"Transparency!" Is Dumb When Patients Have No Idea What They're Looking At
Another genius idea from government!
Joel Zinberg writes at City Journal that Medicare and Medicaid will begin publishing annual reports of the amounts doctors were paid and the procedures they performed:
The new policy will accomplish little beyond confusing patients and embarrassing physicians.The problem is that patients cannot intelligently interpret the CMS data. If the records show, for example, that a doctor has received what seem like high payments for a particular procedure--and for performing that procedure an unusual number of times--is the doctor an expert, or a crook? Health researchers have long maintained that high-volume providers have better outcomes. Perhaps the doctor is especially proficient, and her expertise attracts large numbers of patients who need the procedure? The CMS records won't help patients assess the quality of the services provided or compare one doctor with another. A patient could just as easily believe that the highly paid doctor is over-utilizing the procedure, performing unnecessary and possibly harmful procedures to boost revenue.
The payment records could also mislead patients because they don't indicate whether a payment was made to a single provider or to multiple providers out of a single office, using one provider's Unique Physician Identification Number for billing purposes. A pathologist in Minnesota collected $11 million from Medicare in 2012. It wasn't fraud; he was chairman of the Mayo Clinic's Department of Laboratory Medicine and Pathology, one of the busiest in the country, and the entire lab billed under his name and Medicare number.
...One is left with the suspicion that the primary purpose of the record release is to shame doctors whom policymakers believe routinely exploit the current fee-for-service payment system for personal gain. True, some physicians are guilty as charged; as in any profession, some bad apples exist. But most physicians take their professional duties seriously. They make a good faith effort to perform services for the best interests of their patients and not for personal gain. They don't deserve to be pilloried based on misleading information.
And a comment from "Nikki" at City Journal:
Medicare and Medicaid have always been so quick to blame the physician for fraud and abuse when they should be looking elsewhere.Take the hospital/independent laboratory setting for example. They are routinely submitting claims for reimbursement for the following: lack of medical necessity, unbundling, upcoding, duplicate billing, and billing for services that were never performed. Specimens that are grossly hemolyzed should not be billed, however, because they "did the work" they feel they should be paid for them. If the physician orders a re-draw, this test is being billed within 1-3 days of the original draw or it is being billed with the appendage of a modifier. Medicare and Medicaid reimburse the provider without blinking an eye.
Non-blood specimens are being billed on occasion with a venipuncture charge -- also paid by Medicare and Medicaid. Specimens that are drawn in the physicians office and sent to the laboratory for processing are being billed with a draw fee. If the laboratory bills first, they get paid and the physician's charge is denied. I agree that these reports are going to be misleading and not at all accurate.
Good article. Nikki's comments miss the point, though. Looking for someone in the system to blame is a red herring. The people to blame are the people who are on top of the system: government officials, licensing boards, the AMA, the insurance companies, and ultimately Congress and the President. They are the ones who created this mess. It would not surprise me to find out that within the medical industry today, more money is spent on billing and compliance than on actually providing treatment.
Cousin Dave at March 2, 2015 7:28 AM
Agree, Cousin Dave. But I just liked it because it laid out some of the nonsense.
Amy Alkon at March 2, 2015 7:33 AM
I have never been billed correctly through Blue Cross, Blue Shield, and the local hospital has SIX billing addresses (so far), all but one of which are out of state!
Radwaste at March 2, 2015 11:32 AM
I am currently using a high-deductible medical plan with a pre-tax health savings account in the mix. I do this because it's a wee bit cheaper, albeit more work for all involved (billing and me) - and it took a good bit of financial estimation and charting to figure out, for sure.
But, what this does, is quite interesting. I get a "reduced" rate (the "negotiated" rate, same as the ins co gets, as opposed to the "retail" cash patient rate). And when I get the bill, I go over it, and pay for it out of my health savings account. I just today caught an over-charge on a routine visit. Do you think I would have cared, or even *seen*, that overcharge, if I were simply charged a $20 copay?
I think that style of insurance would fix most of the problems. Give people real information, and make them care enough to ask questions, and costs will come down and errors will be reduced. People will go to providers that give them good service at a reasonable price. They'll avoid quacks (even cheap ones), and they'll avoid providers that are skimming for profit.
Traditional insurance puts a big quilt over all this information, now - and so it's just too easy for these problems to fester.
flbeachmom at March 2, 2015 1:09 PM
All those shortcomings being true, if it gets the conversation rolling on a large scale, I'm all for it.
More discussion about how to tell the expert whether a doctor is an expert at performing a procedure or just someone who over does it to milk a cash cow. -Etc.
There's a lot to learn about what questions to ask, what to look for to get answers, and how to interpret data - as well as what hasn't been asked or cannot be quantified, and the shortcomings of proxies. That's an ever evolving inquiry, but not one to be avoided.
I'm for having the conversation become a national topic of interest, and this brick of a report might be a clumsy but effective way to break the ice.
Michelle at March 2, 2015 7:59 PM
...More discussion about how to tell *whether* a doctor is an expert at performing a procedure or just someone who...
Michelle at March 2, 2015 8:02 PM
> They are the ones who created
> this mess.
Aw, c'mon... c'mon... They had a LOT of help from the man on then street.
This is very much like the real estate crash. No sinister public servant (though we have hundreds of thousands) nor shameless Wall Street manipulator (again) could have created a crisis like that without help from a public eager to be deluded about market truths.
Same with health care. Because it's so very good, and worth so much money, people want to pretend they should never have to pay for it. Because it's too important. To create the wealth to pay for it. Because it will mean to much to their lives on an individual level. So they shouldn't have to offer some corresponding blessing. In order to pay for it. For their own well-being. Because it's too important to pay for.
Are you tracking me here?
People want to think it's a policy problem, not a I-personally-need-to-do-something-to-be-worthy-of-these-miracles problem.
Specifically:
> That's an ever evolving inquiry...
..She means, people ought to know what health care is worth in dollars and sense...
> but not one to be avoided.
..She means, people are too chickenshit to face up to the fact that they, as individuals, perhaps don't deserve the best.
Because health care is too important to leave up to people who want to be paid well.
(So it's about to get a lot shittier.)
Crid [CridComment at Gmail] at March 2, 2015 9:19 PM
Whoops, meant to type "dollars and cents"... I wasn't trying to be tricky.
Just has the Bush/Obama responses to the real estate prices have left people unable to judge the price of properties, insurance and policy arrangements prevent people from knowing the worth of their health care.
Crid [CridComment at Gmail] at March 2, 2015 9:47 PM
Crid, thank you for putting a fine point on it.
Aside from the matter of deserving the best - as a consumer who is not a medical professional I am hard pressed to even know what is the best purchase for me to make, much less which professional or office would be the best person or organization from whom to make the purchase.
Before ACA, I once called a hospital to learn the cash prices for a surgery, and the hospital would not tell me. My insurance provider would not tell me whether they would cover the planned procedure, because they could not guarantee that they would cover whatever might occur that was unplanned. Crazy. I definitely had the right surgeon (among the best in the country) and the best course of action planned, but could not get simple prices.
More recently, I had an ultrasound done to rule out a hereditary condition (I'm in the clear for that) and the doctor discovered a node on my thyroid. I had two biopsies at two different hospitals, in the same hospital system. Both came back labeled "undetermined significance."
The first biopsy involved two lidocaine injections and three biopsy samples. I asked for topical lidocaine but was told it wouldn't help because the "pinching and burning" sensation would occur below the reach of the topical lidocaine. After the results came back "undetermined significance," a doctor recommended I use a different lab at a different hospital, and assured me that they would get what they needed. I pointed out that the first lab had someone on hand to confirm that they would get what they needed, the person confirmed, and yet they didn't get what they needed. I questioned whether the standard is the same among the labs in the hospital system. The doctor replied that her lab is better.
How would I know which lab is better? When it comes to putting needles into my neck, when I can I'd pay extra for "better."
The second lab did not inject lidocaine, but applied it topically, and proceeded to take the biopsy immediately. The doctor assured me the topical lidocaine would work instantly and be enough. When I mentioned the comments from the guy at the other lab, he said this sample would be taken closer to the surface and therefore not need a deep lidocaine application. Is that the truth? I don't know. This is not my area of expertise.
If I had to choose up front which numbing option to purchase, I would have to know that there were two options, and then poll my friends beforehand and ask about their experiences. (It's worth noting that consumer experience is subjective and a hard way to rate a method or a care provider. Health care can involve a multitude of similar choices.) Then I'd have to call around and find a lab that uses my preferred method of lidocaine, because the guys at each of these labs claimed to take only one of the two approaches. This is a simple choice for a relatively simple procedure, and I was not equipped to make an informed purchase.
Consumers need a lot of information about processes and procedures, options and their implications, to make informed purchases. I'm all for having the information, because this inquiry has to start somewhere.
At the second lab, they took five biopsy samples. Again they confirmed that they had what they needed. Again the results came back "undetermined significance."
My bill for the first procedure was about $70, and the second procedure at the second lab cost about $40. The hospital removed one of the charges from my account, but there was no breakdown of the costs for either biopsy.
The protocol for two biopsy results of undetermined significance, is to remove the thyroid and then find out if it's malignant - rather than remove the node and then go back to remove the thyroid if the node is malignant. The explanation I'm given is that: the synthetic hormone prescription one must take after having the thyroid removed, is cheap; and one surgery plus a lifetime of synthroid is cheaper than two thyroid surgeries (one to remove the node, and one to remove the thyroid if the node it malignant).
But I don't want to throw away my thyroid and then find out if it's malignant. I don't want a lifetime dependency on a prescription drug and blood monitoring, if I do not need it. But I don't want to walk around with a possibly malignant node in my thyroid.
Can I even pay cash for this surgery, if I wanted to in order to get the node removed and biopsied when the doctor will only recommend following the protocol? Was the protocol set by the insurance companies? Was it influenced by the company that makes the synthetic hormone? At what point does a protocol get molded by what the insurance companies will reimburse? With whom can I negotiate a good lump sum price on a lifetime of blood work?
I'm reading studies on "atypia of undetermined significance" and genetic testing and node removal, rather than jumping right to a surgery followed by a lifetime of pills and blood tests. Thyroid cancer is considered slow moving, so the thinking is that I have some time to sort this out - but sorting through this for emergency procedures or complex conditions is currently impossible.
It's complicated. We have to start somewhere.
Michelle at March 3, 2015 12:26 AM
"Give people real information, and make them care enough to ask questions, and costs will come down and errors will be reduced. People will go to providers that give them good service at a reasonable price."
Which is why I push this solution, even though I am sure that since it doesn't give the government enough power, it will never be arranged.
Radwaste at March 3, 2015 2:32 PM
I truly believe this:
You will not get to say what happens unless you are the one paying. --Radwaste
And Michelle's story, the only hope of a solution for what she's seen, is some form of Angies List to happen. If there isn't a need (there is no need, now), it won't happen. But if there is a need, because we all suddenly have to pay and need that kind of review - it'll happen.
flbeachmom at March 5, 2015 8:56 AM
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