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A physician/policy wonk faces our health care financing system

As consumers' out-of-pocket costs grow, will the patient bill-of-rights movement rise again?

By Harris Meyer
Modern Healthcare, September 1, 2018

Emergency physician Dr. Matthew Wetschler was body surfing off Ocean Beach in San Francisco last November when a wave slammed him head-first onto the ocean floor, breaking his neck and paralyzing him. Another surfer pulled him out of the water just before he drowned.

He was taken to Zuckerberg San Francisco General Hospital, the closest hospital that was well-equipped to treat him, where neurosurgeons performed surgery to fuse five vertebrae and maintain blood flow to his spinal cord. After months of physical therapy at Santa Clara Medical Center and Valley Medical Center, he's walking, but still has no feeling in his hands.

During his grueling recovery, Wetschler received frequent calls from bill collectors seeking payment of nearly $500,000 in medical bills from the hospitals and physicians, plus a $13,000 bill from the air ambulance company that flew him 40 miles to Santa Clara for rehab care. Those providers were not in network for his insurer, Oscar Health.

Wetschler's experience with a large out-of-network bills and opaque healthcare bureaucracies is common. Nearly 18% of hospital stays for members of large-employer health plans resulted in patients facing out-of-network balance bills, the Kaiser Family Foundation recently found. That rose to 27% when patients passed through the emergency department.

Healthcare consumers also face other common problems with cost, coverage and access, which may increase as the federal government allows the expansion of skimpier, less-regulated health plans. These problems include:

* Coverage denials for emergency department visits that insurers later deem unnecessary.

* Lack of access to specialty providers in health plan networks.

* Difficulty in getting coverage for mental health and substance abuse treatment from health plans.

* Delays in receiving care due to plans' preauthorization requirements on providers.

* Patients' inability to find out from providers ahead of time how much they will owe for particular services.

* Large out-of-pocket costs for prescription drugs, particularly specialty medicines.

“There's plenty to do in the area of consumer protection, with high deductibles and out-of-network bills,” said Dr. David Blumenthal, president of the Commonwealth Fund. “But there is an anti-regulatory fervor we're seeing in Congress and conservative circles that will be an obstacle to moving a consumer-protection agenda.”

Wetschler, the doctor injured in the surfing accident, has finally gotten the hospitals, physicians and his health plan, Oscar Health, to waive most of out-of-network bills. But he still gets calls from collectors on about $27,000 of that total, including $13,000 for air ambulance services from ProTransport-1.

In his view, there should be consumer protections in place so patients don't find themselves in this type of terrible situation, which can destroy their finances.

“I'm a doctor with a master's degree in health policy, yet I feel so overwhelmed that it's almost paralyzing,” Wetschler said. “I'm stuck in no man's land. For a person with no medical training, what hope is there?”

http://www.modernhealthcare.com...

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Oscar

Oscar's story begins, fittingly, in a hospital room. In 2012, Oscar CEO Mario Schlosser and his wife were going through their first pregnancy in New York. Confronted with a maze of insurance jargon and no practical way to identify the best obstetrician, their first meaningful experience with the health care system put them at a loss as to how to navigate care or hold anyone accountable.

Mario’s friend Josh Kushner had recently had his own frustrating encounter following what should’ve been a routine treatment for an injury. Mario and Josh knew that their experiences were reflective of a larger problem in health care: consumers were powerless. That spring, they founded Oscar Health.

Oscar has been focused on one mission – to be a health insurance company centered around the patient.

https://www.hioscar.com/about

***

Comment:

By Don McCanne, M.D.

A young emergency physician with a master's degree in health policy should understand better than anyone how to interact with our health care financing system. Dr. Wetschler was insured by Oscar, a relatively new health insurance company cofounded by Josh Kushner, the brother of Jared Kushner of White House fame - a company that professes to be centered around the patient. Yet if the system is not working well in this situation, it could hardly be expected to work better for the rest of us.

Imagine having an improved version of Medicare wherein you receive the medical care you need, when you need it, and wherever you need it, and payment is taken care of automatically through a public system of health care financing. Instead we have a system in which even the most innovative insurers, like Oscar, restrict your choices and burden you with further debt. How can Oscar claim to be "a health insurance company centered around the patient" when they create additional problems for the patient that would be unnecessary in a well designed, publicly-financed and publicly-administered system?

It appears that President Trump and his son-in-law and advisor Jared Kushner are not going to help resolve these problems even though there is already more than enough money in the health care system, and they both profess to know a lot about how to manage money. Maybe instead of having a political leadership of money managers dedicated to business interests, we should replace them with political leaders who are dedicated to serving the people. It would really be nice to be rid of these unnecessary barriers to health care, and it wouldn't cost us any more than we are already spending collectively.

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