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Problems With Your Hospital Care? Speak Up!

My dad was in excruciating pain over Labor Day weekend, so my mom rushed him to the emergency room of a renowned university hospital.

Doctors determined that he needed surgery that night, and luckily I was able to fly in and see him before he was wheeled away. “Take care of your mom if anything happens to me,” he said as my mom and I wept.

Thankfully, my dad made it through. But he had to spend 11 days recovering in the hospital, a place he now equates with prison.

One night, he suffered for five hours, desperately calling for help after his pain meds had run out. A nurse’s aide stationed in his room had fallen asleep.

“I called on the intercom so many times, and nobody showed up,” he recounts.

That was just one of the many failures in care that we encountered during my dad’s stay. Others included inconsistent nursing quality, waiting all day for doctors to respond to pages, insensitive communication of bad news, trying in vain to reduce noise levels so my dad could sleep, and so much more.

My job is to give you advice on health care and insurance issues. My mom is a registered nurse. Yet we both felt frustrated that we couldn’t make things better for my dad.

Unfortunately, this happens to a lot of people. “Everything you hear these days is about patient-centered care, this and that,” says Terry Bay, who owns a Casper, Wyo.-based business that provides advocacy services to older patients. But “we don’t live in a patient-centered health care environment.”

Today I’m going to offer advice for you in case you or a loved one lands in a hospital.

There are state and federal laws that cover, among other things, your rights to privacy, nondiscrimination, language interpretation and visitation, says Lois Richardson, vice president and legal counsel of the California Hospital Association.

But beyond legal protections, there are people you can talk to and steps you can take to improve your situation if you feel you’re not getting the care you deserve. And patients’ opinions do count.

“All hospitals increasingly are being scored and paid based on patient and family satisfaction scores,” says Rebecca Kirch, an executive vice president with the National Patient Advocate Foundation. “There is power in the people.”

That power starts with a few simple things.

First, make sure a spouse, child, family member or friend — anyone concerned for your well-being — can spend time with you in the hospital and be your advocate. You cannot do it by yourself while you’re in pain, medicated and not thinking clearly.

“It’s having someone else in your court, someone who can check in and make sure your questions are being answered,” says Dr. Rebecca Sudore, a geriatrician and palliative care physician at the University of California-San Francisco.

Before you or your advocate speaks to your nurse or doctor, write down your questions. Keep track of your glasses, hearing aids and dentures — the personal belongings that most often go missing in hospitals, Sudore says.

“How can someone speak up for themselves if they can’t see someone? Or can’t hear?” she asks.

When the time comes to ask questions — or express frustration — don’t be afraid to speak up. You have every right, even though it can feel intimidating to question your doctors or complain about your nurses.

“You can say, ‘No, I don’t want to go for that test. I want to speak to my daughter first,’” Bay says.

If you’re getting jostled out of sleep for a blood draw or blood pressure check in the middle of the night, ask your doctor the next day if it’s really necessary. Often, it can wait till early morning, says Julianne Morath, president and CEO of the Hospital Quality Institute.

“It’s up to us to put our own humanity back into decisions,” Sudore says.

But here’s where speaking up can get thorny.

Let’s say you don’t feel you’re getting adequate care or you’re unhappy with how you’re being treated. You can start with your nurse, but if that’s uncomfortable — perhaps because that nurse is the source of the problem — approach the charge nurse, who manages the staff in your unit.

You can also ask to talk to a hospital-based social worker, who can intercede or help you figure out who to talk to, Kirch says.

If that doesn’t help, take your complaints to the next level.

Every hospital that participates in the Medicare program — which is most — must have an ombudsman or patient rights advocate, Richardson says. My mom and I eventually complained to the patient rights advocate. It helped, and we wish we had done it sooner.

If you can’t go to the patient rights advocate yourself, “you can call them or ask your nurse to call them and have them come up to your room,” Richardson says. Hospitals must acknowledge patient complaints immediately, she says, and must respond in writing once they are resolved.

As part of this process, no matter whom you talk to, there are some phrases that can spur quick action, Kirch explains. One is “This doesn’t feel like quality care to me.” Another is “I see my loved one suffering.”

If you have a serious illness and you’re suffering from symptoms that aren’t being managed correctly, you can also request a consultation with a palliative care team. Palliative care isn’t only about end-of-life issues, it’s about quality of life, Kirch says.

Most large hospitals have a multidisciplinary team of doctors, nurses, social workers, chaplains and others who can provide added support on top of the medical treatment you’re receiving, especially if you’re getting shuffled among medical specialties.

“They can help tremendously to fill in the blanks. … It can be pain management. It can be spiritual or psychological distress,” Kirch says. “The palliative care team treats the person beyond the disease.”

If you have done all that and still have concerns, Kirch’s organization has case managers who provide free, one-on-one support for patients. Call 800-532-5274 for more information or visit www.patientadvocate.org/help.php.

To be clear, I’m not suggesting you complain about every little thing. Be realistic. For instance, a hospital doctor may see up to 30 patients a day. So you might have to wait for your page to be answered unless you have a serious, potentially life-threatening problem, Sudore says.

“It may not be that you’re being ignored. It might be that someone has to figure out the competing priorities,” she says.

And don’t forget that your caregivers are human too, Morath advises. “They get tired, they get stressed,” she says. “Very often, just letting them know you’re not getting what you need and asking for their help … is a very powerful act.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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Health Giant Sutter Destroys Evidence In Crucial Antitrust Case Over High Prices

Sutter Health intentionally destroyed 192 boxes of documents that employers and labor unions were seeking in a lawsuit that accuses the giant Northern California health system of abusing its market power and charging inflated prices, according to a state judge.

In a ruling this week, San Francisco County Superior Court Judge Curtis E.A. Karnow said Sutter destroyed documents “knowing that the evidence was relevant to antitrust issues. … There is no good explanation for the specific and unusual destruction here.”

Karnow cited an internal email by a Sutter employee who said she was “running and hiding” after ordering the records destroyed in 2015. “The most generous interpretation to Sutter is that it was grossly reckless,” the judge wrote in his 12-page ruling.

Sutter, which has 24 hospitals and nearly $12 billion in annual revenue, said the destruction was a regrettable “mistake.”

“It’s stunning what Sutter did to cover up incriminating documents in this case,” said Richard Grossman, the lead plaintiffs’ lawyer representing a class of more than 1,500 employer-funded health plans.

Employers and policymakers across the country are closely watching this legal fight amid growing concern about the financial implications of industry consolidation. Large health systems are gaining market clout and the ability to raise prices by acquiring more hospitals, outpatient surgery centers and physician offices.

In April 2014, a grocery workers’ health plan sued Sutter and allegedit was violating antitrust and unfair competition laws. The plaintiffs began requesting documents related to contracting practices, such as “gag clauses” that prevent patients from seeing negotiated rates and choosing a cheaper provider and “all-or-nothing” terms that require every facility in a health system to be included in insurance networks.

Sutter disputes the broader allegations in the lawsuit over its market conduct and said its charges are in line with its competitors’.

The judge said that in 2015 Melissa Brendt, Sutter’s chief contracting officer in the managed-care department, and an assistant general counsel, Daniela Almeida, authorized Brendt’s executive assistant to destroy 10 years’ worth of managed-care documents going back to 1995. The company earlier had scheduled the documents to be destroyed in 2035 — 20 years later.

The executive assistant, Sina Santagata, testified in a deposition she wasn’t aware of any other time in her 17 years at Sutter when the managed-care department destroyed records held in storage.

In his Nov. 13 ruling against Sutter, the judge singled out an email by Santagata as “particularly noteworthy.”

The executive assistant emailed Brendt, the chief contracting officer, on July 30, 2015, after sending the order to destroy the records. She wrote, “I’ve pushed the button … if someone is in need of a box between 3/15/95 & 11/23/05 … I’m running and hiding. … ‘Fingers crossed’ that I haven’t authorized something the FTC will hunt me down for.”

The Federal Trade Commission (FTC) enforces antitrust laws in health care to prevent hospitals, drugmakers and other industry players from engaging in anti-competitive behavior that could harm consumers.

Santagata testified that she was being “sarcastic” in her email, and Sutter told the judge that the FTC reference was just a “joke.”

Karnow saw no humor in it. “There are infinite topics for jokes, and the choice of this one is strong evidence” in the plaintiffs’ favor, he wrote in his order Monday.

As part of his sanctions against Sutter, the judge ordered the health system to examine email backup tapes covering 2002 through 2005 to search for documents on some of the same topics as the destroyed records. Also, Karnow said he will consider a plaintiffs’ motion for issuing jury instructions that are adverse to Sutter in light of the document destruction. The trial is scheduled for June 2019.

“The record shows that Sutter’s conduct was more than just an inadvertent error,” Karnow wrote.

Sutter spokeswoman Karen Garner said the incident was a “mistake made as part of a routine destruction of old paper records” and the Sacramento-based health system disclosed the error as soon as it was discovered.

“We regret that as part of a routine archiving process we failed to preserve some boxes of decades-old hard-copy documents,” Garner said.

The United Food and Commercial Workers and its Employers Benefit Trust initially filed the case against Sutter in 2014. The joint employer-union health plan represents more than 60,000 employees, dependents and retirees. The court certified the case as a class action in August, allowing hundreds of other employers and self-funded health plans to potentially benefit from the litigation.

In addition to its 24 hospitals, Sutter’s nonprofit health system has 35 surgery centers and more than 5,000 physicians in its network. It reported $11.9 billion in revenue last year and income of $554 million.

Grossman, the plaintiffs’ counsel, said he welcomed the judge’s ruling. But he said much of the evidence is irreplaceable, particularly handwritten notes from negotiating sessions and meetings involving key Sutter executives.

He said those records covered a critical period in the early 2000s when there was a “sea change in Sutter’s contracting strategy” and it implemented provisions that insulated the health system from price competition.

“This was groundbreaking in the industry,” Grossman said. “Until we address the anti-competitive behavior of entities like Sutter, we will not solve the problem of high costs in health care.”

The plaintiffs are seeking to recover hundreds of millions of dollars from Sutter from what it claims are illegally inflated prices. The lawsuit alleges that an overnight hospital stay at Sutter hospitals in San Francisco or Sacramento costs at least 38 percent more than a comparable stay in the more competitive Los Angeles market.

A study published last year found that hospital prices at Sutter and Dignity Health, the two biggest hospital chains in California, were 25 percent higher than at other hospitals around the state. Researchers at the University of Southern California said the giant health systems used their market power to drive up prices — making the average patient admission at both chains nearly $4,000 more expensive.

“Sutter is a pretty extreme case of market power, but health care consolidation has become a really important issue across the country,” said Kathy Hempstead, a health care researcher at the Robert Wood Johnson Foundation. “It’s been on the back burner somewhat because of the debate over the Affordable Care Act, but there is bipartisan interest in tackling this.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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For Millions of Insured Americans, State Health Laws Don’t Apply

Let’s say you have health insurance through your employer and live in one of 21 states with laws protecting consumers against surprise medical bills from out-of-network providers.

Should one of those unwanted bills land in your mailbox, you can turn to your state law and regulators for help, right?

Not necessarily.

If you’re among the millions of Americans with a category of job-based health coverage known as self-funded insurance, most state health care laws do not apply to you.

Plus, if you have an issue with your coverage, you must go through a different appeals process than other state residents with private insurance. You must seek help from a federal regulator that may — or may not — be responsive.

“We have unequal consumer protections for a big chunk of our population,” says Tam Ma, legal and policy director for the advocacy group Health Access California.
For Millions of Insured Americans, State Health Laws Don’t Apply
Nationally, 61 percent of covered workers were in self-funded plans last year, according to the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

In California, about 5.7 million people were enrolled in such plans. Last year, the Golden State’s two health insurance regulators received more than 1,000 requests for help from consumers in self-funded plans. The departments have no authority over those plans and had to refer many of the enrollees to the U.S. Department of Labor, which regulates them.

Businesses that opt for self-funded plans — also called self-insured plans — generally pay the medical bills of their employees directly.

Under a fully insured plan, on the other hand, the employer — or an individual or family — buys coverage from a state-regulated insurance company, which assumes the financial risk. In California, fully insured plans are overseen by the state Department of Managed Health Care or the state Department of Insurance.

Large companies are more likely to self-insure. Among companies with 5,000 or more employees, 94 percent of covered workers were in self-funded plans last year, KFF data show.

More businesses — including smaller ones — are self-insuring because they can save money, says Dean Hoffman, an employee benefits consultant based in Wisconsin who specializes in self-insured plans.

One way they save is by avoiding the cost of complying with state-mandated benefits. For example, Hoffman says, for every premium dollar spent on fully insured plans in Wisconsin, about 11 cents goes toward state-mandated requirements.

“Every time you add a benefit, there’s a price associated with that,” he says.

It might not be obvious that you’re covered by a self-funded plan. Most businesses contract with health insurance companies to administer them, pay claims and provide access to their provider networks. That means your insurance card will likely have a Cigna, Blue Shield or other familiar logo on it even if your plan is self-funded.

If you’re not sure whether your plan is self-insured, ask your human resources department.

“To the consumer, it feels no different,” says Karen Pollitz, a senior fellow at KFF. “If you work for a big company, it’s a pretty good bet you’re in a self-funded plan.”

If you are, you may feel the difference in coverage, consumer protection and grievance procedures, however. “The only consumer protections available to those folks are just what federal law provides,” Ma says.

Consider state laws relating to surprise medical bills. Among the states that have adopted various protections against such bills, Connecticut, Illinois, New York, Florida, Maryland and California have the strongest and most comprehensive measures.

But even if you live in one of these states, “you still might get hit by large medical bills” if you’re in a self-funded plan, Pollitz says.

Some self-insured businesses, however, voluntarily provide many of the same protections as state law, says Lauren Vela, a senior director at the Pacific Business Group on Health, which represents about 75 companies that self-insure nationwide.

In the case of surprise bills — from out-of-network doctors such as anesthesiologists, for instance — “a lot of employers, not all of them, would have it written into their plan that it would not be considered out-of-network,” Vela says. “No employer wants to have employees get these kinds of surprise bills.”

To handle complaints about coverage, most states have laws allowing consumers in private health plans to appeal to an independent, external reviewer chosen by the state if your plan denies a claim and you disagree, Ma says.

In self-insured plans, you are entitled to external review — but your employer chooses, hires and pays the reviewer, Pollitz says. “It’s not independent in the way that state programs are.”

Plus, your regulator, the U.S. Department of Labor, may be slow to get involved in the grievance process, Ma says.

The department “doesn’t really have the resources or the ability to protect consumers in a timely way,” she says. “It may take them a very long time to get to your case, if they do at all, compared to state-regulated plans.”

So, if you’re in a self-funded plan and disagree with a coverage decision, look at your explanation of benefits, which will describe how to appeal. You can also ask your human resources department for guidance, or your union, if one represents you.

Most experts agree that your first step will likely be to contact the customer service line on your insurance card and request a review.

If your concern isn’t resolved that way, reach out to the Employee Benefits Security Administration (EBSA) through the Department of Labor at 866-444-3272 or www.askebsa.dol.gov.

EBSA “has experts who can help on this,” says Michael Trupo, a spokesman for the department, though he did not answer follow-up questions for more details.

If you don’t get your questions answered, many states have Consumer Assistance Programs that help you navigate insurance problems, including those with self-funded plans. The Department of Managed Care administers California’s program, which can be reached at 888-804-3536.

“They’ll help you file your appeal and make inquiries on your behalf,” Pollitz says. “They can be your advocate.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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California Fines Anthem $5 Million For Failing to Address Consumer Grievances

California’s managed-care regulator has fined insurance giant Anthem Blue Cross $5 million for repeatedly failing to resolve consumer grievances in a timely manner.

The state Department of Managed Health Care criticized Anthem, the nation’s second-largest health insurer, for systemic violations and a long history of flouting the law in regard to consumer complaints.

“Anthem Blue Cross’ failures to comply with the law surrounding grievance and appeals rights are long-standing, ongoing and unacceptable,” said Shelley Rouillard, director of the Department of Managed Health Care. “Anthem knows this is a huge problem, but they haven’t addressed it.”

Before this latest action, California had already fined Anthem more than $6 million collectively for grievance-system violations since 2002.

The state said it identified 245 grievance-system violations during this latest investigation of consumer complaints at Anthem from 2013 to 2016.

Rouillard cited one example in which Anthem denied a submitted claim for an extensive surgical procedure, even though it had issued prior approval for the operation. Twenty-two calls contesting the denial — placed by the patient, the patient’s spouse, the couple’s insurance broker and the medical provider — failed to resolve the complaint. It was not until the patient sought help from the managed-care agency, more than six months after the treatment, that Anthem paid the claim.

Anthem Inc. could not be immediately reached for comment. The company, based in Indianapolis, sells Blue Cross policies in California and 13 other states.

California is known for having tough consumer protection laws on health coverage and for assisting policyholders when they exhaust their appeals with insurers. In other actions, the state has fined insurers for overstating the extent of their doctor networks and for denying patients timely access to mental health treatment.

Jamie Court, president of Consumer Watchdog, an advocacy group in Santa Monica, Calif., said the regulatory response to these problems varies greatly by state.  He singled out New York, Washington and Kansas as some of the states with good track records of holding health insurers accountable.

“The real problem is when states don’t act there is not a great avenue for the consumer. It’s very hard to bring legal action,” Court said. “Anthem definitely needed a wake-up call. But this will also send a message to other insurers.”

Nationally, consumers continue to express their displeasure with health insurers over a wide range of issues, including denials for treatment, billing disputes and the lack of in-network doctors.

Verified complaints related to health insurance and accident coverage rose 12 percent in 2016 compared to the previous year, totaling 53,680, according to data compiled by the National Association of Insurance Commissioners. The data only includes incidents in which state regulators confirmed there was a violation or error by the insurer involved.

Court and other advocates welcomed the significant fine in California and said this is just the latest example of Anthem’s failure to uphold basic consumer protections.

Overall, state officials said that calls to Anthem’s customer service department often led to repeated transfers of calls and that the company failed to follow up with enrollees.

After previous fines, Anthem has pledged to provide more training to employees and to better track grievances and appeals in order to reduce delays.

“If you look at the history of Anthem and the penalties assessed over the years, they are definitely an outlier compared to other health plans,” Rouillard said.

“All the plans have some issues with grievances, but nothing to the degree we are seeing with Anthem.”

The managed-care department said a health plan’s grievance program is critical, so that consumers know they have the right to pursue an independent medical review or file a complaint with regulators if they are dissatisfied with the insurer’s decision. The grievance system can also help insurers identify systemic problems and improve customer service, state officials said.

The state’s independent medical review program allows consumers to have their case heard by doctors who are not tied to their health plan. The cases often arise when an insurer denies a patient’s request for treatment or a prescription drug.

In 2016, insurance company denials were overturned in nearly 70 percent of medical review cases and patients received the requested treatment, according to state officials.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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California Firm Running Physician Practices Is Closing Down as Scrutiny Ramps Up

SynerMed, a company that manages physician practices serving hundreds of thousands of Medicaid and Medicare patients across California, is planning to shut down amid scrutiny from state regulators and health insurers.

The company’s chief executive, James Mason, notified employees in an internal email Nov. 6, obtained by Kaiser Health News, that audits by health plans found “several system and control failures within medical management and other departments.”

As a result, Mason wrote, the company “will begin the legal and operational steps to shut down all operations.” He said he was working on the transition of SynerMed’s clients to another management firm within the next 180 days.

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Separately, the California Department of Managed Health Care confirmed it is investigating the company.

“There is an open investigation of SynerMed, but the details are confidential right now,” said spokesman Rodger Butler. His agency monitors the financial solvency and claims-payment practices of many physician groups that contract with health plans.

The company’s sudden decision to shut down has sparked alarm among some doctors and medical groups that have relied on the company to handle their finances and business operations.

For years, SynerMed has served as a key middleman between health plans and independent physician practices, handling insurance contracting, paying claims and performing other administrative tasks so doctors can focus on treating patients. That role has expanded as millions more Californians are enrolled in Medicaid managed-care plans under the Affordable Care Act.

SynerMed has billed itself as “one of the largest Medicaid/Medicare management service organizations in the nation.” Last year, the company boasted that it had enrollment of 1 million patients in California, aided by an influx of enrollees who got coverage under the federal health law.

Mason, the CEO, didn’t respond to requests for comment. The company referred calls to its general counsel, but she couldn’t be reached.

In his email to employees, Mason said he had “discovered certain internal control issues within the medical management department.”

“Well,” he wrote, “as a result of the manner in which those issues were disclosed to the health plans and regulatory agencies, we have been subject to unannounced audits by almost all of our health plan partners.”

The CEO said two medical groups, AlphaCare and EHS (Employee Health Systems) Medical Group, have already terminated their contracts with SynerMed.

“I am heartbroken and saddened by these events after we have worked so hard to build our reputation as a company that operates with integrity,” Mason wrote in his email to employees.

Part of SynerMed’s growth had come from managing care for low-income seniors and people with disabilities who are eligible for both Medicare and Medicaid, called Medi-Cal in California. The state has been at the forefront nationally in trying to shift those “dual-eligible” patients into managed-care plans, which are paid a fixed rate per patient to coordinate a range of medical care.

A spokesman for the Medi-Cal program said the agency had no information to share on SynerMed.

SynerMed is a subsidiary of PAMC, Ltd., which also owns Pacific Alliance Medical Center in Los Angeles’ Chinatown. The hospital agreed to pay $42 million in June to settle federal allegations of improper kickbacks to referring physicians.

The U.S. Justice Department said Pacific Alliance Medical Center agreed to the settlement to resolve a whistleblower lawsuit alleging that the hospital submitted false claims to Medi-Cal and Medicare. In a news release at the time, federal officials said the hospital and its owners did not admit liability in settling the case.

The hospital is closing later this month. Officials there attributed the closure to the fact that the lease on the property is ending and it wasn’t financially feasible to retrofit facilities to meet the state’s seismic requirements.

In a statement to Kaiser Health News, PAMC said “there is no connection between the closure of [the hospital] and any matters involving SynerMed. SynerMed is a wholly owned subsidiary that provides completely different services.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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Can Apps Slay The Medical Bill Dragon?

Rachael Norman needed to submit a pile of out-of-network medical bills to her insurance company for reimbursement. Short on time, she started searching for a company that could do that tedious work for her.

She failed to find one, so she started one herself.

Norman said her company, Better, along with a handful of other Silicon Valley start-ups, is attempting to usher medical billing technology into the 21st century. Banking, transportation, furniture and grocery shopping can all be managed with some fancy finger work on smartphone screens. She and other entrepreneurs wondered: Why not medical bills?

Today, Norman’s clients submit digital copies of their out-of-network bills through an app on their phones. Better’s employees navigate the bureaucratic thicket to track down reimbursements — and keep 10 percent of the money they recover from insurers.

The company has processed millions of dollars in claims, for everything from psychiatry to acupuncture to contact lenses, Norman said. The majority of Better’s customers have Preferred Provider Organizations (PPOs) or other types of insurance policies with out-of-network benefits. Unlike visiting in-network doctors, patients using out-of-network services often must pay upfront, then ask for reimbursement from their insurer later.

“For a lot of people, it becomes magic that we’re able to solve those problems and get them the money they are owed from insurance,” said Norman, who founded Oakland-based Better about a year and a half ago.

Better is among a new breed of start-ups trying to lead customers through the labyrinth of medical billing. Each has taken on a different aspect of billing — helping patients file claims, scanning bills for errors or making charges easier to understand.

But in their quest to revolutionize an industry, these start-ups face a variety of obstacles, including trouble getting access to medical records and difficulty cracking complex insurance policies. Some of the young companies are flourishing. Others are folding.

Pairing a technological solution with an industry that still uses faxes, distant call centers and snail-mailed bills can prove challenging. “You can’t automate repeated phone calls to a guy in a basement who doesn’t want to do his job,” said Victor Echevarria, whose company, Remedy Labs, folded two years after he founded it.

The emergence of these businesses reflects the fact that medical billing is a complicated, often byzantine process that can mystify even the savviest consumers. Adding insult, these bills often start to pile up while patients are still at their lowest — either dealing with serious medical issues, or just beginning to recover.

Kristin-Leigh Brezinski, who works for a small tech company in Seattle, said she started using Better to address a pile of therapy bills she’d been meaning to submit for reimbursement. She had put off the task partly because she knew it would be a headache to spend hours on interminable phone calls, she said.

“I didn’t really want to sit on hold for the rest of my life,” said Brezinski, 28. She liked Better’s service so much that she continues to use it and has recommended it to others.

Experts agree that consumers need help tackling costly and complicated medical bills.

“Medical problems and medical bills are very likely to be the straw that breaks the camel’s back of a family’s finances,” said Anthony Wright, executive director of Health Access California, a health care consumer advocacy organization.

Wright said the Affordable Care Act provided some protection for people, such as banning annual and lifetime limits on coverage and capping out-of-pocket maximums.

Many states, including California, have also adopted consumer protections against surprise medical bills. These are the often costly charges consumers receive from out-of-network providers, even though they went to an in-network facility.

Despite those advances, Wright said many aspects of medical billing remain a major problem for consumers. He thinks apps might help patients navigate certain issues, but policy fixes could be even more effective.

For example, an app could notify consumers when they’ve hit their annual out-of-pocket maximum, but the state could simply require insurers to provide that notice, negating the need for the app.

“I would love to put in place some laws and consumer protections that make some of these apps obsolete,” Wright said.

The landscape isn’t necessarily friendly to medical billing start-ups, as Echevarria discovered after he founded San Francisco-based Remedy Labs two years ago.

He was inspired to tackle the problem of medical overbilling after his infant son had to go to the emergency room for a fever-related seizure and his family incurred about $12,000 dollars in medical bills, many of them laced with errors.

Co-founder Marija Ringwelski had looked at her own bills and found errors about 80 percent of the time. The two decided to build a platform similar to Credit Karma, the popular credit and financial management platform that offers a free credit score and free credit monitoring. Only this one would be for medical bills.

“Everybody wanted that product,” Echevarria said. “They wanted the medical bill version of identity protection.”

Using new technology and a team of experts that scrutinized clients’ medical bills in search of errors, Remedy eventually figured out how to operate efficiently in all ways but one, Echevarria said: While patients had a legal right to their own medical information, many billing offices refused to hand it over to third parties.

“The industry operates in a way that is decades old,” he said. While a lot of the operation could be automated, some of it remains frustratingly hands-on and time-intensive, he said.

The problem proved insurmountable, and the company went out of business this past summer.

Even if companies manage to get their hands on required medical records, insurance policies are extremely complicated and can be difficult to navigate, said Betsy Imholz, special projects director for Consumers Union.

Rules vary among companies, and regulations among states, she said. To help an individual, companies must comb through piles of documents and figure out each customer’s specific situation. As Remedy’s experience illustrates, that process can’t always be accomplished with simple technology.

There’s also a marketing problem: Many consumers “don’t realize there’s help to be had,” said Mark Hall, director of the Health Law and Policy Program at Wake Forest University’s School of Law.

Palo Alto-based Simplee addressed some of these challenges by shifting its business model.

Rather than directly serving consumers — as it did when it was a new start-up seven years ago — Simplee now markets its software to hospitals. Its clients currently include more than 400 hospitals and more than 2,000 clinics.

The software gives patients access to all of their bills in one place and attempts to make charges easier for them to understand. It also allows patients to see detailed explanations of charges and to create payment plans when necessary, said John Adractas, the company’s chief commercial officer.

“It’s not like there’s one formula for how to tackle health care problems,” Adractas said.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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Taking A Page From Pharma’s Playbook To Fight The Opioid Crisis

https://californiahealthline.files.wordpress.com/2017/11/unsellingopioidsbartolone.mp3

Dr. Mary Meengs remembers the days, a couple of decades ago, when pharmaceutical salespeople would drop into her family practice in Chicago, eager to catch a moment between patients so they could pitch her a new drug.

Now living in Humboldt County, Calif., Meengs is taking a page from the pharmaceutical industry’s playbook with an opposite goal in mind: to reduce the use of prescription painkillers.

Meengs, medical director at the Humboldt Independent Practice Association, is one of 10 California doctors and pharmacists funded by Obama-era federal grants to persuade medical colleagues in Northern California to help curb opioid addiction by altering their prescribing habits.

She committed this past summer to a two-year project consisting of occasional visits to medical providers in California’s most rural areas, where opioid deaths and prescribing rates are high.

“I view it as peer education,” Meengs said. “They don’t have to attend a lecture half an hour away. I’m doing it at [their] convenience.”

This one-on-one, personalized medical education is called “academic detailing” — lifted from the term “pharmaceutical detailing” used by industry salespeople.

Detailing is “like fighting fire with fire,” said Dr. Jerry Avorn, a Harvard Medical School professor who helped develop the concept 38 years ago. “There is some poetic justice in the fact that these programs are using the same kind of marketing approach to disseminate helpful evidence-based information as some [drug] companies were using … to disseminate less helpful and occasionally distorted information.”

Recent lawsuits have alleged that drug companies pushed painkillers too aggressively, laying the groundwork for widespread opioid addiction.

Avorn noted that detailing has also been used to persuade doctors to cut back on unnecessary antibiotics and to discourage the use of expensive Alzheimer’s disease medications that have side effects.

Kaiser Permanente, a large medical system that operates in California, as well as seven other states and Washington, D.C., has used the approach to change the opioid-prescribing methods of its doctors since at least 2013. (Kaiser Health News is not affiliated with Kaiser Permanente.)

In California, detailing is just one of the ways in which state health officials are attempting to curtail opioid addiction. The state is also expanding access to medication-assisted addiction treatment under a different, $90 million grant through the federal 21st Century Cures Act.

The total budget for the detailing project in California is less than $2 million. The state’s Department of Public Health oversees it, but the money comes from the federal Centers for Disease Control and Prevention through a program called “Prevention for States,” which provides funding for 29 states to help combat prescription drug overdoses.

The California doctors and pharmacists who conduct the detailing conversations are focusing on their peers in the three counties hardest hit by opioid addiction: Lake, Shasta and Humboldt.

They arrive armed with binders full of facts and figures from the CDC to help inform their fellow providers about easing patients off prescription painkillers, treating addiction with medication and writing more prescriptions for naloxone, a drug that reverses the toxic effects of an overdose.

“Academic detailing is a sales pitch, an evidence-based … sales pitch,” said Dr. Phillip Coffin, director of substance-use research at San Francisco’s Department of Public Health — the agency hired by the state to train the detailers.

In an earlier effort, Coffin said, his department conducted detailing sessions with 40 San Francisco doctors, who have since increased their prescriptions of naloxone elevenfold.

“One-on-one time with the providers, even if it was just three or four minutes, was hugely beneficial,” Coffin said. He noted that the discussions usually focused on specific patients, which is “way more helpful” than talking generally about prescription practices.

Meengs and her fellow detailers hope to make a dent in the magnitude of addiction in sparsely populated Humboldt County, where the opioid death rate was the second-highest in California last year — almost five times the statewide average. Thirty-three people died of opioid overdoses in Humboldt last year.

One recent afternoon, Meengs paid a visit during the lunch hour to Fortuna Family Medical Group in Fortuna, a town of about 12,000 people in Humboldt County.

“Anybody here ever known somebody, a patient, who passed away from an overdose?” Meengs asked the group — a physician, two nurses and a physician assistant — who gathered around her in the waiting room, which they had temporarily closed to patients.

“I think we all do,” replied the physician, Dr. Ruben Brinckhaus.

Brinckhaus said about half the patients at the practice have a prescription for an opioid, anti-anxiety drug or other controlled substance. Some of them had been introduced to the drugs years ago by other prescribers.

Dr. Ruben Brinckhaus says his small family practice in Fortuna, Calif., has been trying to wean patients off opiates. (Pauline Bartolone/California Healthline)

Meengs’ main goal was to discuss ways in which the Fortuna group could wean its patients off opioids. But she was not there to scold or lecture them. She asked the providers what their challenges were, so she could help them overcome them.

Meengs will keep making office calls until August 2019 in the hope that changes in the prescribing behavior of doctors will eventually help tame the addiction crisis.

“It’s a big ship to turn around,” said Meengs. “It takes time.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California Healthline, Health Industry, Mental Health, Public Health

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