SMOKINCHOICES (and other musings)

September 26, 2014

Robber fees in Medicine?

Health care

Mysterious surgeons hit patients with fees

By Elisabeth Rosenthal THE NEW YORK TIMES

 

                                             JOSHUA BRIGHT THE NEW YORK TIMES   Peter Drier was shocked by a $117,000 bill                                                                 from a surgeon he never met during his neck surgery. Insurance paid the bill.

Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms.

A bank-technology manager who had researched his insurance coverage, Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.

  • He was blindsided, though, by a bill for about $117,000 from an “assistant surgeon,” a neurosurgeon based in Queens, N.Y., whom Drier had never met.

“I thought I understood the risks,” Drier, who lives in New York City, said. “But this was just so wrong — I had no choice and no negotiating power.”

In operating rooms and on hospital wards across the country, physicians and other health providers typically help one another in patient care. But in an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They might be called in when their need is questionable. And patients usually do not realize they have been involved until the bill arrives.

The practice increases revenue for physicians and other health-care workers at a time when insurers are cutting reimbursement for many services. The surprise charges can be especially significant because, as in Drier’s case, they might involve out-of-network providers who bill 20 to 40 times the usual local rates and often collect the full amount.

“The notion is you can make end runs around price controls by increasing the number of things you do and bill for,” said Dr. Darshak Sanghavi, until recently a health-policy expert at the Brookings Institution. This contributes to the nation’s $2.8 trillion in annual health costs.

Insurers, saying the surprise charges have proliferated, have filed lawsuits challenging them. In recent years, unexpected out-of-network charges have become the top complaint to the New York state agency that regulates insurance companies. Multiple state health-insurance commissioners have tried to limit patients’ liability, but lobbying by the health-care industry stymies their efforts.

“This has gotten really bad, and it’s wrong,” said James J. Donelon, the Republican insurance commissioner of Louisiana. “But when you try to address it as a policymaker, you run into a hornet’s nest of financial interests.”

  • In Drier’s case, the primary surgeon, Dr. Nathaniel L. Tindel, had said he would accept a negotiated fee determined through Drier’s insurance company , which ended up being about $6,200. (Drier had to pay $3,000 of that to meet his deductible.) But the assistant, Dr. Harrison T. Mu, was out of network and sent the $117,000 bill. Insurance experts say surgeons and assistants sometimes share proceeds from operations, but Tindel’s office said he and Mu do not. Mu’s office did not respond to requests for comment.

The phenomenon can take many forms. In some instances, a patient might be lying on a gurney in the emergency room, unaware that all of the people who turn up at the bedside will charge for their services. At times, a fully trained physician is called in when a resident or a nurse, who would not charge, would have sufficed. Services that once were included in the daily hospital rate now often are provided by contractors, and even many emergency rooms are staffed by out-of-network physicians who bill separately.

  • Insurers say they have limited ability to fight back. Insurance examiners “are not in the room on the day of surgery to see the second surgeon walk into the room or why they were needed,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry group. And current laws do not require hospitals that join an insurance network to provide in-network doctors, labs or X-rays, for example.

So sometimes insurers just pay — to protect their customers, they say — which encourages the practice. When Drier complained to Anthem Blue Cross Blue Shield that he should not have to pay the out-of-network assistant surgeon, Anthem agreed it was not his responsibility. Instead, the company cut a check to Mu for $116,862, the full amount.

When Drier agreed to surgery in December, he was not in a good position to bargain or shop around. Several weeks earlier, he had woken up to excruciating pain in his upper back and numbness and weakness in two fingers of his left hand, which persisted. A scan showed that one of the disks that normally serve as cushions between vertebrae was herniated and pushing on a nerve. With a busy job and social life, he was living on painkillers.  (* See note below)

The rate of spinal surgery in the United States is about twice that in Europe and Canada and five times that in Britain, said Dr. Richard A. Deyo of Oregon Health and Science University, who studies international comparisons. Studies have generally concluded that after two years, patients who have surgery for disk problems do no better than those treated with painkillers and physical therapy — although the pain, which can be debilitating, resolves far more rapidly with surgery.

The United States has more neurosurgeons per capita than almost any other developed country, and they compete with orthopedists for spinal surgery. At the same time, Medicare and private insurers have reduced payments to surgeons. The average base salary for neurosurgeons decreased to $590,000 in 2014 from $630,000 in 2010, according to Merritt Hawkins, a physician-staffing firm.

To counter that trend, some spinal surgeons have turned to consultants for advice on increasing revenue through “innovative” coding, claim generation and collection services.

Some strategies, including billing large amounts for a second surgeon in the room or declaring an operation an emergency, raise serious questions. The indications for immediate spinal surgery, such as loss of bladder function or paralysis, are rare. But insurers are more likely to reimburse a surgeon with whom they do not have a contract if a case is labeled an emergency.

For months, Drier stewed over what to do with the $117,000 check Anthem Blue Cross had sent him to pass on to Mu, refusing to sign over a payment he considered “outrageous and immoral.” He worried that such payments could drive up premiums at his employer.

Drier tried to negotiate with the surgeons to divvy up the $117,000 payment in a way he believed was more fair; he felt Tindel was being underpaid. Drier’s idea, he wrote in an email, was to settle on “a reasonable fee” for both the surgeon and assistant and return the rest of the check to the insurance company.

But in July, he received a threatening letter from Mu’s attorney noting that he had failed to forward the $117,000 check. So he sent it along, with regret.

 

Jan’s musings. . .        

 . . .the Medical Community as a general class have continued to sink further and further into  the ranks of car salesmen, or worse still, Congressional politicians —  — totally driven by greed alone.  Pathetic, really considering all the dire parameters our country faces.  For every good and decent thing which comes out of Washington,  it seems we then have to take many steps back.  Why?  Because the Haves keep demanding more.    

But all this  is especially vile, for  health care was and remains desperately needed in our great and wealthy land with all its rich resources, but struggling  masses  remain without decent healthcare, or the ability to pay what it is costing. The details of this article are despicable, and immoral.  When did such freedom to steal become so easy?  Why is no one able to correct this and do something to fix it?  It is wrong, blatant and should be totally illegal;  after all, our taxpayers are footing this bill.  Medicine is not a sacred cow that no one dare touch!   It is nothing more than a greedy business with far too much latitude to do as it damned well pleases.  The affordable care act is not affordable at all unless one is penniless to begin with, in which case  a stripped down model is doled out which is difficult to deal with and provides little choice.  The picture hasn’t changed much;  we still pay more for less than any other country in the world for the worst standard of care given to the fattest, sickest people in the world — mostly, without choice!

One final thought here has to do with the issue of back pain in general.  It is common knowledge that surgical solutions for back pain are often useless.  It rarely corrects the problem.  Primarily our pains of back, neck, shoulder and hips are almost entirely anchored in our lifestyle habits and activities.  The body was meant for movement and motion with equal amounts of play and recreation for balance.  Whether one is among the needy and underprivileged, or living in splendor with every choice imaginable open to them, we as a species have distorted our posture in numerous ways through too much sitting and inactivity to the extent that we have corrupted our once beautiful and balanced posture and the ability to move the way we were meant to. Our biological ‘core structures’ which hold our bones in place and allow perfect movement, become shortened, weakened.  We can see it in the forward thrust of shoulders and head and feel pains in hips, knees, rib cages and so on.  

Countless books have been written on this very subject by many fine physicians from various specialties including surgeons and chiropractors, etc.,.  It is known that many, many people walk around with bulging discs which biologically can impinge on the nerves which of course, can cause pain  but in these people, it isn’t painful or a bother to them. When it is determined that such a condition exists, the general recommendation, often,  is to operate.  It’s what they do.   I have sought solutions in some of these books and profited from one in particular written by Dr John Sarno – The Mindbody Prescription . . . Healing  the Body,  Healing the Pain. I loved it. . . it worked for me.  But you have to work it.  I recommend it,  have given away about six of them to friends.  But this is an aside, not what I was going to relate.  Mostly, this is or can be a fixable problem corrected by a chiropractic treatment for almost instant pain relief.  Just reach out and get it whenever its needed. I have been doing this since I was 16.  Long time.    

If memory serves,  about one or two years ago I watched a video of an interview between Dr Mercola and a beautiful young doctor (chiropractor) by the name of Eric Goodman;  it was simply superb.  He demonstrated quite a bit of what he is teaching  others in his “Foundation Training” of Structural Biomechanics.  Can’t tell you just where that post is  (can’t access my behind the scenes files due to computer problems.)   But I can put up a smaller post on Dr Goodman which I received recently and therein he is explaining what I am trying to explain — plus he shows how to do the Foundational movement.  The link  follows. There is a 2nd video further down the page in which Eric is speaking to a group at a TED meeting.  He has written a book, but I neglected to write it down.  Enjoy. . .

 

One of the Worst Things You Can Do for Your Back Pain
Odds are 3 in 4 you’ll get it at some stage, but don’t do this. Not only could it cost you $20,000 per year, it has a slew of nasty side effects including tuberculosis, life threatening infections, increased risk of cancer, heart failure, and liver problems. Try this instead…

 

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