Egregious Billing Practices by USA Health Care Organizations

Taking Surprise Medical Bills To Court Under the Theory of “Mutual Assent”

Consumers are increasingly vulnerable to... so-called balance bills, which represent the difference between what insurers pay and hospitals’ list prices. List prices can be several times higher than what they accept from Medicare or in-network insurers.

Congress is considering bipartisan legislation to limit balance billing. But some legal scholars say that patients should already be protected against some of the highest, surprise charges under long-standing conventions of contract law.

That’s because contract law rests on the centuries-old concept of “mutual assent,” in which both sides agree to a price before services are rendered, said Barak Richman, a law professor at Duke University.

Thus, many states require, and consumers expect, written estimates for a range of services before the work is done — whether by mechanics and plumbers or lawyers and financial planners.

But patients rarely know upfront how much their medical care will cost, and hospitals generally provide little or no information.

While consumers are obligated to pay something, the question is how much? Hospitals generally bill out-of-network care at list prices, their highest charges.

Without an explicit price upfront, contract law would require medical providers to charge only “average or market prices,” Richman said.

In several recent cases, for example in New York and Colorado, courts have stepped in to mediate cases where a patient received a big balance bill from an out-of-network provider. They ordered hospitals to accept amounts far closer to what they agree to from in-network private insurers or Medicare.

I strongly believe congress should pass a law outlawing the existing practices. And it is good to know the most egregious, and increasingly common, practices of the USA hospitals are already illegal. If you state hasn't already taken hospitals using such practices to court and required refunding all ill gotten gains, contact your attorney general to make sure they do so. And contact you state legislators to make sure they act also. Several states have been much more concerned with protecting their citizens from being abused by large health care providers but most states have not.

The existing practices are unethical and it is unconscionable that our elected representatives have allowed such egregious practices to continue and even become more common.

Related: Democrats and Republicans Have Failed the USA on Health Care for Decades (2015) - USA Health Care System Remains Broken, Neglected (2011) - The USA Should be Ashamed of Who We have Elected - Decades of Failure by Those Responsible for USA Health Care System Needs to be Addressed (2012)

The USA Should be Ashamed of Who We have Elected

The bill passed by the House of Representatives in the USA today to cut taxes for the very rich and eliminate heath care coverage for tens of millions of people was a disgrace.

Every Republican who voted for this abomination must be held accountable

I won’t mince words. The health-care bill that the House of Representatives passed this afternoon, in an incredibly narrow 217-to-213 vote, is not just wrong, or misguided, or problematic or foolish. It is an abomination. If there has been a piece of legislation in our lifetimes that boiled over with as much malice and indifference to human suffering, I can’t recall what it might have been. And every member of the House who voted for it must be held accountable.

He is right. We have to stop voting in such reprehensible individuals.

The last 2 administrations have been very disappointing. The actions of the administration and the Republicans in the House and Senate now though are taking things to a level not seen since at least Watergate and maybe back to McCarthism.

It is shocking to see the country so let down by those we vote in and day after day see that disgrace trumped by even greater failures of basic decency, honesty or competence.

Democrats and Republicans Have Failed the USA on Health Care for Decades

It is so sad that Democrats and Republicans have played games for decades while those of us in the USA are stuck coping with the disaster of a health care system those two parties have created. A good health care system is very close to the most important feature of a modern society. Yet those two parties have bungled for decades and left us to suffer.

Many Flexible Health Plans Come With A Costly Trap

Vince Hess of Grandview, Mo., racked up about $800 in costs related to surgery for a broken hand in 2013. Hess, an actuary, first checked that his surgeon was in network. He had the operation at an in-network surgical center, but only learned later when he was billed that the two anesthesiologists who assisted in the surgery were not.

This kind of thing should result in health care providers (insurers etc.) going to jail. It is intolerable that someone has insurance and is expected to police the health care provided to them in such a way. Costs must be detailed up front or they should not legally allow to be billed.

I realize emergency situations will create some complexity with providing all costs in advance, fixing that part can be delayed. This behavior of billing after the fact for huge expenses has gone on for at least a decade. It should have been stopped after a year. It is intolerable that our political parties just make excuses and sacrifice our lives to disreputable business practices by health care providers. This needs to be fixed now. Not after another decade or two of the parties not fixing it. Now.

If you have insurance and use the insurance, the insurer must be expected to deal with the games hospitals and doctors chose to play to try and stick USA citizens with bills after the fact. This isn't about making the USA system close to as good as the second worst rich country heath care system this is about fixing an intolerable hardship placed on citizens by the medical care system the Democrats and Republicans have put in place over the last 20 to 40 years.

Related: Medical Debt Increases as Economy Declines - Out of Pocket “Maximum” – Understanding USA Health Care Costs - USA Health Care Spending 2013: $2.9 trillion $9,255 per person and 17.4% of GDP - USA Spends $7,960 Compared to Around $3,800 for Other Rich Countries on Health Care with No Better Health Results (2009 data) - Our Failed Health-care System (2008)

Our Diets Are Greatly Changing the Ecosystem Inside Our Bodies

We still have so much to learn about human health. The rich interaction of our bodies and our microbiome is amazing and important and complex and not very well understood.

Some posts I have made on these topics on the Curious Cat Science Blog: Waste from Gut Bacteria Helps Host Control Weight (2008) - Tracking the Ecosystem Within Us (2007) - People Have More Bacterial Cells than Human Cells (2007) - Microbes Flourish In Healthy People (2010) - Human Gene Origins: 37% Bacterial, 35% Animal, 28% Eukaryotic (2013)

Here is a recent article looking at variation in human microbiome.

Burgers and fries have nearly killed our ancestral micro biome.

A group of Italian microbiologists had compared the intestinal microbes of young villagers in Burkina Faso with those of children in Florence, Italy. The villagers, who subsisted on a diet of mostly millet and sorghum, harbored far more microbial diversity than the Florentines, who ate a variant of the refined, Western diet. Where the Florentine microbial community was adapted to protein, fats, and simple sugars, the Burkina Faso microbiome was oriented toward degrading the complex plant carbohydrates we call fiber.
...
The Western microbiome, the community of microbes scientists thought of as “normal” and “healthy,” the one they used as a baseline against which to compare “diseased” microbiomes, might be considerably different than the community that prevailed during most of human evolution.
...
a remarkable and somewhat quixotic effort has begun to catalog and possibly preserve, before they disappear, the microbes of people who live in environments thought to resemble humanity’s past—people whose microbiomes may approximate an ancestral state. Researchers are motoring down rivers in the Amazon, off-roading in the East African savanna, hiking into the mountain villages of Papua New Guinea. They see themselves as rushing to catalog an ecosystem that may soon disappear.

“It’s really our last chance to harvest a lot of these microbes from around the world,” Rob Knight, a microbiologist at the University of California, San Diego, told me. “We have to do it before it’s too late—and it’s very nearly too late.”

It is a very good idea to learn much more about this area. And it is also wise to learn what microbes we have co-evolved with for so long - before that information is lost.

Homicides by Gun Have Declined a Great Deal in the USA the last 20 Years - Still Over 11,000 People Killed with Guns in the USA Every Year

Homicides using guns in the USA have seen a big decline in the last 20 years. In 2010, CDC data counted 11,078 gun homicide deaths, compared with 18,253 in 1993 which is a rate of 3.6 gun homicides per 100,000 people, compared with 7.0 in 1993. This is great news. But this leaves the USA with 11,078 gun homicides in 2010 which is horrible.

From 1993 to 2000, the death rate dropped 45%. From 2000 to 2010, the death rate declined only 7% more.

The Pew Research report provides a large amount of detail on this aspect of our safety and health.

Deaths from mass shootings are a relatively small share of firearm homicides. According to a recent Congressional Research Service report (Congressional Research Service, 2013), 78 public mass shootings occurred in the United States from 1983 through 2012, claiming 547 lives and injuring 476 people.

... The United Nations Global Study on Homicide (UNODC, 2011) estimated that 199,000 homicides, or 42% of the 468,000 worldwide total in 2010, were committed by firearm.

According to U.N. statistics, the U.S. firearm homicide rate and overall homicide rate are higher than those in Canada and in Western European and Scandinavian nations, but lower than those in many Caribbean and Latin American countries for which data are available.

Where does the U.S. rank internationally in terms of gun crime of all types? A report that compared 2003-2004 victimization survey data for 30 countries, including most developed nations, found that the U.S. ranked about average in an overall index of common crimes (Van Dijk et al., 2007).

However, the report placed the U.S. among the top countries for attacks involving firearms. “Mexico, the USA and Northern Ireland stand out with the highest percentages gun-related attacks (16%, 6% and 6% respectively).” The U.S. had the highest share of sexual assault involving guns.

If the USA had the rates of gun homicides as Western European countries over 9,000 people would spared every year. At the Japan rate nearly 11,000 people would be spared every year.

USA rate for 2011 4 per 100,000 (homicide 3.6 + accident .3 + undetermined .1)
France = .68
Canada = .59
Italy = .47
Germany = .3
Spain = .2
UK = .07
Japan = .02

The improvement in the USA is good, but we shouldn't ignore the 9,000 people killed every year that other societies have shown is not necessary. That is 90,000 people every decade. That is a huge number, even based on the lower rate of gun homicides we have today compared to 20 years ago.

Related: Militarized Police Culture Creates Long Term Large Scale SWAT Raid Failure for Society - Using Deming’s Management Ideas to Reduce Violence in Prison - Police Failing to Enforce Law If Lawbreaker is a Police Officer - Police State

The People We Elect Recently Are Dramatically Falling Us

Bill Moyers is a great journalist. He has done a great job, for decades, doing what great journalists do to help a country - shining the light on our society and what our politicians are doing. We desperately need more people like him and more institutions that promote real journalism.

Sadly we elect politicians that then let special interest and crazy extremists in their party dictate everything that is done. And sadly we watch special interest produced pabulum like Fox. As Bill Moyers states this stuff is consistently so full of lies and falsehoods no sensible person could consider it even up to the standard worthy of contempt. It isn't good enough to even be contemptible. It is a very sad commentary on how foolish many of our are that Fox is actually tolerated. The other mainstream news is bad but Fox isn't even in the same galaxy. That a country has a news source with more than 1% market share (having crazy extremists is normal and isn't a bad commentary on a country) even remotely as bad as Fox is an extremely bad commentary on that country.

I find both parties very disappointing. But the Republicans have become so bad so apposed to debate, discourse, thought, solutions, science, liberty, society, working together... that I am close to losing faith in the entire party.

None of them seem willing to stand up for the country. They are all either the fools pumping what some lobbyist tells them or the cynical politician unwilling to stand up for their country because they care more about pleasing their most extreme elements in their party than the country. I understand that standing up to extremists can be challenging. It is one of those traits that is necessary for political leaders though. They need to be willing to stand up for the country even if that means making their friends and colleagues unhappy. Even if those people threaten to make their lives difficult if they stand up for what they believe.

I understand most politicians will just take the easy way out. We don't elect many thoughtful, courageous, leaders. We can't expect thoughtful, courage, actions from most of them. But for a party to be completely missing any of them who have any clout is a serious problem, as I see it. The Republicans have let extremists dictate so much for so long that they created a much more difficult climate. To stand up to the crazy extremist actions now requires much more than would be required if you hadn't let them run wild for more than a decade.

I think the extreme elements can play a vital role when the sensible center is called out for just implementing what the lobbyists pay both parties for. But the extreme on the Republican side for about the last 15 years has been dictating policy and implementing whatever the lobbyists tell them to.

A few years of cowardly behavior by an entire party is frustrating but, given the low quality of leaders we elect, isn't surprising. Over a decade of such behavior though is very close to an unforgivable sin.

The Democrats are not doing well, in fact they are doing horribly. But compared to the Republicans for the last 15 years the Democrats look almost tolerable. The overriding problem, as I have seen it, has been that both parties together have been doing an extremely lousy job for the last 30 years. But the Republicans have become so unhinged from reality and unwilling to govern that it is getting close to the point where the main problem is going to be them, if that hasn't already happened.

It is a very sad state of affairs.

Related: We Continue to Vote for Those that Sell Out the Country for Cash Gifts - Living Through Your Society Becoming a Police State - Security Theatre Thinking is Damaging the USA - Real Journalism Exposes Bail Bond Corruption - Lobbyists Keep Tax Off Billion Dollar Private Equities Deals and On For Our Grandchildren - Money Is Corrupting Our Political Process - Anti Liberty Sentiment in Congress

Separated Bike Lanes Reduced Injuries by 45% and Increased Retail Sales 49% (for nearby stores)

Urban planning can greatly increase our quality of life. This report has some good ideas and shares results of tests of improvements - Measuring the Street: New Metrics for 21st Century Streets.

Results from first protected bicycle lane in the US: 8th and 9th Avenues (Manhattan):

• Injuries reduced 45%
• Retail sales increased 49% (near the new lane, compared to 3% increase for the whole "borough" - essentially the large surrounding area)

Related: The Case for Physically Separated Bike Lanes (2007) - The Rebirth of Cities - Designing Cities for People, Rather than Cars - The Economic Benefits of Walkable Communities

Decades of Failure by Those Responsible for USA Health Care System Needs to be Addressed

The reasons for the failures of the USA health care system are complex. Given decades of failure those with leadership positions (hospitals, doctors, politicians, insurers) all have failed. Drug companies I would put below those 4 (they mainly just take advantage of lots of weak politicians to buy bad policy, for the country, that favors drug companies). Exactly what percentage of the failure to put at each groups footstep is hard to judge, but the collective failure is obvious. It is something we couldn't afford in 1980 and the damage to us grows every year. The USA health care system costs twice as much as other rich countries and the results are mediocre. Big business has some responsibility but mainly they just have ignored the problem and not done anything to help (versus actually intentionally sustaining the broken system). Voters have a huge responsibility for decades of re-electing those that maintain the broken system.

Related: International Health Care System Performance - Overview of 5 Nations Health Care Systems - USA Health Care System Remains Broken, Neglected

Can Mental Health Treatment Facilities Notice Healthy People?

On Being Sane In Insane Places by David L. Rosenhan

Despite their public “show” of sanity, the pseudopatients were never detected. Admitted, except in one case, with a diagnosis of schizophrenia,[4] each was discharged with a diagnosis of schizophrenia “in remission.” The label “in remission” should in no way be dismissed as a formality, for at no time during any hospitalization had any question been raised about any pseudopatient’s simulation. Nor are there any indications in the hospital records that the pseudopatient’s status was suspect. Rather, the evidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label. If the pseudopatient was to be discharged, he must naturally be “in remission”; but he was not sane, nor, in the institution’s view, had he ever been sane. The uniform failure to recognize sanity cannot be attributed to the quality of the hospitals, for, although there were considerable variations among them, several are considered excellent. Nor can it be alleged that there was simply not enough time to observe the pseudopatients. Length of hospitalization ranged from 7 to 52 days, with an average of 19 days. The pseudopatients were not, in fact, carefully observed, but this failure speaks more to traditions within psychiatric hospitals than to lack of opportunity. Finally, it cannot be said that the failure to recognize the pseudopatients' sanity was due to the fact that they were not behaving sanely. While there was clearly some tension present in all of them, their daily visitors could detect no serious behavioral consequences—nor, indeed, could other patients. It was quite common for the patients to “detect” the pseudopatient’s sanity. During the first three hospitalizations, when accurate counts were kept, 35 of a total of 118 patients on the admissions ward voiced their suspicions, some vigorously. “You’re not crazy. You’re a journalist, or a professor (referring to the continual note-taking). You’re checking up on the hospital.” While most of the patients were reassured by the pseudopatient’s insistence that he had been sick before he came in but was fine now, some continued to believe that the pseudopatient was sane throughout his hospitalization. The fact that the patients often recognized normality when staff did not raises important questions.

This study was done in 1973, do you think the results would be any better today? In looking around for current research I can't find much (that may be my fault). It does seem to me if mental health organizations or educational institutions cared about improvement they would do more real world research on what happens. I'm not sure who makes money from improving it so if the research has to be funded by someone with money to gain from the research that may explain it. That isn't a very healthy place for a health care system to be in.

Health Care System Remains Broken, Neglected

I think the real problem is decades of resistance to fundamental change. The health care system in the USA has been broken for decades and resisted change to bring costs and other burdens into line with other rich countries. Piling on decades of neglect to a system broken decades ago has left a huge (huge - over 17% of GDP, costs twice as high as many other rich countries and results no better than average rich countries) problem. Trying to reform a huge broken system after the crisis point has been reached (where we are now) is very difficult. I think looking for short term causes of the current problems is deceptive. The real cause of the current mess is decades in the making.

The USA health care system is huge. Tons of great stuff has been done for decades. The problem is with such a huge system enormous problems remain and have festered for decades. I think things will get much worse (difficult to deal with the long overdue needed, improvement) before getting better. The system is unimaginably expensive and wasteful. The fundamental brokenness continues to be ignored. Even the good stuff being done now, seems to be minor compared to the fundamental changes needed.

The USA economy has many problems and strengths. The health care problem remains the largest - larger than investment banking, unemployment, unfunded liabilities (which the health care system is by far the largest factor - unfunded retire health care costs), huge jail population, education system needing improvement... The good news is the USA economy, even with all this, has enough strengths to carry the weak parts of the economy for decades to come. It is true however, that even the USA economy cannot carry huge under performing parts of the economy forever and remain strong. Of all the economic problems we face, failing to address the huge problems in the health care system is the most likely to lead to a dramatic decline in the USA's economic future. We have avoided systemic changes for decades. Year after year the problem grows (even with lots and lots of great things being done - which seem large but are unnoticeable within the enormous scope of the problem) - with the health care system not only costing more but a larger percentage of GDP EVERY YEAR for decades (I may be wrong but I think this is true). Dr. Deming pointed out the system was a deadly disease decades ago. And it has gotten worse (costing more and continuing huge economic problems - huge cost to business and people and huge worry, bankruptcies, focus on disease treatment not health care...).

I'm sorry to say I think things will get much more hectic in the coming decades than they have been as the cumulative effect of putting off needed system improvements for decades come home to roost.

Reaction to, Industry in Crisis

Across the nation delivery systems, policy makers, insurers and consultants are searching for new ways to solve problems or create value. Systems are banding together to form Accountable Care Organizations, we are reorganizing around Value Streams, Value Based Benefit plans are getting created to shape behaviors, large hospital systems are buying practices and consolidating the market etc. The list goes on and on.

The good news is that there seems to be more experimentation taking place than ever before and some ideas are gaining traction (just read Atul Gwande’s article last week in the New Yorker or my own organizations work in the Medical Home and Hospital Transitions). The challenge is that so many things are happening all at once that our current management systems are neither disciplined nor flexible enough to effectively manage this change.

Related: USA Heath Care System Needs Reform - CEOs Want Health-Care Reform - Health Care Crisis