whether any entity, including a hospital, could be a non-profit in the eyes of the State of California.

The Board decided to embark on a stakeholder process to refine the proposal to collect the information.

The information desired by Ms. Yee (available online at www.boe.ca.gov) includes such basic information as how much charity care hospitals provide as well as whether liens on primary residences are levied on consumers.

In addition, Ms. Yee wanted to know whether non-profit hospitals had revenues in excess of expenditures (otherwise known as profits) of more than 10% and if so, what the hospitals spent the money on. There is existing case law in California (the Rideout case) that allows hospitals to have excess profits and still be non-profit so long as they put the money back into the hospital, rather than taking it out in profits.

We know that when Senators Baucus (D-Montana) and Grassley (R-Iowa) investigated hospitals, a bipartisan effort that has spanned the change in control of the US Senate, they were dismayed to discover excessive CEO compensation, overcharging of the uninsured, and various other bad behavior by hospitals benefitting from not paying taxes.

Given the bipartisan support in Congress for efforts that have resulted in the IRS revising the reporting for non-profit hospitals, perhaps we should not have been surprised that the California Board of Equalization voted unanimously on a bipartisan vote to support the concept of collecting the information by May 2009. But I certainly was. Bill Leonard said plainly that if a non-profit hospital is acting like a for-profit, it should lose its non-profit tax status.

For those of you who are wondering what in the blazes the Board of Equalization is, you should know that you have the opportunity to elect its members every four years. Among those who currently serve on the Board of Equalization is Judy Chu, former Chair of Assembly Appropriations, as well as Betty Yee, State Controller John Chiang, Bill Leonard, and Michelle Steel (verify). The Board of Equalization is a key tax agency responsible for determining the equity of taxes across counties as well as whether entities are worthy of non-profit tax status. Its hearing room was as crowded as any legislative hearing for that reason.

Labels: Hospitals, MedicalDebt

posted by Beth Capell | Permalink | 8:23 PM

As a Yankees fan from the Bronx, it's weird to see the Tampa Bay Rays in the World Series, with the second-lowest payroll in baseball, especially given the enormous mismatch between the money the teams spend.

In health care, there's also a mismatch between how much we spend, and the results.

Californian Billy Beane, the general manager of the Oakland As, co-authored an op-ed today in the New York Times on this subject, with the improbable duo of Newt Gingrich and John Kerry. Beane invokes the excellent book MoneyBall, which shows the power of statistics to make tough decisions, when they write:

Remarkably, a doctor today can get more data on the starting third baseman
on his fantasy baseball team than on the effectiveness of life-and-death medical
procedures. Studies have shown that most health care is not based on clinical
studies of what works best and what does not — be it a test, treatment, drug or
technology.

This is why we have fought so hard for better transparency, like in last session's AB2967(Lieber), so we have better data on the cost and quality of the care provided by California doctors and hospitals.

Let's be clear: some insurers inappropriately use "evidence-based" arguments to deny needed care and treatments (some treatments haven't had full study, but still work); some policymakers use the lack of correlation between costs and outcomes as an excuse to cut, not recognizing the significant consequences (after all, the As or Rays in the Series is the exception, not the rule.)

But there should be no debate that we need much better information about the care we receive, and that we pay for. We'll be back on this issue next season.

Labels: CostContainment, Hospitals, Quality, Transparency

posted by Anthony Wright | Permalink | 8:35 AM

Some of the first signature on health bills were made today, on the vital issue of hospital infections... We wrote about them when the Consumers Union RV came to town (unfortunately, the other bills mentioned in that post stalled in the Legislature)...

The Governor signed:

SB 1058 by Senator Elaine Alquist (D-San Jose) establishes the Medical Facility Infection Control and Prevention Act or “Nile’s Law,” which requires hospitals to develop more comprehensive policies and procedures to improve and ensure effective infection control practices. It also requires the Department of Public Health to establish a health care acquired infection program that will receive reports from hospitals on specified hospital-acquired infection rates. In addition, hospitals would be required to screen certain high-risk patients for Methicillin-Resistant Staphylococcus Aureus (MRSA) and to provide instructions regarding aftercare and precautions to prevent the spread of the infection to others.

SB 158 by Senator Dean Florez (D-Shafter) expands upon the current responsibilities of the existing California Department of Public Health’s (CDPH) Healthcare Associated Infections Advisory Committee. The bill requires hospitals and skilled nursing facilities to establish plans to improve patient safety. This bill also contains detailed training requirements for hospital infection control committee chairs, clinicians, and all licensed and non-licensed hospital staff.

The Center for Disease Control (CDC) estimates that every year two million patients contract a hospital acquired infection while being treated for something else, and almost 100,000 die every year from these infections.

Labels: Hospitals, Quality

posted by Anthony Wright | Permalink | 11:11 PM

Consumer Reports Health’s Cover America Tour, a nationwide road trip chronicling the difficulties many American families face getting affordable, high quality health care, rolled into Sacramento Tuesday, with a message around state and federal reform.

Consumers Union staff, including former Health Access staffer Meg Bohne (pictured), had driven an RV over 12,000 miles before coming to Sacramento, talking with health care consumers and videotaping their stories with the health care system. Among their stops on the way back to the East Coast will be Denver and Minneapolis, as they make the case to elected leaders of all parties and political stripes of the need for health care reform next year.

But the RV stop in Sacramento also focused on what we in California can do--not just next year, but in the next few days and weeks.

Health care reform may have stalled earlier this year, but there are pending bills in the California legislature that can help our state move down the road to reform, that can help Californians have more confidence in the quality of their care and their coverage.

Those bills include:

* HOSPITAL INFECTIONS: SB 1058 (Alquist) and SB 158 (Florez), geared to reducing hospital acquired infections. SB 1058 would mandate public disclosure of hospital acquired infection rates, and require hospitals to screen high risk patients to identify those colonized with methicillin-resistant Staphylococcus aureus (MRSA) bacteria, and to take special precautions with those who test positive to prevent its spread to other patients. SB 158 gives the Department of Health Services additional authority to investigate infection outbreaks and complaints about lax infection control practices. The Department of Health Services estimates that as many as 9,600 Californians die from hospital infections annually, and it is esimated that hospital infections add a staggering $3 billion to California’s health care bill every year.

Speaking at the press conference was Cindy Gaston of Elverta (pictured speaking), who developed a serious MRSA infection following the C-section delivery of her child. She had to be rushed back to the hospital a few days after giving birth when her surgical incision burst open and it became clear that she was very sick. She required multiple surgeries to clean out the infection and ended up staying another ten days in the hospital while undergoing IV antibiotic treatments. Cindy was surprised by the sometimes poor infection control practices she observed at the hospital and how little information she was provided about how to prevent the spread of her infection to others. She has had three outbreaks of her antibiotic-resistant infection since she was discharged from the hospital and hopes that she won’t become sick again.

* TRANSPARENCY: AB 2967 (Lieber) would require public reporting of information about the cost and quality of care delivered by health care providers in the state. It would establish the Health Care Cost and Quality Transparency Committee to develop a plan for making cost and quality data available to the public. The goal is to provide the public and purchasers with data to seek more cost effective care that improves patient outcomes and to enable hospitals and other care providers to compare themselves with their peers and identify areas where improvement is needed.

* HEALTH INSURANCE STANDARDS: SB 1522 (Steinberg) would set standards to help consumers compare health insurance products and weed out “junk” insurance plans.

Under existing California law, health insurers can sell products characterized as health insurance that cover only hospitals or only physicians. Health insurers can sell products that have no maximum out of pocket cap, exposing consumers to hundreds of thousands of dollars in out of pocket costs in the case of catastrophic illness. Insurers can sell health insurance that covers only a small fraction of the actual cost of care.

SB 1522 would help eliminate “junk” insurance by requiring health insurance to cover doctors, hospitals, preventive care, and any existing statutory mandates, and to have a cap on out-of-pocket expenses. The bill also requires the Department of Insurance and the Department of Managed Care to create five coverage categories that would help organize the insurance market so that consumers can shop more knowledgably. Insurers would be required to offer benchmark plans to assist with apples to apples comparisons.

Senator Elaine Alquist (pictured above and left), who is on the Senate Health Committee, also spoke on her hospital infection bill, as well as the need for health care reform in general.

In an "MTV:Cribs" moment (see picture left), the Senator also toured the RV, as did Daniel Zingale and Richard Figueroa, who both work in the Governor's office and advice the him on health policy, and who came by to watch the press conference.

These bills are up for final floor votes in the California Legislature in the next week and a half. If they pass that final legislative hurdle, then their fate will be in Governor Schwarzenegger's hands, where he can sign the bills, help consumers and help lay a better foundation for health reform--or just leave us with the deteriorating status quo in California.

More information about the Cover America Tour can be found at: http://www.coveramericatour.org/.

Labels: Federal, Hospitals, Insurers, Legislation, SCHIPHealthyFamilies, YearOfReform

posted by Anthony Wright | Permalink | 11:39 AM

Jordan Rau at the Los Angeles Times has an important article (with lots of links to primary source documents!) on the key issue of "never events"--those things that should never, ever happen when you get care.

It's a list that includes getting severe ulcers from bedsores, having equipment left in a person during surgery, undergoing the wrong surgery or having the wrong limb amputated, or being given the wrong medication or wrong dosage. Unlike other parts of the art of medicine, these are problems that are preventable if the systems are in place.

The number of these adverse events reported is over 1,000 in a 10-month period. It's a wake-up call--Many in the health care community would not have predicted such a large number. These medical errors are serious--in some cases, deadly serious. By definition, these are "never" events--not "sometimes OK" events.

The article highlights AB2146 (Feuer), an important bill supported by many consumer groups like Health Access California, AARP, CALPIRG, Consumers Union, as well as business and labor organizations. It would have California follow the federal government in not paying for these adverse events, as part of a shift to change the financial incentives in this category.

I would also add AB2967 (Lieber), which would add more transparency to the cost and quality of the care being provided in California. This information is valuable in its own right, and will have a impact in getting hospitals to prevent these errors, which will improve health outcomes, and save money too. Information shouldn't be the only tool, but it should be part of more aggressive oversight.

Read the article. It's worth your time.

Labels: Hospitals, InTheNews, Legislation, Prevention, Research

posted by Anthony Wright | Permalink | 1:32 AM

HEALTH ACCESS UPDATE
Thursday, June 25th, 2008

HEALTH BILLS LIVE AND DIE BY THE COMMITTEE
* Health legislation heard in final policy committees before July break
* Bills pass to require 85% of premium to go to patient care; regulate recissions; foster a public insurer; discourage "never events," encourage hospital community benefits.

Click Here for What's New on the Health Access WeBlog: Continued Real-Time Budget Conference Committee Reports; The Perils of "Junk" Insurance; Gender Discrimination in the Individual Insurance Market; The Mortgage Metaphor for SB1522; Improving Medicare with a Phone Call.

With tomorrow's deadline for legislation to have cleared policy committees in the second house, lawmakers heard a battery of bills this past week. Key pieces of legislation of interest to health advocates were also on the agenda. Many of the bills advocates have been tracking passed.

Following is a list of the bills heard this week and the outcome. Additionally, advocates may visit the Health Access website, at http://www.health-access.org/advocating/2008_bills.html for a complete list of bills.

The following bills passed in Assembly Health Committee, chaired by Assemblyman Mervyn Dymally, on Tuesday:

* SB 1198 (Kuehl): DURABLE MEDICAL EQUIPMENT: Would require group health plans and insurers to offer coverage for durable medical equipment, such as wheelchairs and shower seats. Support
* SB 1440 (Kuehl): CAPPING ADMINISTRATION AND PROFIT: Would set a minimum medical loss ratio – requiring every insurer to spend at least 85 percent of premiums on patient care. Would also require plans to report how much they spend on health care versus administration on each single product they offer. Support
* SB 973 (Simitian) PUBLIC INSURER: Would create a statewide public insurer, connecting existing regional, county-based health care plans, to compete with private health care plans and provide consumers more affordable coverage choices.
* SB 1300 (Corbett): CONFIDENTIALITY CLAUSES: Would prohibit confidentiality clauses, which keep secret information on pricing and health care quality from consumers, in contracts between providers and insurers. Support
* AB 1351 (Corbett): DISTRICT HOSPITAL OVERSIGHT: Would require Attorney General oversight into transactions involving district hospitals. Support

The following bills passed in Senate Health Committee, chaired by Senator Sheila Kuehl, on Wednesday:
* AB 2146 (Feuer): ‘NEVER EVENTS’: Bans providers from billing patients or insurers when they have made an avoidable mistake, such as operating on the wrong person, prescribing the wrong drugs, or leaving foreign objects inside a surgery patient. Support
* AB 2549 (Hayashi) RECISSION TIME LIMIT: Would impose an 18-month time limit in which insurers have to rescind individual health care policies once consumers’ applications are approved. This bill was amended from previous versions, which limited the time frame for rescission to the first six months. Watch, seeking shorter time limit.
* AB 2569 (De Leon) RESCISSION AND BROKER ACCOUNTABILITY: Ensures that family members whose coverage depends on that of the rescinded person may be offered another individual policy. Also requires brokers who take applications to attest, under penalty of perjury, that the information is complete and accurate to the best of their knowledge. Support.
* AB 2697 (Huffman) BOUTIQUE HOSPITALS: Would require so-called “boutique hospitals’’ to asses their impact on a community’s health system annually, specifically whether they siphon doctors, workers, providers from general acute hospitals caring for less affluent populations. Support
* AB 2942 (Ma) COMMUNITY BENEFITS: Would standardize what non-profit hospitals report as “community benefits” to justify their non-profit status. Support

The Legislature will now take a break from committees while budget negotiations are expected to continue throughout July. Both houses will resume committees on August 4. These bills will need to pass fiscal committees by August 15th and the final floor votes by August 31. If they pass through the Legislature, the Governor will have the month of September to decide to sign or veto the bills.

Health Access will continue to track the progress of this legislation in the coming months. For information, please contact the author of this report Hanh Kim Quach at hquach@health-access.org.

Labels: Hospitals, Insurers, Legislation, Updates

posted by Anthony Wright | Permalink | 1:28 AM

If you want to know more about the financial consequences of being uninsured, read yesterday's Wall Street Journal article by Sara Rubenstein.

In a move that consumer groups say could increase pressure on people with unpaid medical bills, some hospitals are trying out a new tactic to recoup patients' debts: They're auctioning the debt online.

Hospitals have long relied on outside collection agencies to go after debtors. Under traditional arrangements, these agencies receive a percentage of any money they get from a debtor; the more they collect, the more they earn.

Now, some of the same collection agencies, as well as other firms that purchase debt outright, have begun participating as bidders in online auctions, in which they buy the debt or provide guaranteed payments to hospitals for access to the unpaid accounts. Some experts say this gives them more reason to aggressively pursue patients in arrears. Auctions can drive up the amount paid for debt, meaning a collector must recoup more money from patients to cover its initial investment and turn a profit. And the winning bidders often get to keep all the money they collect on the auctioned debt.

Health Access California has talked to lots of Californians with medical debt, as we worked to pass AB774(Chan), to prevent hospitals from overcharging the uninsured. Invariably, the experience of these patients in dealing with the bill was worse after the bill was referred to collections, and much worse after the debt was sold. That's why AB774 included a moratorium on patients being sent to collections. There are other existing consumer protections against aggressive collections practices, but is it enough?

Winning bidders may "have to work harder" to make a profit from auctioned debt, says Michael Klozotsky, an analyst at Kaulkin Ginsberg Co., a collections-industry strategic-advice company. "Working harder means sometimes using strategies that are more aggressive.

"Many of the auctions of hospital debt have been done through Web site ARxChange.com1 -- shorthand for "accounts receivable exchange" -- owned by TriCap Technology Group. Another site is medipent.com2, run by Medipent LLC. The auction-site owners, both small companies based in New York, say their systems create safeguards that protect patients from potential abuse. Collection firms are vetted for their tactics and approach to patient needs and concerns before they are allowed to participate in auctions, the site owners say. The site owners also try to ensure that collectors comply with hospital rules -- whether they must record phone calls, for instance, or get the hospital's permission before initiating a lawsuit against a patient. Hospitals have final say over who bids on their accounts, and, on ARxChange.com, don't necessarily award the contract to the highest bidder.

Consumer advocates say patients are less likely to successfully dispute bills or negotiate them downward if they are dealing with a third-party collector rather than a hospital directly. Collectors also are further removed from hospitals' financial-assistance policies."The hospital is an institution in the community, has a reputation, in many cases has a nonprofit mission to uphold," says Anthony Wright, executive director of the consumer-advocacy coalition Health Access California. "Once it goes to collections, that starts a process that can get a lot more antagonistic, a lot more aggressive, and a lot more damaging to a family's credit history and financial future."
The federal Fair Debt Collection Practices Act and some state laws govern how debt collectors can treat consumers. For instance, debt collectors aren't allowed to harass consumers or make false statements, including implying they will sue if they don't intend to do so. Consumer groups say calling the medical provider or your insurer could help clarify any confusion about what you owe. The hospital also could provide information about financial assistance or charity-care.

A hospital bill is typically the biggest bill a person gets in their entire life. The first goal is to prevent these situations from happening in the first place: to make sure people are covered, or have other financial options that can help pay the bill. But in any case, patients with medical debt should have basic consumer protections. We don't want people to not go to the hospital for fear of the bill, or those who come to collect it.

Labels: Hospitals, InTheNews, MedicalDebt

posted by Anthony Wright | Permalink | 10:59 AM

HEALTH ACCESS UPDATE
Tuesday, May 27th, 2008

KEY HEALTH BILLS PASS FLOOR VOTES IN CALIFORNIA LEGISLATURE
* Senate Passes SB1522 (Steinberg), Standardizing Insurance & Prohibiting "Junk" Coverage
* Assembly Passes AB2967 (Lieber), Providing Transparency on Cost and Quality of Care
* Also: Bills Pass to Regulate Insurers on Rescission, Maternity Coverage, Mental Health Parity, and Requiring 85% of Premium for Patient Care

* More on the Legislative Debate and much more at the Health Access WeBlog (www.health-access.org/blogger.html):

Health reform continues to be a hot topic at the State Capitol. Passing their first floor vote and the half-way point in the California Legislature, key health bills would provide patients with new information and needed consumer protections regarding their care and coverage.

The Assembly and Senate passed several key health care bills, including ones to protect consumers from "junk" insurance; to increase transparency about the cost and quality of care; to regulate the practice of retroactively denying coverage to patients; and to mandate coverage of maternity and mental health services. The health reform conversation is alive and well.

The following bills passed:

INSURER OVERSIGHT

* STANDARDIZING INSURANCE: SB1522(Steinberg), eliminating "junk" insurance and standardizing the insurance market to allow for "apples-to-apples" comparison for consumers. The bill would set a minimum benefit standard for coverage by requiring coverage to have an overall cap on out-of-pocket costs, and cover doctor, hospital, and preventative care. It would sort health insurance policies into five coverage categories, ranging from “comprehensive’’ to “catastrophic." Here's a fact sheet, and a patient story that illustrates the issue.

Organization of plans into these categories would enable consumers to better track premium, benefits and cost-sharing. The bill would also prevent consumers from not understanding their coverage, or having "junk" coverage where they are paying a premium by are still facing unlimited financial exposure. Sponsored by Health Access California. (Passed by the Senate 22-16 with most Democrats in support; Ducheny and Ridley-Thomas not voting; Correa voting no.)

* MEDICAL LOSS RATIO: SB1440(Kuehl), to require that at least 85% of premium dollars go to patient care, rather than administration, marketing and profit. The proposal seeks to ensure that consumers are getting value for their dollar. (Passed by the Senate 22-16, with most Democrats in support, with Machado and Simitian not voting, and Yee voting no.)

* RESCISSIONS: AB1945(De La Torre), to require insurers to get an independent review before retroactively denying coverage from patients. (Passed the Assembly 57-16, with significant bipartisan support.) Also passing was AB2549(Hayashi) which sets a six-month time limit for insurers to rescind once consumers' applications are approved. (Passed the Assembly 44-26.)

BENEFITS

* MENTAL HEALTH: AB1887(Beall) to expand the requirement on insurers to cover mental health services. (Passed by the Assembly 44-26, with most Democrats in support, and with Arambula, Mullin, Calderon, Galgiani not voting; Soto absent.)

* MATERNITY: AB1962(De La Torre), to require insurers to cover maternity benefits. (Passed the Assembly 44-31, with most Democrats in support; Soto absent; Galgiani not voting; and Calderon and Parra voting no.)

PROVIDER OVERSIGHT

* TRANSPARENCY: AB2967(Lieber), to require better data from health providers and plans to increase the transparency of the cost and quality of care. This effort has yielded one of the most interesting coalitions, with strong support by prominent consumer, labor, and business groups--all purchasers of health care trying to get a better sense of what they are getting for their money. (Passed by the Assembly 41-32, with most Democrats in support but Soto absent; Fuentes, Krekorian, Ruskin, Portantino, Solorio not voting; and Arambula voting no.)

* DISTRICT HOSPITAL TRANSACTIONS: SB1351(Corbett), to require Attorney General oversight over district hospital sales and closures. (Passed the Senate 24-14, with most Democrats in support, and Scott not voting.)

Health Access will continue to track these and other bills on our website, at
http://www.health-access.org/advocating/2008_bills.html

Labels: Hospitals, Insurers, Legislation, Updates, YearOfReform

posted by Anthony Wright | Permalink | 7:46 PM

Busy and productive day in the Assembly and Senate on many of the key health care bills. The health reform conversation is alive and well...

Here's what passed (partial list--we'll have a fuller update later today):

* SB1522(Steinberg), eliminating junk insurance and standardizing the insurance market to allow for "apples-to-apples" comparison for consumers. (Passed by the Senate 22-16 with Ducheny and Ridley-Thomas not voting; Correa voting no.)

* AB2967(Lieber), to require better data from health providers and plans to increase the transparency of the cost and quality of care. (Passed by the Assembly 41-32. Party line vote with Fuentes, Krekorian, Ruskin, Portantino, Solorio not voting; Soto absent; Arambula voting no.)

* SB1440(Kuehl), to require that at least 85% of premium dollars go to patient care, rather than administration, marketing and profit. (Passed by the Senate 22-16, with Machado and Simitian not voting, and Yee voting no.)

* AB1945(De La Torre), to require insurers to get an independent review before rescinding coverage from patients. (Passed the Assembly 57-16, with significant bipartisan support.) Also passing was AB2549(Hayashi) which sets a time limit for insurers to rescind. (Passed the Assembly 44-26.)

* AB1887(Beall) to expand the requirement on insurer to cover mental health services. (Passed by the Assembly 44-26, with Arambula, Mullin, Calderon, Galgiani not voting, Soto absent.)

* AB1962(De La Torre), to require insurers to cover maternity benefits. (Passed the Assembly 44-31, with Galgiani not voting; Soto absent; and Calderon and Parra voting no.)

* SB1351(Corbett), to require Attorney General oversight over district hospital sales and closures. (Passed the Senate 24-14, with Scott not voting.)

Good things. Good day for consumers.

Labels: Hospitals, Insurers, Legislation

posted by Anthony Wright | Permalink | 5:59 PM

HEALTH ACCESS UPDATE
Thursday, May 22nd, 2008

FISCAL COMMITTEE REPORT: OUTCOME OF KEY HEALTH BILLS
* In budget crisis, only a third of proposed bills pass Appropriations Committee
* Health bills move to standardize insurance, provide transparency, protect consumers
* Deadline to pass full floor vote in the house of origin is Friday, May 31st

Click Here for What's New on the Health Access WeBlog: Budget reactions; The media's miss in reporting the impact of the health budget cuts; Over 1,000 rescinded patients reinstated; the lessons of health reform for the budget, and vice versa; Big balance billing fight; McCain's high-risk pool highjinks from California perspective; Prescription drug discounts in peril

Today was a big day for the fate of many bills of interest to health advocates, which would provide consumer protections and place needed oversight over health insurers and providers.

For those who follow legislation, the Appropriations Committees in both the Assembly and Senate made decisions about whether to let legislation proceed to floor votes, or to hold them in committee, evaluating them on how much the bills will cost the state's general fund.

The Appropriations Committees in both houses considered nearly 600 bills Thursday. Given the state's $17.2 billion -- and growing -- deficit, only one-third passed. In the Assembly, only 79 of 414 bills survived. In the Senate, it was 99 out of 157 bill passing--and of the only $26 million in general fund spending approved, $23 million was in two bills responding to court orders.

Many health consumer bills in committee--many with no general fund cost--cleared this hurdle, however, and will head to the respective houses next week. All bills must pass their respective houses by May 31st. Many bills face difficult floor votes next week.

BELOW is a list of health consumer bills--it will be updated on the Health Access California website as the session continues, at http://www.health-access.org/advocating/2008_bills.html

For every bill, the list includes the bill number (the author) and A SHORT DESCRIPTION IN CAPS: There's also a longer description of the legislation, Health Access California's position on the legislation, and finally, where the legislation is currently pending.

Health Access will send out another list Friday of all bills pending on the Assembly and Senate floors for a vote. Coverage of the floor votes will be available on the Health Access blog, at: http://www.health-access.org/blogger.html

Health Access California -- Selected Bill List

INSURER REGULATIONS

Insurance Oversight & Market Reforms
· PASSED- SB 1522 (Steinberg) INSURANCE MARKET STANDARDS: Would sort health insurance policies into five coverage categories, ranging from “comprehensive’’ to “catastrophic.’’ Organization of plans into these categories would enable consumers to better track premium, benefits and cost-sharing, and assist consumers in making apples-to-apples comparisons between plans. Would weed out “junk’’ insurance by developing minimum benefit standards. Health Access California is the sponsor. Support. PASSED Senate Appropriations. To Senate Floor.
· PASSED- SB 1440 (Kuehl) CAPPING ADMINISTRATION AND PROFIT: Would set a minimum medical loss ratio – requiring every insurer to spend at least 85 percent of premiums on patient care. Support, seek amendments. PASSED Senate Appropriations. To Senate Floor.

Rescissions
· PASSED- AB 1945 (De La Torre) INDEPENDENT REVIEW: Would require approval by Department of Managed Health Care or Department of Insurance for each individual rescission. Support. PASSED Assembly Appropriations. To Assembly Floor.
· PASSED- AB 2549 (Hayashi) TIME LIMIT: Would impose a six-month time limit in which insurers have to rescind individual health care policies once consumers’ applications are approved. Support. PASSED Assembly Appropriations. To Assembly Floor.

Benefit Mandates
· PASSED- AB 1887 (Beall) MENTAL HEALTH PARITY: Would require health plans to provide coverage for all diagnosable mental illnesses. Support. PASSED Assembly Appropriations. To Assembly Floor.
· PASSED- AB1962 (De La Torre) MATERNITY COVERAGE: Would require all individual insurance policies to cover maternity services. Support. PASSED Assembly Appropriations. To Assembly Floor

Improved Insurance Options
· HELD IN COMMITTEE- SB 1622 (Simitian) PUBLIC INSURER: Would create a statewide public insurer, connecting existing regional, county-based health care plans, to compete with private health care plans and provide consumers more affordable coverage choices. Support. HELD. Will not advance this year.

HEALTH CARE PROVIDERS

Transparency
· PASSED- AB 2967 (Lieber) TRANSPARENCY AND DISCLOSURE: Would require public reporting of cost and quality by doctors, hospitals HMOs and others in the health care industry. Support. PASSED Assembly Appropriations. To Assembly Floor.
· PASSED- SB 1300 (Corbett) CONFIDENTIALITY CLAUSES: Would prohibit confidentiality clauses, which keep secret information on pricing and health care quality from consumers, in contracts between providers and insurers. Support. PASSED Senate Appropriations. To Senate Floor.

Doctor and Hospital Oversight
· PASSED- AB 2146 (Feuer) ‘NEVER EVENTS’: Bans providers from billing patients or insurers when they have made an avoidable mistake, such as operating on the wrong person, prescribing the wrong drugs, or leaving foreign objects inside a surgery patient. Support. PASSED Assembly Appropriations. To Assembly Floor.
· PASSED- AB 2942 (Ma) COMMUNITY BENEFITS: Would standardize what non-profit hospitals report as “community benefits” to justify their non-profit status. Support. PASSED Assembly Appropriations. To Assembly Floor.

Hospital Transactions
· PASSED- AB 2741 (Torrico) HEALTH IMPACT ANALYSIS: Would require for-profit hospital sales to undergo health impact analyses to gauge the transaction’s effects on the affected community, health care services, and the community’s public interest. Support. PASSED Assembly Appropriations. To Assembly Floor.
· PASSED- SB 1351(Corbett) OVERSIGHT: Would require Attorney General oversight into transactions involving district hospitals. Support. PASSED Senate Appropriations. To Senate Floor.

Balance Billing
· PASSED- AB 2220 (Jones) BINDING ARBITRATION: Requires providers and health plans to resolve contracting and payment disputes through binding arbitration. Watch. PASSED Assembly Appropriations. To Assembly Floor.

UNDERSERVED COMMUNITIES

· PASSED- AB 2902 (Swanson) COMMUNITY HEALTH WORKERS: Would require the Office of Multicultural Health to encourage the use of community-based health care workers to help facilitate and coordinate better health outcomes in underserved communities. Support. PASSED Assembly Appropriations. To Assembly Floor.
· HELD IN COMMITTEE- AB 3027 (De Leon) LANGUAGE ACCESS: Would require health plans to translate materials into Medi-Cal threshold languages. Support. HELD in Assembly Appropriations. Will not advance this year.
· HELD IN COMMITTEE SB 1332 (Negrete-McLeod) MANDATORY MEDI-CAL MANAGED CARE: Would require seniors and persons with disabilities in Riverside-San Bernardino Counties to enroll in Medi-Cal managed care. Oppose. HELD in Senate Appropriations. Will not advance this year.

COVERAGE

· HELD IN COMMITTEE: SB 1593 (Alquist) BRIDGING COVERAGE: Would clarify that children currently covered by county health initiatives would be first in line to receive Medi-Cal and Healthy Families coverage once those programs are expanded. Support. HELD in Senate Appropriations. Will not advance this year.

Labels: Hospitals, Insurers, Legislation, Updates

posted by Anthony Wright | Permalink | 9:35 PM

Beth Capell, Health Access' contract lobbyist extraordinaire, has been advocating for consumers for more than two decades. She offers these thoughts on balance billing, an insidious practice of some doctors and hospitals who decide to threaten insured consumers with aggressive collection agency if the consumer does not pay the “balance” between the insurer or HMO paid for their care and what the doctor or hospital wanted to be paid. (Relatedly, we blogged on a recent and egregious example of the Prime/Kaiser situation. 5/17 UPDATE: There's a new development, where a legal injunction has been ordered, as reported in the Orange County Register on balance billing. The LA Times also has a story.)

“Balance” billing has been illegal for Medicare and Medicaid enrollees for decades. It is illegal for HMO enrollees if they go to a contract facility. And until a few years ago, we probably would have said balance billing was illegal when an insured consumer got emergency care, even at a non-contract hospital.

As consumers, we are sympathetic to doctors and hospitals who feel badly treated by HMOs and insurers. We know what that’s like.
But as consumer representatives, we are pretty impatient with doctors and hospitals that treat consumers badly. We don’t like that either. And when it is all about a billing dispute between providers and plans, we say a pox on both their houses: get consumers out of the middle.

Well, this week DMHC had a hearing on a regulation to do just that: to say that if a consumer with coverage regulated by DMHC gets emergency care, then the consumer is only responsible for applicable copays or deductible, not for the difference between what the emergency doctor or the hospital wanted to be paid and what the HMO paid. Health Access is fortunate that our representative at this hearing is Elizabeth Abbott, who formerly headed the federal Centers for Medicare and Medicaid Services (CMS) in the western region of the United States: she has heard plenty of plan-provider disputes in her day and has no surfeit of patience with whining. She reports that doctors are furious at the proposed regulation.

As we said, we are sympathetic to doctors and hospitals fighting with HMOs. And indeed we as well as the Department have spent endless hours listening to the complaining of doctors and hospitals.

After all that, we know several things: first, consumers deserve to be protected from bad behavior by doctors and hospitals as well as HMOs and insurers. Second, under California law, doctors and hospitals that do not have a contract with the consumer’s HMO do in fact get paid and usually get paid in a reasonable period of time (less than 60 days). So what are the doctors and hospitals fighting with the HMOs about? It turns out it is not just about the amount of the payment but also what counts how.

You would think that it would be easy to decide that when an ER doc takes care of you because you have a broken bone, he should be paid for reading the x-ray or MRI, but it turns out whether that is part of the bundle of services or not is part of what providers and plans fight over. And they fight over it partly because there is no standardization of bundling. The docs, not surprisingly, want the bundling system the docs have developed (called the AMA/CPT code, if you care). But Medicare decided a long time ago that letting the docs set the rules by which they are paid does not make much sense and ditto with Medi-Cal.

And we made it lots more complicated in California when we allowed the development of the “delegated medical model”. (If your eyes are crossing, welcome to my world.) That means that Blue Shield does not just contract with individual docs, but instead contracts with Sutter Medical Group or Hill Physicians or Beaver or Scripps or some other outfit with thousands of docs and hundreds of thousands of patients. So if you are a Sutter Medical Group patient but you end up at UC Davis emergency room because that is where the ambulance took you, what are the rules for bundling the claim? Is that thing-y they put on your finger to check your blood oxygen in or out of the bundle? Is it the Medicare rules? The Sutter group rules? The Blue Shield rules? Or are you actually HealthNet? And why do you care? Well, probably you will when the ER doc or the hospital loses their
patience with the HMO and just decides to send you to collections and let you
fight it out with the HMO.

And yes, this is yet another way in which our current system piles on administrative overhead for no good reason. So in addition to fighting to prohibit balance billing of consumers, we are trying to help figure out how to minimize the provider-plan disputes by supporting a single set of rules for bundling as well as other changes.

The need to end balance billing got a lot more obvious this week when we found out that one hospital system in Southern California, Prime Healthcare, had sent over 6,000 Kaiser members to collections because Kaiser would not pay whatever Prime Healthcare wanted to charge for their emergency care. Prime Healthcare is a system that refuses to contract with most insurers---so it is not just Kaiser members who are at risk: it is anyone with insurance who walks into their emergency room. It looks as if Prime Healthcare took on Kaiser first but nothing prevents the hospitals from doing the same thing to consumers covered by other insurers that Prime fails to contract with. And Prime also seems to be engaged in the same old game that for-profit Tenet used to play of turbo-charging the charges for care so that the sticker price goes up and up.

As well as the proposed regulations, we are working on AB1203 (Salas) and SB981 (Perata) to prevent balance billing of patients who get emergency care. While both these bills are still in progress, we hope this year we can get consumers out of the middle of these provider-plan disputes.

Labels: BalanceBilling, Hospitals, Insurers, Schwarzenegger

posted by Hanh Kim Quach | Permalink | 4:53 PM

Dr. Prem Reddy, owner of Prime Healthcare Services, is running around terrorizing 6,000 Southern California Kaiser Permanente members -- sending them enormous hospital bills (via an aggressive collection agencies) and telling them to pay up, or ruin their credit. See the story here. One patient featured is being asked to pay $50,739.70 in full by June.

The company, with 9 hospitals Southern California, is demanding payment for emergency services that are currently under dispute with Kaiser. The patients are being told they must come up with the money to pay for their treatment (the portion that Kaiser is disputing and has not agreed to pay).

The tactic being used by the hospital chain is called "balance billing,'' where patients are asked to pay the difference between what the hospital billed, and what the insurance company paid. The Schwarzenegger Administration has been working on regulations to ban this practice, and in a strongly worded notice releasing their proposed rules, accused providers -- such as hospitals and physicians -- who engage in this behavior of using "innocent enrollees'' as "bargaining chips in an unfair provider billing pattern'' that leads to "long-term harm o the enrollee's health, safety and financial stability.''

Coincidentally -- the Administration's Department of Managed Health Care will hold a hearing on this very issue in Irvine on Wednesday, the heart of Orange County where three of Prime's hospitals are located (and presumeably many of the recipients of these giant bills.)

Testimony anyone?

(Relatedly, AB1203 by Mary Salas would ban this practice.)

Labels: Affordability, BalanceBilling, Hospitals

posted by Hanh Kim Quach | Permalink | 12:56 PM

"Don't Blame Crowded ERs on the Uninsured" is the pitch-perfect headline of an article by Suzanne Bohan in the San Mateo County Times and other papers.

The articles reports on a UC-San Francisco study that reports that asks "Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States?" and answers "no." In fact, the "proportion of adult ED visits by persons without insurance was stable across the decade," roughly in the 14-15% range.

Despite the belief that the uninsured are the majority of those crowded in our emergency rooms, I note that this figure is a bit lower than the overall percentage of uninsured people in the country, which is around 16%.

This is consistent with other findings, such as a 2004 Urban Institute report by researchers Zuckerman and Shen on ocassional and frequent ER users. That paper concludes, in part, "The uninsured and the privately insured adults have the same risk of being frequent users... It seems hard to blame the overcrowding of EDs on the uninsured."

MISSING THE MESSAGE: Some conservative commentators will use this research to attack the notion that of a "hidden tax" that we all pay in our premiums for having such a large uninsured population, and to attack the notion of health reforms and coverage expansion generally. I get a very different lesson from the study.

I too have been a skeptic of the Governor Schwarzenegger's "hidden tax" rhetoric, because it led people to blame the uninsured for high health costs, rather than the reverse.

If the uninsured go to the emergency room, they have only a right to be stabilized. But even then, they get a bill--typically the biggest bill they will see in their lives, and often one that is inflated well above what an insurer would pay for the same service. No wonder they may actually go to the ER less.

LOTS OF FACTORS: That said, there's nothing inconsistent with saying that the uninsured, when they finally do go to get care, are in a worse condition since they let their conditions linger and mestatisize, costing the health system more money in the long run. Or that the uninsured get the bill, but some face bankruptcy not being able to pay, and as a result leave the hospital unpaid.

In other words, I think the real world in health care is more complicated than one cause. Some uninsured get the care they need. Others go without and simply die. And in between, some uninsured wait until the problem gets worse. And some of these factors end up costing the health system. So reforming health and increasing coverage is needed and urgent, even for the regular, insured California.

SOLUTIONS: So how much is the "hidden tax?" I don't know, but it's real. But I think the focus should be on fixing the system, not the victims of that system:

* We all pay when McDonald's, Wal-Mart, or Applebee's don't, when some employers don't pay their fair share. Those who are uninsured are those who fall through our health system that relies on voluntary employer contributions.

* We should ensure that those who are uninsured are not overcharged and thus discouraged from getting needed care. California passed a fair hospital pricing law in 2006, and other protections would be helpful.

* We who are *insured* would not go to the emergency room as much if we had the ability to get timely access to care to primary care and specialists. There's pending regulations for insurers and providers at the California Department of Managed Health Care.

Our health care system doesn't have just one problem, and doesn't have just one solution. The new research helps us understand that.

Labels: ExpandingCoverage, Hospitals, Research, TimelyAccess, Uninsured

posted by Anthony Wright | Permalink | 10:45 PM

Another moment during the debate on the transparency bill, AB2967(Lieber) was when Assemblymember Ted Gaines questioned a key supporter of the bill, Laurie Sobel from Consumers Union, and asked "isn't this something that you should be doing?"

It's not a uncommon question for those who work at Consumers Union, publisher of Consumer Reports magazine--one of the one of the most read magazines in the country, and one of the most trusted. I've been proud to work alongside them in different roles in my decade-and-a-half of consumer advocacy.

Laurie had an answer: she thanked the Assemblymember for the confidence, but that as much as Consumer Reports would be happy to provide the same kind of evaluation of doctors and hospitals as they do for cars and ceiling fans, with the trademark circles, there's a limit to what they can do without this bill in place.

Most tellingly, no independent group can mandate reporting of doctors and hospitals, and it's hard to provide a meaningful and complete report with the largely voluntary reporting systems we have now. This is a governmental function. There might be a role for CU or other advocates in analyzing the data, but we need the government to collect it and appropriately categorize it.

There's often been several times in just the last few years when policymakers who oppose legislation to set consumer standards or provide more consumer information will say on the floor of the Assembly that this should be the role of Consumer Reports, not government. Yet these same policymakers never seem to follow the position of the actual publisher of Consumer Reports.

Labels: Employers, Hospitals

posted by Anthony Wright | Permalink | 11:05 PM

HEALTH ACCESS UPDATE
Wednesday, April 8th, 2008

HEALTH CONSUMER PROTECTIONS PASS ASSEMBLY HEALTH
* Insurers would face restrictions in cancelling coverage retroactively
* Patients would be better able to assess hospital cost and quality data
* Other bills on hospital community benefits, boutique hospitals, and others

Click Here for What's New on the Health Access WeBlog: Balancing the Budget; Re-Examining Hillary-Care; Balance Billing; Dennis Quaid and Medical Mistakes; Prescription Drug Gifts to Doctors; PHRMA's Revenge; Coverage Matters; Deaths Due to Uninsurance; The Health Wonk Review Spotlight; The Individual Market; Nuggets from the Medi-Cal Cuts Hearings.

The Assembly Health Committee on Tuesday approved a smattering of bills that would begin to set the foundation for health care reform, providing security to health consumers – both for their coverage and choice of provider.

Two of the bills deal with the insurer practice of retroactively canceling policies after patients become sick and need expensive treatments. These rescissions leave patients tens of thousands – if not hundreds of thousands in debt. Another bill would require medical providers to disclose cost and quality information in order to give purchasers more power in selecting the highest quality and most efficient care.

RESCISSIONS

* AB1945 (De La Torre) would create an independent panel to review cases where an insurance company wishes to rescind a policy. The bill passed on a bipartisan 11-0 votes, with Republicans Alan Nakanishi and Bill Emmerson voting for the bill. In addition to an independent panel, and review by regulators for rescissions, AB1945 would establish a standardized application for consumers to fill out. De La Torre cited recent investigations by state regulators, which found violations in every single instance.“That’s not an accident,’’ he said. Insurers, he said, should not be permitted to “act as judge and jury whenever they want to rescind a policy.’’

SUPPORT: California Medical Association, Health Access, California Alliance for Retired Americans, AARP, Congress of California Seniors, CalPIRG, Consumers Union, California Teachers’ Association, California Academy of Family Physicians and Consumer Federation of California spoke in support of the bill.

INDUSTRY: Industry associations were not completely opposed to the bill, but were concerned about whether the application would give insurers enough information about a potential enrollees condition so that “they can do reasonable underwriting up front,’’ said Charles Bacchi, for the California Association of Health Plans. That means the industry wants to be able to deny for pre-existing conditions, and the questions need to elicit enough detail to do that. Others had concerns about the need for regulator approval of rescissions, and the authority given to the state to revoke the licenses of health plans. Blue Cross of California opposed the measure.

* AB2549 (Hayashi) is a related measure would limit health plans ability to cancel coverage because of a fraudulent application to six months after the application is approved. The bill passed on a party line vote, with Republicans either abstaining or opposing. The industry opined that the six-month period was too short. Current industry practice allows a period of two years for insurers to rescind because an expensive claim may not occur within the first six months – usually the trigger to review an enrollees application.

SUPPORT: Health Access, California Teachers Association, Congress of California Seniros, AARP, California Medical Association, California Academy of Family Physicians, AFSCME, California Psychological Association and Having Our Say!

OPPOSITION: Association of California Life and Health Insurance Companies, California Association of Health Plans, California Association of Health Underwriters.

TRANSPARENCY

Another important bill passed by Assembly Health Committee on Tuesday would require medical providers to publicly disclose price and safety information.

* AB2697 (Lieber) would create an independent panel, which would include hospitals, doctors, consumer and labor representatives to recommend a plan that would be continuously updated. The data collected would be scientifically based, consider where providers practiced (urban, rural, affluent or poor communities) and risk adjusted – to account for the fact that some physicians/hospitals would attract higher risk patients. This bill passed 11-5 on a party line vote, with Republicans opposing in spite of small business support.

SUPPORT: Along with a usual cast of consumer groups, the National Federation of Independent Businesses, Pacific Business Group on Health and Small Business California supported the measure. “We all know the challenges small businesses face. A system of comparable statistics is important to helping rectify the situation,’’ said Michael Shaw, with NFIB. Other supporters included Health Access, SEIU, AARP, CalPIRG, California Labor Federation, Consumers Union, Congress of California Seniors, Having Our Say among many others.

OPPOSE: The California Medical Association opposed saying that the state should work on the existing program, rather than create a new expensive one funded by providers. The hospitals also opposed the measure.

OTHER HEALTH CONSUMER BILLS ON HOSPITALS

The following bills also passed in Assembly Health Committee on Tuesday. For a broader list of interest to health advocates and Health Access California, visit our website, at:
http://www.health-access.org/

* AB2942 (Ma) would require all hospitals to develop and publicly a community benefit plan, just as non-profit hospitals are currently required to. The plans would need to consider and report what the community needs and levels of charity and discount care. The bill passed 11-3.

* AB2697 (Huffman) requires “boutique hospitals,’’ which tend to serve more affluent patients to assess its impact on the community health system, and whether it siphons dollars and workers from providers and hospitals that take care of sicker or less affluent populations. This bill passed 12-5.

In addition to these and other bills heard this past Tuesday, another bill, SB1633 (Kuehl), passed Senate Business and Professions Committee on Monday. SB1633 addresses the issue of credit cards for dental services. These are offered in dentists offices with little explanation to the patient of their course of treatment or the terms, and interest rates on the cards. Patients are often charged the full amount of services, even before they are rendered and some are asked to sign for the credit line while under the influence of anesthesia. This bill passed with a unanimous vote.

Bills need to pass policy committees by April 18. Health Access will continue to provide updates on actions taken in the Legislature. For more information, contact the author of this report, Hanh Kim Quach, at hquach@health-access.org.

Labels: Hospitals, Insurers, Legislation, Updates

posted by Anthony Wright | Permalink | 2:14 AM

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