Tagged Health Care Costs

Industry Roundup: A Medicare Advantage Pay Bump; Hospitals’ Partnerships With Local Agencies; Social Safety Nets And Health

Second Time Around? Health Care Issues Trump Might Tackle If Reelected

If President Donald Trump wins a second term in the White House, what health care policies might the nation expect from his administration?

Julie Rovner, Kaiser Health News’ chief Washington correspondent, examines that issue in the new edition of Washington Monthly magazine.

Although changes in health care might not have ranked high on the president’s priorities for a second term ― particularly if Democrats retain a majority in the House of Representatives — external factors such as the coronavirus pandemic could force the White House and Congress to work together to improve the nation’s public health infrastructure. And the administration might move to weaken the Affordable Care Act through regulations. You can read the article here.

Related Topics

Elections Health Care Costs Health Industry Public Health

First Pandemic Since Health Law Was Instituted Will Put It Through The Wringer

‘You’ve Been Served’: Wisconsin Hospitals Sued Patients Even During Pandemic

When her doorbell rang Sunday night, Blanche Jordan was just starting a new Game of Thrones puzzle on her living room floor.

Jordan, 39, is a breast-cancer survivor who is taking social distancing seriously, so she put on a mask before opening the door. A woman handed Jordan a paper and said: “You’ve been served.”

The paper was a court summons that said Froedtert Memorial Lutheran Hospital, Inc. was suing Jordan for $7,150. Just three weeks before, Jordan had paid off a different $5,000-plus Froedtert debt linked to a hysterectomy that her insurance did not cover.

A lawsuit was the last thing Jordan expected during a viral pandemic.

“This lady came to my door. She didn’t have a mask on. She didn’t have gloves. And she looked at me like I’m crazy because I had a mask across my face,” said Jordan, who lives in Milwaukee and works as a caregiver at an assisted living facility outside of the city. “I’m high-risk,” she said.

Life in Wisconsin, as in the rest of the country, has been transformed by COVID-19 in the past three weeks. Wisconsin declared a public health emergency on March 12, yet firms representing health systems in the state continued to sue patients over medical debt.

Jordan is one of at least 46 people sued by Froedtert in small claims court since March 12. Those cases are among at least 104 similar suits filed statewide by health systems over the same period, according to an analysis of small claims cases by Wisconsin Public Radio and Wisconsin Watch.

Steve Schooff, a spokesman for the hospital, said Tuesday that Froedtert “suspended filing small claims suits” as of March 18 in response to COVID-19.

“In addition, we continue to work with patients related to financial counseling and are allowing patients with financial hardship who are on a payment plan to defer payments while financial assistance is discussed with them,” he said.

Yet court records at the time showed at least 18 lawsuits filed on the hospital’s behalf since then, including 15 filed on March 31 alone. (The suit against Jordan was filed on March 17; she was served on March 29.) Schooff did not explain the discrepancy. All 18 of those cases have since been dismissed.

‘Really? In The Middle Of All This?’

Court records show that at least six additional health systems have also sued patients during the pandemic.

UW Health in Madison has filed 19 lawsuits since March 12. Marshfield Clinic, which covers northern, central and western Wisconsin, has filed at least 14 since that date, followed by Bellin Health, based in Green Bay (11); La Crosse-based Gundersen Health System (10); and Aspirus Grand View Health System, which serves parts of northern Wisconsin (3). Froedtert South, which serves southeastern Wisconsin, also filed one suit.

Bellin chief operating officer and chief financial officer Jim Dietsche said Thursday the health system ceased legal actions on debt collection on March 18, and that the nine suits filed since then were “an error and we apologize for that.”

The five other systems contacted for this story said they have since paused certain legal actions, which court records support.

Tom Russell, a UW Health spokesman, said the health system instructed its legal agencies on March 26 “to cease pursuit of any legal activity.”

“These should be stopped for now,” he said.

Tom Duncan, vice president and chief operating officer for Froedtert South, said his system has generally “suspended filing small claim suits” during the pandemic. “However, in rare circumstances, certain small claim suits may be filed to preserve Froedtert South rights. For example: If a medical debt has been in existence for six years, and the statute of limitations is about to end.”

One Madison resident described being “mortified” when a process server knocked on her family’s door on March 28 to serve papers for a UW Health lawsuit over $1,135.90 in medical debt. UW Health filed that lawsuit before March 26. In a phone interview, the resident asked not to be named in this story because she was embarrassed by the debt related to her husband’s heart condition.

“I couldn’t believe someone would do that,” she said about receiving legal papers during a pandemic. “They’re our bills, but really? In the middle of all of this?”

The woman said her husband offered the process server sympathy, apologizing that the man had to serve papers during a public health emergency.

The woman, who works for a Madison-based nonprofit, saw things differently. “That’s a choice, too. I wouldn’t be able to sleep at night.”

Medical Debts And State Response

Some hospitals have stopped the practice of suing patients in recent months following investigative reporting by Kaiser Health News, MLK50, ProPublica and other outlets.

Jessica Roulette, an attorney with Legal Action of Wisconsin, which provides free legal services to low-income people, said medical bills often fall below things like rent, utilities and food in the “hierarchy of bills and obligations.” Most people facing hospital lawsuits are working and “underinsured,” with plans that leave them on the hook for thousands of dollars in health bills, Roulette said.

Bobby Peterson, executive director of ABC for Health, a nonprofit public-interest law firm in Madison, called it stressful under normal circumstances to face a medical debt lawsuit.

“Today it’s a whole new ballgame,” he said, referring to workers who have lost their jobs and possibly health insurance during the pandemic.

Peterson saw a possible disconnect between some hospitals’ recent decisions to stop suing and the law firms they’ve retained.

“Are the hospitals communicating their own policies internally? And are they communicating with their hired guns out there, making sure that they back off?” Peterson asked.

Paycheck To Paycheck

The state of Wisconsin considers Blanche Jordan, the Milwaukee caregiver, an “essential” worker during the pandemic, meaning her job is not subject to the “Safer At Home” order. She works five days each week at an assisted living facility from 7 a.m. to 3 p.m., alternating work on the weekends. The pay — $15.75 per hour — barely covers her expenses.

Rent, health insurance, utilities and the nearly $300 in garnishments by Froedtert that recently ended, left Jordan with little of her $1,300 biweekly paycheck to spend on other necessities. She filed for bankruptcy in 2016 when, despite being insured, she said she could no longer afford to pay off her debts from treating her aggressive breast cancer.

That journey briefly left her homeless following an eviction, but she generally manages to pay her current landlord on time, Jordan said.

“I’m blessed to have a landlord that’s understanding because his wife died of breast cancer,” she said.

Jordan said her most recent medical debt stemmed from a hysterectomy that was separate from but related to her cancer treatment. She chose Froedtert to perform the procedure, considering it “the best hospital that we have in Wisconsin.”

What she did not realize, she said: Froedtert did not accept her insurance, which she purchased on a federal exchange created by the Affordable Care Act. Hospital administrators accepted and ran her insurance card, Jordan said, but never mentioned that her insurer would not cover the procedure.

In 2019, a judge in the Milwaukee County Small Claims Commissioner Court awarded Froedtert a judgment against Jordan for about $5,300, including court fees, which the hospital claimed by garnishment of her wages. She finished paying that debt during the first week of March — only to be served papers for the alleged $7,150 debt three weeks later.

Jordan assumes this covers the remainder of the bill for her hysterectomy, which she remembers totaling around $12,000. Wisconsin caps small claims at $10,000.

She will eventually see her day in court, although it’s not clear when. The coronavirus postponed her court date to May 28, assuming court proceedings resume by then.

Until then, Jordan will continue to take care of people at the assisted living facility, and she will otherwise stay isolated at home, she said, likely playing Scrabble or Uno with her family.

This story is part of a partnership that includes Wisconsin WatchWisconsin Public RadioNPR and Kaiser Health News.

Related Topics

Cost and Quality Courts Health Care Costs Health Industry Insurance Public Health States

Advocates Say There Must Be Investment In Medicaid Which Will Likely Become Default Insurance Plan For Many

Analysis: He Got Tested For Coronavirus. Then Came The Flood Of Medical Bills.

By March 5, Andrew Cencini, a computer science professor at Vermont’s Bennington College, had been having bouts of fever, malaise and a bit of difficulty breathing for a couple of weeks. Just before falling ill, he had traveled to New York City, helped with computers at a local prison and gone out on multiple calls as a volunteer firefighter.

So with COVID-19 cases rising across the country, he called his doctor for direction. He was advised to come to the doctor’s group practice, where staff took swabs for flu and other viruses as he sat in his truck. The results came back negative.

In an isolation room, the doctors put Andrew Cencini on an IV drip, did a chest X-ray and took the swabs.(Courtesy of Andrew Cencini)

By March 9, he reported to his doctor that he was feeling better but still had some cough and a low-grade fever. Within minutes, he got a call from the heads of a hospital emergency room and infectious-disease department where he lives in upstate New York: He should come right away to the ER for newly available coronavirus testing. Though they offered to send an ambulance, he felt fine and drove the hourlong trip.

In an isolation room, the doctors put him on an IV drip, did a chest X-ray and took the swabs.

Now back at work remotely, he faces a mounting array of bills. His patient responsibility, according to his insurer, is close to $2,000, and he fears there may be more bills to come.

“I was under the assumption that all that would be covered,” said Cencini, who makes $54,000 a year. “I could have chosen not to do all this, and put countless others at risk. But I was trying to do the right thing.”

The new $2 trillion coronavirus aid package allocates well over $100 billion to what Senate Minority Leader Chuck Schumer of New York called “a Marshall Plan” for hospitals and medical needs.

But no one is doing much to similarly rescue patients from the related financial stress. And they desperately need protection from the kind of bills patients like Cencini are likely to incur in a system that freely charges for every bit of care it dispenses.

On March 18, President Donald Trump signed a law intended to ensure that Americans could be tested for the coronavirus free, whether they have insurance or not. (He had also announced that health insurers have agreed to waive patient copayments for treatment of COVID-19, the disease caused by the virus.) But their published policies vary widely and leave countless ways for patients to get stuck.

Although insurers had indeed agreed to cover the full cost of diagnostic coronavirus tests, that may well prove illusory: Cencini’s test was free, but his visit to the ER to get it was not.

As might be expected in a country where the price of a knee X-ray can vary by a factor of well over 10, labs so far are charging between about $51 (the Medicare reimbursement rate) and more than $100 for the test. How much will insurers cover?

Those testing laboratories want to be paid — and now. Last week, the American Clinical Laboratory Association, an industry group, complained that they were being overlooked in the coronavirus package.

“Collectively, these labs have completed over 234,000 tests to date, and nearly quadrupled our daily test capacity over the past week,” Julie Khani, president of the ACLA, said in a statement. “They are still waiting for reimbursement for tests performed. In many cases, labs are receiving specimens with incomplete or no insurance information, and are burdened with absorbing the cost.”

There are few provisions in the relief packages to ensure that patients will be protected from large medical bills related to testing, evaluation or treatment — especially since so much of it is taking place in a financial high-risk setting for patients: the emergency room.

In a study last year, about 1 in 6 visits to an emergency room or stays in a hospital had at least one out-of-network charge, increasing the risk of patients’ receiving surprise medical bills, many demanding payment from patients.

That is in large part because many in-network emergency rooms are staffed by doctors who work for private companies, which are not in the same networks. In a Texas study, more than 30% of ER physician services were out-of-network — and most of those services were delivered at in-network hospitals.

The doctor who saw Cencini works with Emergency Care Services of New York, which provides physicians on contract to hospitals and works with some but not all insurers. It is affiliated with TeamHealth, a medical staffing business owned by the private equity firm Blackstone that has come under fire for generating surprise bills.

Some senators had wanted to put a provision in legislation passed in response to the coronavirus to protect patients from surprise out-of-network billing — either a broad clause or one specifically related to coronavirus care. Lobbyists for hospitals, physician staffing firms and air ambulances apparently helped ensure it stayed out of the final version. They played what a person familiar with the negotiations, who spoke on the condition of anonymity, called “the COVID card”: “How could you possibly ask us to deal with surprise billing when we’re trying to battle this pandemic?”

Even without an ER visit, there are perilous billing risks. Not all hospitals and labs are capable of performing the test. And what if my in-network doctor sends my coronavirus test to an out-of-network lab? Before the pandemic, the Kaiser Health News-NPR “Bill of the Month” project produced a feature about Alexa Kasdan, a New Yorker with a head cold, whose throat swab was sent to an out-of-network lab that billed more than $28,000 for testing.

Even patients who do not contract the coronavirus are at a higher risk of incurring a surprise medical bill during the current crisis, when an unrelated health emergency could land you in an unfamiliar, out-of-network hospital because your hospital is too full of COVID-19 patients.

The coronavirus bills passed so far — and those on the table — offer inadequate protection from a system primed to bill patients for all kinds of costs. The Families First Coronavirus Response Act, passed last month, says the test and its related charges will be covered with no patient charge only to the extent that they are related to administering the test or evaluating whether a patient needs it.

That leaves hospital billers and coders wide berth. Cencini went to the ER to get a test, as he was instructed to do. When he called to protest his $1,622.52 bill for hospital charges (his insurer’s discounted rate from over $2,500 in the hospital’s billed charges), a patient representative confirmed that the ER visit and other services performed would be “eligible for cost-sharing” (in his case, all of it, since he had not met his deductible).

This weekend he was notified that the physician charge from Emergency Care Services of New York was $1,166. Though “covered” by his insurance, he owes another $321 for that, bringing his out-of-pocket costs to nearly $2,000.

By the way, his test came back negative.

When he got off the phone with his insurer, his blood was “at the boiling point,” he told us. “My retirement account is tanking and I’m expected to pay for this?”

The coronavirus aid package provides a stimulus payment of $1,200 per person for most adults. Thanks to the billing proclivities of the American health care system, that will not fully offset Cencini’s medical bills.

Related Topics

Health Care Costs Insurance Public Health States

Pandemic-Stricken Cities Have Empty Hospitals, But Reopening Them Is Difficult

As city leaders across the country scramble to find space for the expected surge of COVID-19 patients, some are looking at a seemingly obvious choice: former hospital buildings, sitting empty, right downtown.

In Philadelphia, New Orleans, and Los Angeles, where hospitalizations from COVID-19 increase each day, shuttered hospitals that once served the city’s poor and uninsured sit at the center of a public health crisis that begs for exactly what they can offer: more space. But reopening closed hospitals, even in a public health emergency, is difficult.

Philadelphia, the largest city in America with no public hospital, is also the poorest. There, Hahnemann University Hospital shut its doors in September after its owner, Philadelphia Academic Health System, declared bankruptcy. While not public, the 496-bed safety-net hospital mainly treated patients on public insurance. Philadelphia Mayor Jim Kenney began talks with the building’s owner, California-based investment banker Joel Freedman, as soon as his administration saw projections that the demand for hospital beds during the pandemic would outpace the city’s capacity. Not long after negotiations started, city officials announced the talks were going badly.

“Mr. Freedman was difficult to work with at times when he was the owner of the hospital, and he is still difficult to work with as the owner of the shuttered hospital,” said Brian Abernathy, who is Philadelphia’s managing director and heading the city’s COVID-19 response.

In New Orleans, where the soaring COVID-19 infection rate is disproportionately high compared with its population, Charity Hospital sits vacant in the middle of town. The former public hospital never reopened after Hurricane Katrina in 2005. The Louisiana State University System, which owns the building, incorporated Charity Hospital into the city’s new medical center, but the original building remains vacant. Instead of using it during the pandemic, the New Orleans Convention Center is being converted to a “step-down” facility with the capacity to treat up to 2,000 patients after they no longer need critical care.

Elsewhere, city governments have struck deals with the owners of empty hospital buildings to lease their space. At St. Vincent Medical Center in Los Angeles, the city is paying $236 per night per bed, for a total of $2.6 million each month.

In Philadelphia, Freedman offered the Hahnemann building to the city for $27 per bed per night, plus taxes, maintenance and insurance, which the city would pay directly. All told, that added up to just over $900,000 per month.

“I think he is looking at how to turn an asset that is earning no revenue into an asset that earns some revenue, and isn’t thinking through what the impacts are on public health,” Abernathy said of Freedman. “I think he’s looking at this as a business transaction rather than providing an imminent and important aid to the city and our residents.”

This isn’t the first time Freedman has come under fire by Philadelphians for his handling of the hospital. Its closure sparked protests from city officials, health care unions, and even presidential hopeful Bernie Sanders. Critics speculated that Freedman, whose private equity firm bought the struggling hospital in 2018, didn’t try in earnest to save it and planned to flip it for its valuable downtown real estate. Notably, Hahnemann’s real estate was parsed out into a separate company, Broad Street Healthcare Properties, also owned by Freedman, and not included in Philadelphia Academic Health System’s Chapter 11 bankruptcy petition.

A representative for Freedman said the building has an interested buyer, and that is one reason Broad Street Healthcare will not let the city use the building at cost.

“We’re offering this facility because of the public benefit in a health crisis, but it comes at a cost to the property owner,” said Broad Street representative Sam Singer.

As urban hospitals have struggled in recent years, it’s become increasingly common for private equity to get involved: Big firms buy struggling medical centers with the promise of financial support and to improve their operations and business strategy. When things go right, the business succeeds, and the private equity firm sells it in a public offering or to another bidder for more than it paid.

In other cases, though, the firms load companies up with debt, take dividends out for themselves, sell off valuable real estate and charge fees and high-interest loans, leaving a company in a much weaker position than it would have been otherwise, and often on the verge of bankruptcy.

“The house never loses,” said Eileen Appelbaum, co-director at the Center for Economic and Policy Research. “The private equity firm makes money whether the company succeeds or it doesn’t.”

For instance, Steward Health Care was able to expand from its base in Massachusetts to a 36-hospital network nationwide with backing from Cerberus Capital Management. Now, said Appelbaum, the chain of community hospitals is stuck paying rent to Iasis, another private equity-owned company, on all its properties, while also struggling to stay in the black. The network announced last week it would furlough non-clinical workers across nine states because the requirement to cancel elective surgeries caused too great a financial strain.

Freedman’s private equity firm is called Paladin Healthcare, and it has previously bought and managed hospitals in California and Washington, D.C., where it helped the struggling Howard University Hospital out of the red. Paladin then sold the hospital to Adventist HealthCare last summer.

Urban hospitals like Hahnemann have struggled to stay afloat in recent years, in part due to their lack of privately insured patients. Hospitals often finance the care of uninsured patients or those on Medicaid by treating those with private insurance, which reimburses the hospitals faster and at a higher rate. At Hahnemann, two-thirds of patients were on Medicaid or Medicare. While a financially struggling public or nonprofit hospital might continue serving a poorer community, a for-profit hospital has different incentives, said Vickie Williams, a former law professor for Gonzaga University.

“If your urban hospital is purchased by a for-profit company and it doesn’t perform sufficiently, they don’t have the same necessarily mission-driven directives to keep that hospital functioning for the good of the community at a loss,” said Williams, who is now senior counsel for CommonSpirit Health in Tacoma, Washington.

Freedman has said that he tried to sell the Hahnemann property to a nonprofit and requested money from the city and state to keep it open, but neither option worked.

Following news that Philadelphia had abandoned negotiations with Freedman, calls to seize the property in order to save lives came pouring in, including from elected officials.

“Eminent Domain was created for situations like #Hahnemann,” City Council member Helen Gym wrote on Twitter. “This is a public health emergency and Philly is the largest city in the nation WITHOUT a public hospital. We cannot allow unconscionable greed to get in the way of saving lives. Eminent domain this property.” Legal experts say the lengthy process of eminent domain and the requirement to pay the owner fair market value for the building make it an unlikely mechanism for an instance like this.

But in public health emergencies, local, state and federal governments do have broad authority to commandeer private property, such as hotels, convention centers, university dormitories or even defunct hospitals for disaster response. Williams, whose research has focused on preserving hospital infrastructure during a pandemic, said that so far in the United States, that hasn’t had to happen ― at least not in the traditional sense.

In Pennsylvania, the governor’s emergency declaration gives him the authority to “commandeer or utilize any private, public or quasi-public property if necessary to cope with the disaster emergency.” A health department representative said all options remain on the table in the event that the city’s hospital bed capacity is overrun.

In the interim, the mayor made a deal with Temple University to use its basketball arena, which would have the capacity to treat 250 non-critical patients, at no cost to the city.

This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.

Related Topics

Cost and Quality Health Care Costs Health Industry Public Health States

KHN’s ‘What The Health?’: All Coronavirus All The Time


Can’t see the audio player? Click here to listen on SoundCloud.


The medical and economic needs laid bare by the coronavirus pandemic are forcing some immediate changes to the U.S. health system. Congress, in its latest relief bill, provided $100 billion in funding for the hospital industry alone. Meanwhile, the federal government has quickly removed previous barriers to telehealth and other sometimes controversial practices.

But big fights are still brewing, including whether the federal government will reopen the Affordable Care Act marketplaces it runs and whether states can use emergency powers to ban abortions as “elective medical procedures.”

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • The ACA was passed on the heels of the Great Recession. The coronavirus outbreak has produced the first big economic downturn since then, and the law’s provisions to expand Medicaid and to provide an insurance option to those without jobs could provide a critical safety net during this crisis.
  • About a dozen states running their own ACA insurance marketplaces have opened up enrollment again to let people who did not enroll in the fall but are feeling the pinch from the coronavirus pandemic to reconsider. President Donald Trump said this week that he is mulling a similar move, but the messages from the administration on such action have been confusing.
  • People who had insurance through work and have lost their jobs don’t need a special enrollment period to sign up for an Obamacare plan. They are eligible because their job situation changed. However, the administration has not been publicizing that message.
  • Hospitals are eager to receive the $100 billion appropriated by Congress in response to the influx of patients with COVID-19, the disease caused by the coronavirus. But the administration has not yet said how that money will be apportioned.
  • A handful of states have prohibited abortions during the coronavirus emergency because, officials say, they are seeking to preserve protective gear for hospital staff treating COVID-19 patients. But it’s not clear that the abortion procedures ― especially medication abortions — are interfering with efforts to safeguard protective clothing or masks needed by hospitals. And women who do not get abortions will consume far more medical care by remaining pregnant and giving birth.

Also, this week, Rovner interviews KHN’s Liz Szabo, who reported the latest KHN-NPR “Bill of the Month” installment about a patient who underwent a very expensive genetic test. If you have an outrageous medical bill you would like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The New York Times’ “A Ventilator Stockpile With One Hitch: Thousands Do Not Work,” by David E. Sanger, Zolan Kanno-Youngs and Nicholas Kulish

Joanne Kenen: The New Yorker’s “The Life and Death of Juan Sanabria, One of New York City’s First Cornavirus Victims,” by Jonathan Blitzer

Margot Sanger-Katz: Bloomberg News’ “Hospitals Tell Doctors They’ll Be Fired If They Speak Out About Lack of Gear,” by Olivia Carville, Emma Court and Kristen V. Brown

Alice Miranda Ollstein: The Washington Post’s “Trump Ban on Fetal Tissue Research Blocks Coronavirus Treatment Effort,” by Amy Goldstein


To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Related Topics

Cost and Quality Health Care Costs Health Industry Insurance Medicaid Multimedia Public Health States The Health Law Uninsured

These 2 LA Hospitals Are Worlds Apart From Each Other–And Neither Has Enough Equipment To Deal With Surge

Funding Cuts Come As Gut-Punch To New York Hospitals Stretched To The Limits With Surge Of Patients

Her Genetic Test Revealed A Microscopic Problem — And A Jumbo Price Tag

Michelle Kuppersmith, 32, feels great, works full time and exercises three to four times a week. So she was surprised when a routine blood test found that her body was making too many platelets, which help control bleeding. Kuppersmith’s doctor suspected she had a rare blood disorder called essential thrombocythemia, which can lead to blood clots, strokes and, in rare cases, leukemia.

Her doctor suggested a bone marrow biopsy, in which a large needle is used to suck out a sample of the spongy tissue at the center of the patient’s hip bone. Doctors examine the bone marrow under a microscope and analyze the DNA. The procedure allows doctors to judge a patient’s prognosis and select treatment, if needed. Kuppersmith had heard the procedure can be intensely painful, so she put it off for months.

The biopsy — performed by a provider in her insurance network, at a hospital in her network ― lasted only a few minutes, and Kuppersmith received relatively good news. While a genetic analysis of her bone marrow confirmed her doctor’s suspicions, it showed that the only treatment she needs, for now, is a daily, low-dose aspirin. She will check in with her doctor every three to four months to make sure the disease isn’t getting worse.

All in all, Kuppersmith felt relieved.

Then she got a notice saying her insurer refused to pay for the genetic analysis, leaving her responsible for a $2,400 payment.

The Patient: New York resident Michelle Kuppersmith, 32, who is insured by Maryland-based CareFirst Blue Cross Blue Shield. She works as director of special projects at a Washington-based, nonpartisan watchdog group. Because she was treated in New York, Empire Blue Cross Blue Shield — which covers that region ― handled part of her claim.

Total Amount Owed: $2,400 for out-of-network genetic profiling

The Providers: Kuppersmith had her bone marrow removed at the Mount Sinai Ruttenberg Treatment Center in New York City, which sent her biopsy sample to a California lab, Genoptix, for testing.

Medical Services: Bone marrow biopsy and molecular profiling, which involves looking for genetic mutations

What Gives: The field of “molecular diagnostics,” which includes a variety of gene-based testing, is undergoing explosive growth, said Gillian Hooker, president of the National Society of Genetic Counselors and vice president of clinical development for Concert Genetics, a health IT company in Nashville, Tennessee.

A Concert Genetics report found there are more than 140,000 molecular diagnostic products on the market, with 10 to 15 added each day.

The field is growing so quickly that even doctors are struggling to develop a common vocabulary, Hooker said.

Kuppersmith underwent a type of testing known as molecular profiling, which looks for DNA biomarkers to predict whether patients will benefit from new, targeted therapies. These mutations aren’t inherited; they develop over the course of a patient’s life, Hooker said.

Medicare spending on molecular diagnostics more than doubled from 2016 to 2018, increasing from $493 million to $1.1 billion, according to Laboratory Economics, a lab industry newsletter.

Charges range from hundreds to thousands of dollars, depending on how many genes are involved — and which billing codes insurers use, Hooker said.

Based on Medicare data, at least 1,500 independent labs perform molecular testing, along with more than 500 hospital-based labs, said Jondavid Klipp, the newsletter’s publisher.

In a fast-evolving field with lots of money at stake, tests that a doctor or lab may regard as state-of-the-art an insurer might view as experimental.

Worse still, many of the commercial labs that perform the novel tests are out-of-network, as was Genoptix.

After lining up an in-network provider at an in-network hospital, Kuppersmith pushed back when she got a $2,400 charge for an out-of-network lab. She appealed and won but says, “There are a lot of people who don’t have the time or wherewithal to do this kind of fighting.”(Shelby Knowles for KHN)

Stephanie Bywater, chief compliance officer at NeoGenomics Laboratories, which owns Genoptix, said that insurance policies governing approval have not kept up with the rapid pace of scientific advances. Kuppersmith’s doctor ordered a test that has been available since 2014 and was updated in 2017, Bywater said.

Although experts agree that molecular diagnostics is an essential part of care for patients like Kuppersmith, doctors and insurance companies may not agree on which specific test is best, said Dr. Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.

Tests “can be performed a number of different ways by a number of different laboratories who charge different amounts,” Nichols said.

Insurance plans are much more likely to refuse to pay for molecular diagnostics than other lab tests. Laboratory Economics found Medicare contractors denied almost half of all molecular diagnostics claims over the past five years, compared with 5-10% of routine lab tests.

With so many insurance plans, so many new tests and so many new companies, it is difficult for a doctor to know which labs are in a patient’s network and which specific tests are covered, Nichols said.

“Different providers have contracts with different diagnostic companies,” which can affect a patient’s out-of-pocket costs, Nichols said. “It is incredibly complex and really difficult to determine the best, least expensive path.”

Kuppersmith said she has always been careful to check that her doctors accept her insurance. She made sure Mount Sinai was in her insurance network, too. But it never occurred to her that the biopsy would be sent to an outside lab ― or that it would undergo genetic analysis.

She added: “The looming threat of a $2,400 bill has caused me, in many ways, more anxiety than the illness ever has.”

Kuppersmith’s doctor recommended a bone marrow biopsy after suspecting she had a rare blood disorder. Though the biopsy was done by an in-network provider at an in-network hospital, Kuppersmith learned she was on the hook for $2,400 for out-of-network genetic profiling.(Shelby Knowles for KHN)

The Resolution: Despite making dozens of phone calls, Kuppersmith got nothing but confusing and contradictory answers when she tried to sort out the unexpected charge.

An agent for her insurer told her that her doctor hadn’t gotten preauthorization for the testing. But in an email to Kuppersmith, a Genoptix employee told her the insurance company had denied the claim because molecular profiling was viewed as experimental.

A spokesperson for New York-based Empire Blue Cross Blue Shield, which handled part of Kuppersmith’s claim, said her health plan “covers medically necessary genetic testing.”

New York, one of 28 states with laws against surprise billing, requires hospitals to inform patients in writing if their care may include out-of-network providers, said attorney Elisabeth Benjamin, vice president of health initiatives at the Community Service Society, which provides free help with insurance problems.

A spokesperson for Mount Sinai said the hospital complies with that law, noting that Kuppersmith was given such a document in 2018 — nearly one year before her bone marrow biopsy ― and signed it.

Benjamin said that’s not OK, explaining: “I think a one-year-old, vague form like the one she signed would not comply with the state law — and certainly not the spirit of it.”

Instead of sending Kuppersmith a bill, Genoptix offered to help her appeal the denied coverage to CareFirst. At first, Genoptix asked Kuppersmith to designate the company as her personal health care representative. She was uncomfortable signing over what sounded like sweeping legal rights to strangers. Instead, she wrote an email granting the company permission to negotiate on her behalf. It was sufficient.

A few days after being contacted by KHN, Kuppersmith’s insurer said it would pay Genoptix at the in-network rate, covering $1,200 of the $2,400 charge. Genoptix said it has no plans to bill Kuppersmith for the other half of the charge.

The Takeaway: Kuppersmith is relieved her insurer changed its mind about her bill. But, she said: “I’m a relatively young, savvy person with a college degree. There are a lot of people who don’t have the time or wherewithal to do this kind of fighting.”

Patients should ask their health care providers if any outside contractors will be involved in their care, including pathologists, anesthesiologists, clinical labs or radiologists, experts said. And check if those involved are in-network.

“Try your best to ask in advance,” said Jack Hoadley, a research professor emeritus at Georgetown University. “Ask, ‘Do I have a choice about where [a blood or tissue sample] is sent?’”

Ask, too, if the sample will undergo molecular diagnostics. Since the testing is still relatively new — and expensive ― most insurers require patients to obtain “prior authorization,” or special permission, said Dr. Debra Regier, a medical geneticist at Children’s National Hospital in Washington and an associate with NORD, the National Organization of Rare Diseases. Getting this permission in advance can prevent many headaches.

Finally, be wary of signing blanket consent forms telling you that some components of your care may be out-of-network. Tell your provider that you want to be informed on a case-by-case basis when an out-of-network provider is involved and to consent to their participation.

Related Topics

Health Care Costs Health Industry Insurance Multimedia

COVID-19 Bonanza: Stimulus Hands Health Industry Billions Not Directly Related To Pandemic

The coronavirus stimulus package Congress rushed out last week to help the nation’s hospitals and health care networks hands the industry billions of dollars in windfall subsidies and other spending that has little to do with defeating the COVID-19 pandemic.

The $2 trillion legislation, which President Donald Trump signed Friday, includes more than $100 billion in emergency funds to compensate hospitals and other health care providers for lost revenue and other costs associated with COVID-19. The measure also calls for spending up to $16 billion to replenish the nation’s depleted stockpile of medical gear, such as ventilators, medicines and personal protective equipment, or PPE.

But health care businesses will get billions of dollars in additional funding not directly related to the pandemic, in some cases because Congress agreed to reverse scheduled cuts in the rates paid by Medicaid and Medicare, which the federal government had tried for years to impose.

“Anything that could tangentially be related to the crisis lobbyists tried to get stuffed in this bill ― particularly health-care-related items,” said Steve Ellis, vice president of Taxpayers for Common Sense, a nonpartisan watchdog group. While the stimulus package is “not as big” a “Christmas tree” as some other bills, Ellis said, “I’m sure we’ll find a few baubles and gifts along the way.”

Hospitals have won widespread praise as their doctors and other medical staffs labor under perilous conditions, including shortages of protective gear. And, perhaps not surprisingly, the industry emerged as a big winner in the stimulus negotiations. Not only can hospitals draw on the $100 billion fund to stem their losses and cover other costs, but they will also see a boost in one stream of revenue as Congress overturned some planned rate cuts.

More than 3,000 hospitals that treat outsize numbers of Medicaid or uninsured patients, for instance, will share in an $8 billion windfall through the stimulus provision that reverses cuts in their Medicaid payments for 2020 and 2021.

Separately, hospitals will rake in at least $3 billion more because of a temporary suspension of a 2% cut in Medicare fees, according to the Federation of American Hospitals, which represents more than 1,000 for-profit hospitals and health systems. The infusion of cash also benefits doctors, nursing homes, home health companies and others.

“That’s welcome news during this time of crisis,” said Joanne Cunningham, executive director of the Partnership for Quality Home Healthcare.

Also tucked into the stimulus: a rollback of planned rate cuts to clinical laboratories and some medical equipment suppliers.

At this stage, it is unclear how much these measures will add to the COVID-19 tab ― or if far more stimulus would be required for the health care industry to rebound.

Take the 2% rate cut known as “the sequester.” The Office of Management and Budget expected it would save Medicare $16.2 billion in fiscal 2021. But the stimulus bill rescinds that rate cut from May 1 through the end of this year. As part of the legislation, Congress said it would, in effect, recoup the payments later by adding another year to the sequester. Whether lawmakers will follow through on that is anyone’s guess.

Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA), expects the sequester relief to translate to a “huge” financial boost for more than 15,000 medical practices his group represents.

“This would never have been done under any other circumstances,” Gilberg said. “The situation was recognized as dire.”

Dr. Patrice Harris, president of the American Medical Association, said the stimulus offers “needed financial relief to hard-hit workers, health systems and physician practices. At this critical moment, physician practices need significant financial support to sustain themselves and continue to meet the health care needs of all Americans during this time.”

Similarly, American Hospital Association CEO Rick Pollack called the legislation “an important first step forward. But, he added, “more will need to be done to deal with the unprecedented challenge of this virus.”

In a nod to clinical laboratories, which have helped bail out the federal government’s early failure to supply enough COVID-19 tests, the stimulus delayed planned rate cuts in 2021 likely to amount to tens of millions of dollars in revenue. Medicare officials have been at odds with the lab industry for years over rates for lab tests.

While other health care interests praised the bill, the laboratory trade association said it comes up short.

Just before the Senate passed the stimulus bill Wednesday, American Clinical Laboratory Association President Julie Khani slammed Congress for not designating funding to support labs. She said labs were in “an untenable situation, absorbing growing, uncompensated costs for testing specimens with no assurance that they will be appropriately or fairly reimbursed for all the tests they are performing.”

She added a not-so-veiled threat, saying: “If Congress fails to designate essential emergency funding for clinical laboratories to support our efforts, labs will be soon be forced to make difficult decisions about whether they can keep building the [testing] capacity our nation needs.”

The lab association, in a statement to Kaiser Health News, said labs have absorbed “stunning” Medicare reimbursement cuts of as much as 30% for many common tests in recent years.

In public securities filings this year, lab giants Quest Diagnostics Inc. and Laboratory Corp of America Holdings, known as LabCorp, reported they expected rate cuts in 2020 totaling more than $150 million. LabCorp said it supported the views of the lab association. Quest did not respond to a request for comment.

While labs processing COVID-19 tests missed out on direct funding, they could be eligible for some of the $100 billion allocated for hospitals and other providers to cover their losses, congressional aides said.

And the stimulus measure states that even in the event a lab is out-of-network, health plans are expected to pay the price it sets — as long as the lab publishes that price online — or negotiate with the lab.

Given that laws in some states ban surprise billing in particular, this provision seems to favor the labs, said Katie Keith, a Georgetown University law professor and health policy expert. “No one just lets the provider set the price,” she said.

The lab association disputes that, saying that many health plans are expected to pay them less than the $51.50 government recommended for a COVID-19 test.

Just how the $100 billion in health care funding will be distributed and how much oversight will occur is another unknown.

Health and Human Services Secretary Alex Azar has the authority to decide how long the emergency provisions remain in effect. Tracking all that money will be a challenge as well.

Ellis, the taxpayer advocate, noted that no government agency “is ready to handle the rush of extra funding.” He said that the stimulus grants extra resources to inspector general offices to monitor spending.

“There will be waste, there will be abuse,” he said. “It’s about exposing and rooting it out.”

The HHS Office of Inspector General expects to receive $4 million to support this oversight, according to spokesman Donald White.

Some groups aren’t waiting to compete over the $100 billion. The MGMA sent a letter March 27 to Azar and the Centers for Medicare & Medicaid Services chief Seema Verma asking for more direct help. Gilberg noted that some medical practices, such as doctors who perform colonoscopies, have not been able to continue their work.

“Doctors and physician practices are having a lot of trouble right now,” Gilberg said. “They are literally shut down, and they are having financial troubles. Their operations have come to a full halt.”

KHN correspondents Rachana Pradhan and Emmarie Huetteman contributed to this report.

Related Topics

Global Health Watch Health Care Costs Health Industry Medicaid Public Health

Already Taxed Health Care Workers Not ‘Immune’ From Layoffs And Less Pay

Just three weeks ago, Dr. Kathryn Davis worried about the coronavirus, but not about how it might affect her group of five OB-GYNs who practice at a suburban hospital outside Boston.

“In medicine we think we’re relatively immune from the economy,” Davis said. “People are always going to get sick; people are always going to need doctors.”

Then, two weeks ago, she watched her practice revenue drop 50% almost overnight after Massachusetts officials told doctors and hospitals to stop performing elective tests and procedures. For Davis, that meant no more non-urgent gynecological visits and screenings.

Late last week, as Davis and her partners absorbed the stunning turn of events, they devised a stopgap plan. The 35 nurses, medical assistants and secretaries they employ would have two options: move from full-time to part-time status or start collecting unemployment. Doctors in the practice would take a substantial pay cut. Davis said she’s hearing from colleagues who may have to permanently close their offices if the focus on crisis-level care continues for months.

“It’s shocking,” she said. “Everyone has been blindsided.”

Atrius Health, the largest independent physician group in Massachusetts, said patient volume is down 75% since mid-March. It is temporarily closing offices, placing many nonclinical employees on furlough and withholding pay for those who remain. The average withholding is 20%, and the company pledges that pay withheld will be returned. The lowest-paid workers, those earning up to $55,000, are exempt.

“What we’re trying to do is piece together a solution to get through the crisis and keep employed as many people as we can,” said Dr. Steven Strongwater, Atrius Health’s CEO.

Atrius cares for 745,000 patients in clinics that often include primary care, specialists, radiology and a pharmacy under one roof.

Strongwater said physician groups must be included when the federal government distributes $100 billion to hospitals from the $2 trillion stimulus package.

It’s not clear if that money will stop the tide of layoffs and lost pay at hospitals as well as in doctor’s offices. A Harvard Medical School physician group will suspend retirement contributions starting April 1.

Beth Israel Lahey Health, the second-largest hospital network in Massachusetts, announced executive pay cuts Monday.

“The suspension of elective procedures and decline in visits to our primary care practices and urgent care centers have resulted in financial challenges,” wrote CEO Dr. Kevin Tabb in an email to employees. Tabb said he would take a 50% salary cut. Other executives and hospital presidents in the system will forgo 20% of their salaries for the next three months.

“Although executive leadership compensation is being reduced, we will never compromise on doing the things that are essential to protect your safety and the safety of our patients,” Tabb told staff.

Dallas-based Steward Health Care has told hospital employees in Massachusetts and eight other states where it operates to expect furloughs focused on nonclinical staff. In a statement, Steward Health Care said it prepared for the pandemic but is experiencing a “seismic financial shock.”

“Elective surgeries are the cornerstone of our hospital system’s operating model — and the negative impact due to the cancellations of these procedures cannot be overstated. In addition, patients are understandably cautious and choosing to defer any nonemergency treatments or routine visits until this crisis has passed.”

Dr. Kaarkuzhali Babu Krishnamurthy, an assistant professor of neurology at Harvard Medical School who studies medical ethics, said employers need to think more carefully about the ethics of asking doctors and nurses to live on less when many are working longer hours and putting the health of their families at risk.

“At a time when health care systems are calling on doctors and nurses to do more, this is not the time to be making it more difficult to do that,” said Krishnamurthy.

There’s talk of redeploying laid-off health care workers to new COVID-19 units opening in shuttered hospitals or to patient overflow sites. Tim Foley, executive vice president for the largest health care union in Massachusetts, 1199SEIU, is promoting the development of a staff registry.

“It is more important, now more than ever, to explore all options to maintain the level of urgent care needed across the state and we look forward to working with all stakeholders to do just that,” Foley said in an email.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

Related Topics

Cost and Quality Health Care Costs Health Industry Public Health States

Different Takes: Private Research Leads The Way On Getting U.S. Back On Course; Federal Response On Medical Supply Shortages Is Woefully Inadequate

Federal Judge Rules Medicare Patients Can Challenge ‘Observation Care’ Status

Hundreds of thousands of Medicare beneficiaries who have been denied coverage for nursing home stays because their time in the hospital was changed from “inpatient” to “observation care” can now appeal to Medicare for reimbursement, a federal judge in Hartford, Connecticut, ruled last week.

If the government does not challenge the decision and patients win their appeals, Medicare could pay them millions of dollars for staggeringly high nursing home bills.

To receive coverage for nursing home care, patients must first be admitted to the hospital as inpatients for three consecutive days. Time spent in the hospital for observation doesn’t count, even though they may stay overnight and receive some of the same treatment and other services provided to inpatients.

And there’s another big difference: While inpatients can file an appeal with Medicare if they question any other coverage denial, observation patients cannot. So, in 2011, seven Medicare beneficiaries and their families sued the Department of Health and Human Services, in what became a nationwide class action lawsuit.

On Tuesday, U.S. District Judge Michael Shea ruled that the patients are entitled to appeal if they are admitted as inpatients to the hospital by their doctor but later switched to observation care by their hospital. However, he said patients whose doctors initially place them in observation care under Medicare’s “two-midnight” rule cannot appeal because that rule requires doctors to base their decision on medical judgment. If the doctor determines that a patient’s stay is unlikely to stretch over two midnights, the patient would most likely receive observation care, though there are exceptions.

Shea’s decision applies to all traditional Medicare beneficiaries who experienced such a switch since Jan. 1, 2009, spent at least three days in the hospital and were enrolled in Medicare’s Part A hospital benefit. If they win their appeal, most hospital expenses and any nursing home bills they paid would be reimbursed under Part A.

Shea estimated that hundreds of thousands of beneficiaries would be able to seek repayment.

Lawyers at the Department of Justice argued that doctors and hospitals make admission decisions so patients can’t ask the government to change a decision it didn’t make. A DOJ spokeswoman declined to comment on the decision or whether the government would appeal. They have until May 25 to decide.

Ervin Kanefsky, one of the plaintiffs in the case, spent five days in the hospital as an admitted patient after fracturing his shoulder. When he was about to leave, a hospital official told him his status had changed to observation. He had to pay $9,145 for a month-long stay in the nursing home that Medicare refused to cover.(Courtesy of Ervin Kanefsky)

But the physician’s decision is not final because it is “reviewed by the hospital’s ‘utilization review staff,’ a team each hospital participating in the Medicare program must have in place to review whether the physician’s decision is correct under mandatory, nationwide standards set by the Centers for Medicare and Medicaid Services,” the judge wrote.

Alice Bers, litigation director at the Center for Medicare Advocacy, one of the groups representing the plaintiffs, said the decision recognized that “Medicare coverage is subject to due process protection.”

“If I had gone home, I would have died,” said Ervin Kanefsky, 94, a plaintiff from suburban Philadelphia. He was admitted to the hospital as an inpatient after fracturing his shoulder in a fall. When he was about to leave after five days to recuperate at a nursing home, a hospital official told him his status had changed to observation. With one arm in a sling, stitches in the other and unable to hold onto his walker, he learned Medicare wouldn’t pay for the nursing home.

“I had to pay $2,000 just to get in the door,” he said, and his month-long stay in 2016 cost $9,145. He called Medicare numerous times, wrote a letter to the hospital’s president and contacted his congressman for help. “I tried every which way,” he said, to no avail.

Medicare has temporarily suspended the three-day inpatient admission requirement during the coronavirus emergency.

Related Topics

Aging Cost and Quality Courts Health Care Costs Medicare

Resurge la telemedicina, por miedo al coronavirus y cambios en los pagos

Lukas Kopacki, quien regresó a casa después que el campus de su universidad cerrara por la pandemia de coronavirus, se había estado sintiendo mal durante días, con dolores de cabeza y garganta, y dificultad para respirar. Pero le preocupaba que ir al consultorio médico pudiera enfermarlo más.

“No tenía ganas de entrar en ese agujero negro de bacterias y virus”, dijo Kopacki, de 19 años, de Ringwood, Nueva Jersey.

Entonces, la semana del 16 de marzo, el estudiante de la Universidad de Vermont decidió llamar a Teladoc, una compañía que conecta a pacientes con médicos por teléfono en todo el país. El médico le diagnosticó una infección sinusal y le envió una receta para un antibiótico a su farmacia local.

Con su cobertura de salud de Aetna, que a principios de marzo renunció temporalmente a su copago de $45 por atención virtual, Kopacki pagó de su bolsillo $1.44, que cubrió los costos del medicamento.

“Fue fácil y rápido”, dijo.

Recibir atención médica por teléfono o videoconferencia ha existido durante varias décadas, pero el brote de coronavirus ha llevado a un aumento en el uso de la telemedicina como nunca antes se había visto, según los sistemas de salud y los grupos de proveedores en todo el país.

Millones de estadounidenses buscan atención conectándose electrónicamente con un médico, muchos por primera vez. Los sistemas de salud, las aseguradoras y los grupos de médicos dijeron que esta práctica permite a las personas practicar el distanciamiento social a la vez que reduce la propagación de la enfermedad, y protege a los trabajadores de salud.

Las empresas privadas de tecnología como Teladoc, Doctor On Demand y Amwell, y los grandes sistemas de atención médica, pueden proporcionar un médico directamente a alguien que se contacte con ellos.

Otros pacientes pueden pedir una cita de telemedicina con su médico habitual, que puede utilizar aplicaciones informáticas a través de celulares y computadoras. Todos los tipos de atención primaria y especializada, y los servicios de salud mental se pueden proporcionar a través de la telemedicina.

Muchos hospitales han agregado recientemente servicios de telemedicina para evitar que los pacientes preocupados por el coronavirus colmen sus salas de emergencia.

También estimulados por el objetivo de mantener a los pacientes alejados de las instalaciones médicas abarrotadas, las aseguradoras, del gobierno y privadas han aumentado el pago de las visitas de telemedicina para que estén a la par de las citas en persona.

Antes del brote, las aseguradoras pagaban menos de la mitad de esa cantidad, lo que disuadía a muchos médicos de ofrecer este servicio.

La semana del 16, Medicare habilitó a todos los afiliados usar la telemedicina, una opción que anteriormente solo estaba disponible para personas que viven en áreas remotas, y para chequeos específicos y breves. El gobierno federal también dijo que los médicos podrían ofrecer servicio fuera de sus estados durante la pandemia para tratar a los pacientes de Medicare virtualmente, incluso si no tienen licencia en el estado del paciente.

California, Florida y otros estados también han renunciado a sus requisitos de que un médico tenga licencia en el estado para brindar atención.

La Clínica Cleveland está en camino de registrar más de 60,000 visitas de telemedicina en marzo, según sus autoridades. Antes de marzo, ese sistema de salud, que tiene hospitales en Ohio y Florida, promediaba unas 3,400 visitas virtuales al mes.

Su sistema Express Care Online atiende a pacientes de todo el país las 24 horas del día. Alrededor del 75% de las llamadas ahora provienen de personas preocupadas de haber contraído COVID-19, dijo el doctor Matthew Faiman, director médico del servicio. Al igual que muchos otros sistemas de salud, la atención de urgencia virtual de Cleveland Clinic está renunciando a los copagos de los pacientes durante la pandemia.

“Estamos viendo un aumento significativo en la demanda de pacientes que buscan atención, tanto las personas preocupadas por el virus como los pacientes que están enfermos y que necesitan saber cómo manejar sus síntomas”, explicó Faiman.

La clínica ha contratado más médicos para telesalud desde que se cancelaron las cirugías electivas y menos pacientes van al consultorio.

“La telemedicina ha estado en los bordes del sistema por un tiempo”, dijo el doctor Manish Naik, director de tecnología de información médica de la Clínica Regional de Austin, en Texas. “Y, cuando todo esto termine, muchos médicos y pacientes querrán que la opción de telemedicina permanezca”.

Por supuesto, tales visitas tienen limitaciones, como cuando los médicos necesitan auscultar los pulmones o el corazón de un paciente u ordenar una radiografía para verificar si hay neumonía. Pero Naik dijo que la telemedicina también brinda a los médicos una visión más completa de los pacientes a través de “observación en el hogar” e interacciones que muestran “cosas que nunca antes pudimos ver”.

Antes de marzo, NYU Langone Health en Nueva York tenía alrededor de 50 visitas virtuales por día a través de su plataforma de telemedicina de atención de urgencia. Durante la semana del 23 de marzo, el sistema hospitalario ha promediado alrededor de 900 por día.

Para el 80% de las visitas de telemedicina, la tos es la principal preocupación, seguida por la fiebre, dijo el doctor Paul Testa, jefe de información médica. NYU Langone tiene 170 médicos que atienden a pacientes a través de la telemedicina, en comparación con 35 antes, dijo.

“No estamos recomendando pruebas para todos, pero estamos aconsejando el cuidado personal, la hidratación y el autoaislamiento”, agregó Testa. “El objetivo es crear una opción para estos pacientes en lugar que se apresuren a una urgencia o a una sala de emergencias”.

Si un paciente tiene problemas para respirar, un proveedor de telemedicina de la NYU le indicará que llame a una ambulancia si es necesario o que vaya a la sala de emergencias.

Teladoc tiene un promedio de 15,000 visitas de pacientes por día en los Estados Unidos, 50% más que en febrero. Los tiempos de espera han aumentado de minutos a horas en algunos casos, dijo un vocero.

En la Clínica Regional de Austin, que cuenta con 340 médicos en 28 consultorios, casi la mitad de las visitas de pacientes ahora son virtuales en comparación con una fracción antes del brote.

“Con la situación de COVID-19, tenemos pacientes que están nerviosos por venir, y no queremos pacientes con síntomas que expongan a otros”, dijo Naik.

La administración Trump estuvo actuando para ampliar las opciones de telemedicina incluso antes de la pandemia. En 2019, le permitió a Medicare pagar por primera vez a los médicos un promedio de $14 por una llamada telefónica de cinco minutos para comunicarse con sus pacientes.

Ken Prussner, de 74 años, de Herndon, Virginia, usó la computadora de su casa el lunes 23 para conectarse con su médico de toda la vida.

Prussner tenía una enfermedad gastrointestinal y un poco de fiebre, y su familia quería asegurarse que no tuviera COVID-19. Habló con su médico como si estuviera en el consultorio. Prussner tenía una infección típica del intestino delgado que desaparecería por sí sola en tres o cinco días.

“Fue bastante sencillo”, dijo Prussner, oficial retirado del Servicio Exterior de los Estados Unidos.

Related Topics

Global Health Watch Health Care Costs Health Care Reform Medicare Noticias En Español Public Health

Telemedicine Surges, Fueled By Coronavirus Fears And Shift In Payment Rules

Lukas Kopacki, home from college after the coronavirus pandemic closed his campus, was feeling lousy for days with headaches, sore throat and difficulty breathing through his nose. But he worried that a trip to a doctor’s office might make him sicker.

“I had no desire to go into that cesspool of bacteria and viruses,” said Kopacki, 19, of Ringwood, New Jersey.

So, last week the University of Vermont student called Teladoc, a company that connects patients to doctors by phone nationwide. Its physician diagnosed his sinus infection and sent a prescription for an antibiotic to his local pharmacy. With his Aetna health coverage, which earlier this month temporarily waived its $45 patient copayment for virtual care, Kopacki paid out-of-pocket $1.44, which covered his costs for the drug.

“It was quick and easy,” he said.

Getting heath care by phone or video conferencing has been around for several decades, but the outbreak of coronavirus has led to an increase in telemedicine use as never seen before, according to health systems and provider groups across the country.

Millions of Americans are seeking care by connecting with a doctor electronically, many for the first time. Health systems, insurers and physician groups said it allows people to practice social distancing while reducing the spread of the disease and protecting health workers.

Private technology companies such as Teladoc, Doctor On Demand and Amwell and large health care systems can provide a doctor directly to someone who contacts them. Other patients may seek a telemedicine appointment with their regular physician, who can use computer applications through smartphones and computers. All types of primary and specialty care and mental health services can be provided via telemedicine.

Many hospitals have recently added telemedicine services to keep patients concerned about the coronavirus from clogging their emergency rooms.

Also spurred by the goal to keep patients away from crowded medical facilities, government and private insurers have increased the payment for telemedicine visits so they are on par with in-person visits. Before the outbreak, insurers paid less than half that amount, which dissuaded many doctors from offering the services.

Medicare last week allowed all enrollees to use telemedicine — an option that previously was available only to people living in remote areas and for a specific, short checkup. The federal government also said doctors could practice across state lines during the pandemic to treat Medicare patients virtually, even if not licensed in the patient’s state. California, Florida and other states have also waived their requirements that a physician be licensed in the state to provide care.

The Cleveland Clinic is on track to log more than 60,000 telemedicine visits in March, according to officials there. Before March, that health system ― which has hospitals in Ohio and Florida — averaged about 3,400 virtual visits a month.

Its Express Care Online system serves patients across the country 24 hours a day. About 75% of the calls now come from people worried they have COVID-19, said Dr. Matthew Faiman, medical director of the service. Like many other health systems, Cleveland Clinic’s virtual urgent care is waiving patient copays during the pandemic.

“We are seeing a significant upsurge in demand from patients seeking care ― both the worried well and patients who are sick and wanting to know how to manage their symptoms,” Faiman said. The clinic has pulled more doctors into the telehealth work since elective surgeries were canceled and fewer patients are making in-person visits.

He applauded the Medicare changes and predicted such changes will likely stay after the national emergency ends.

Dr. Manish Naik, chief medical information technology officer at the Austin Regional Clinic in Texas, also predicted it will be hard to go back.

“Telemedicine has been on the brink for a while now,” Naik said. “And doctors and patients are going to find that when this is all over and the dust settles there are a lot of people who are going to want the telemedicine option to stay.”

Of course, such visits have limitations, such as when doctors need to listen to a patient’s lungs or order an X-ray to check for pneumonia. But Naik said telemedicine also gives doctors a more complete view of the patients through “observation around the home” and interactions there that shows “things we never could see before.”

Before March, NYU Langone Health in New York had about 50 virtual visits a day through its urgent care telemedicine platform. During the week of March 23, the hospital system is averaging about 900 a day.

For 80% of telemedicine visits, cough is the chief complaint followed by fever, said Dr. Paul Testa, its chief medical information officer. NYU Langone has 170 doctors who attend to telemedicine patients, up from 35 two weeks ago, he said.

“We are not recommending testing for everyone, but we are recommending self-care, hydration and self-isolation,” Testa added. “The goal is to create a new front line for these patients rather than have them rush into an urgent care or ER.”

If a patient is having trouble breathing or otherwise is in distress, an NYU telemedicine provider will direct them to call an ambulance if necessary or go to the ER and alert the hospital the patient is coming.

Teladoc is averaging 15,000 patient visits a day in the United States, 50% higher than in February. Wait times have increased from minutes to hours in some cases, a spokesperson said.

At the Austin Regional Clinic, which has 340 doctors in 28 offices, nearly half of patient visits are now virtual compared with a fraction before the outbreak.

“With the COVID-19 situation, we have patients who are nervous about coming in, and we don’t want patients with symptoms coming in and exposing others,” Naik said.

He said that for years the clinic made the telemedicine option available, but it did not make sense financially to promote it because insurers paid less than half the rate they would for an in-person visit.

The Medicare payment change can’t be understated, he said, because it covers such a large number of patients and because private insurers usually follow Medicare policies. “That’s really allowed us to open things up,” Naik said.

Advocates for decades have called on Medicare to expand telemedicine coverage, but federal officials held back because of concerns about increased costs. Critics worried telemedicine would not replace in-person doctor visits but lead to more total visits because of the ease with which people could connect to their doctors via telemedicine.

The Trump administration had been moving to widen telemedicine options even before the pandemic. In 2019, it allowed Medicare for the first time to pay doctors on average about $14 for a five-minute “check-in” phone call with their patients.

Ken Prussner, 74, of Herndon, Virginia, used his home computer Monday to connect with his longtime physician.

Prussner had a gastrointestinal illness and a low-grade fever and his family wanted to make sure he didn’t have COVID-19. His doctor’s office sent him a website link and his physician spoke to him as if he was in the office. He allayed Prussner’s fear, telling him he had a typical lower-bowel infection that would clear up on its own within three to five days.

“It was pretty seamless,” said Prussner, a retired U.S. Foreign Service officer.

Related Topics

Global Health Watch Health Care Costs Health Industry Medicare Public Health

Total Hospital Charges From Coronavirus Treatments Projected To Soar Into The Hundreds Of Billions