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8 questions to ask prior to a planned surgical procedure.

Prior to undergoing a planned procedure such as a knee replacement or gall bladder removal there are questions you can ask to help with calculating your out-of-pocket costs.

1. What is the exact name of the procedure?  Ask your doctor to clearly print the name of the procedure. Correct spelling is important and many surgery names sound similar.

2. What ICD-10 codes will be used? Your health plan pays healthcare providers based on these diagnosis codes, which the doctor’s office or hospital will provide to them. The coding system was recently updated from ICD-9 to ICD-10, which is much more detailed than ICD-9.

3. What is the CPT® code for this procedure? One or more five-digit CPT codes are the billing codes that are used by providers—usually for physician services—throughout the United States.

4. What tests will I need before the surgery? Blood tests, diagnostic imaging tests, such as a CT scan or ultrasound?  Ask for specifics about which blood tests will be ordered. Ask the doctor if you have a choice of facilities for getting these tests done. Check with your health plan before you have the test to find out where your out-of-pocket cost will be lowest.

5. Will other doctors be involved in my care and bill me for their services? A pathologist, a radiologist, and an anesthesiologist may be involved in your care. Even if your surgeon and the hospital are in your health plan’s network, other doctors involved in your hospital care may not be.

6. What kind of anesthesia will I receive? Many surgeries will involve care by an anesthesiologist and other doctors who may or may not be part of your health plan’s network.

7. After my surgery, will I go right home from the hospital? What medications and follow-up care will I need? After you are discharged from the hospital, you should be able to go directly home. After some operations, you may need care in a rehabilitation unit or skilled nursing facility for a while. Or you may need home health care. Your health plan can provide information about coverage and prices.

8. What else should I know about—such as potential complications—that might affect the cost of the procedure? For example a minimally invasive (laparoscopic) gall bladder surgery has to be changed to an “open” cholecystectomy, which may or may not be more expensive. You and your doctor should already have discussed this when you talked about the risks and benefits of the surgery. If not, be sure to ask questions about the open procedure before the day of surgery. Having a different procedure (or an additional procedure) is likely to change the cost. And if you need to stay overnight in the hospital for any reason, that is generally more expensive than an outpatient procedure.

Ultimately you may to call your insurance company (groan) or set up an online account on their web site (further groan). This may or may not give you an answer.  You could also wait for that Explanation of Benefits (EOB) statement in the mail – good luck with making sense of that document !

All of the above can entail a lot of time and effort on your part. The good news is that the whole process is a lot easier with new electronic tools that are now available. These tools do the math for you and calculate these costs. They also make your medical bills easier to read and decipher those confusing EOBs. Check to see if your employer offers these tools to their employees.

For more information on the tools offered by Obeo Health please watch the video on the home page.

The Risks of the 15-Minute Doctor’s Appointment

How would you react if you sent your sputtering car to the auto mechanic, and they stopped trying to diagnose the problem after 15 minutes? You would probably revolt if they told you that your time was up and gave back the keys.

Yet in medicine, it’s common for practices to schedule patient visits in 15-minute increments — often for established patients with less complex needs. Physicians face pressure to mind the clock while they examine you.

That’s not to say that your physician “clocks out” as soon as your 1 p.m. appointment hits 1:15, or that all appointments last that long. What it does mean is that patients and doctors may be deprived of the opportunity for more meaningful discussions about the underlying causes of their problems and plans to improve them. A woman in her 50s who presents with high blood pressure and obesity might need medicine. But a longer conversation about the stresses of being the primary caregiver to her father, who has Alzheimer’s, could help provide strategies to help her look after herself.

When you see a new patient every quarter hour, there is often scant time to get to these root causes, to make accurate diagnoses, and develop the best treatment plans. And there is the danger that you miss a major diagnosis altogether.

The 15-minute appointment arose not out of evidence that it improves patient outcomes but out of production pressures — both the need to meet patient demand and to see enough patients to stay profitable.

Unpopular among patients, these production pressures have few fans among physicians either. A Mayo Clinic report stated that 54 percent of physicians meet the criteria for burnout in 2014 — up nearly 10 percent from three years earlier. Running on a treadmill all day in 15-minute sprints likely contributes to this phenomenon. Onerous documentation requirements and other pressures don’t help, either.

Some patient problems could be solved in 5, 10 or 15 minutes, but others cannot. What if health care trusted its physicians enough to take the time they need with patients and no more — and then monitored and paid for results? Could we realize better care while reducing costs, because patients are getting the right diagnosis sooner, and not coming back after their problem has been missed and their condition has worsened?

It’s not clear whether alternative payment models will achieve this. Concierge practices, in which patients pay a hefty annual fee in exchange for greater access to their physicians, may work well for those who can afford it. While this model is beyond the financial reach of many, a related model called direct primary care — or “concierge care for the masses” — is more accessible. Patients pay a monthly fee of anywhere from $25 to $85 to cover their primary care services, according to a Health Affairs report in December, and are encouraged to have insurance to cover more serious health issues. Patients and physicians might have 45 minutes to spend in an appointment. Because direct primary care usually does not bill insurance, it results in less checking boxes and more conversation.

A criticism of these models is that they may exacerbate the larger physician shortage, because physicians are responsible for significantly fewer patients than in a typical practice. Yet we need to evaluate their impact and see if their lessons might help us reclaim the patient-physician encounter.

This post first appeared in The Wall Street Journal’s blog, The Experts.

Did you pick the right health insurance plan?

Selecting a health insurance plan can cause considerable angst for a consumer and his/her family. Insurance plans are complex and there is a wide variety available on the market. Let’s try to simplify the decision making process. There are basically four areas that the consumer needs to assess for each plan offering;

1. The deductible.

2. The co-payment.

3. The co-insurance.

4. Out-of-pocket spending limits.

The complexity of plan choice arises in part from wide variation among plans across these four features that determine how health costs are shared between the insurer and consumer. And so consumers are faced with a dizzying number of permutations when trying to balance these four areas.

Lack of health literacy also plays a part in the process. A study done in 2013 found that only 14% of consumers could answer four simple multiple choice questions regarding the definition of these four cost sharing features. Also when presented with a simplified plan, most respondents were unable to accurately estimate the cost of their medical services. To confuse things further employees need to know if the plan covers their medications (formulary status) and whether their physicians are in or out of network.

The Affordable Care Act (ACA) organized plans were segregated into four ‘metal’ tiers – platinum, gold, silver and bronze. One investigation of hypothetical plan choices with plan menus designed to mimic those of the exchanges found that metal labels, rather than facilitating better decisions, worsened choices compared with generic labels (eg, plan A, plan B, plan C). This study also found that alternative plan labels that encouraged consumers to forecast how much care they anticipated needing did have a modestly beneficial effect, suggesting that participants may have misinterpreted metal labels as signals of quality, or the breadth of services covered, rather than the degree of cost sharing.

To make a financially efficient choice, employees, most of whom lack extensive prior experience with insurance, have to carefully consider the complicated relationship between plan cost, cost sharing, and their expected health risk. So what can be done to help employees navigate through these complex scenarios? I would like to suggest some possible solutions;

1. Provide decision aids. These may be scenario based examples or so called “people like me” illustrations.

2. The utilization of consumer historical data (claims, pharmacy etc) to help predict future costs should be encouraged. Prescriptive analytics tools can now help perform this task.

3. A more aggressive approach may be the use of plan “defaults” or restricted menus tailored to each consumer.

4. A more long term solution would be to simplify health insurance – period. Insurance products free of the complex features that consumers are least able to understand, such as deductibles and co-insurance,would more likely help consumers make informed decisions regarding plan choice and utilization.

Offering multiple plans seems like a good idea – the typical ACA enrollee is offered an average of 47 plans. One would hope that this large number of choices would help the consumer find an appropriate plan and may stimulate competition among insurers, leading to improvements in plan price and quality. However, these benefits are unlikely to emerge if consumers are not given the right tools and education.

To sign up for a free demo of the tools on offer at Obeo Health please click here.

10 Things you need to know about Compliance in a Healthcare Setting

In this world of instant access to social media, the issue of privacy has expanded into new territories. Data is no longer locked down. It is shared through multiple offices, providers, hospitals, and specialists. This new environment carries increase risk and consequence. Here are ten things to consider about organizational compliance:

1.Privacy policies are too easy to break. All it takes is one frustrating patient and a louder than normal conversation of “venting” between employees. Always be aware of your surroundings, patient care areas, waiting rooms, and other high traffic centers. Some of the most dangerous violations can come from the most innocent intentions.

2. Be wary of gifts. The normal week in a medical office contains a flow of vendors with samples and presentations. They will often attempt to sweeten the dealings with food or other offerings. This practice can extend to patients that mean well. Accepting gifts can land an employee and office on rough legal waters. Know where the line lies and keep the overzealous salesmen in check.

3. File reports. A patient falls getting out of bed. An employee stays an extra hour to help finish a large project. A lunch break is cut short for a meeting. All of these must be reflected in filed reports and accurate time counts. The consequences of falsifying records are much larger than the documentation and scrutiny from management. If legal proceedings occur down the line, you’ll want your files in order.

4. Legal Cooperation. The subpoena may come from different sources but, the minute it arrives, be ready to hold relevant records and provide all needed information. Stop the flow of paperwork until you are prepared to respond and keep to your developed process. It will smooth out any headaches.

5. Keep Current Training. It may be year one or year fifty, either way be sure to keep up with your training courses. OSHA requires yearly sessions in regard to employee and patient safety, along with other relevant issues. When an emergency happens, you’ll know the training works as it is handled in a professional manor.

6. Sharing passwords- In a nod to the first entry on this list, security is highly important for any practice. One day someone may call out sick or a new hire will start without login information. With the pressure and speed of daily operations, this may temp fellow employees to share login information or, even worse, keep them displayed on notes around workstations. Keep access keys secure at all times and let the new employee wait to get their own digital identification in the system.

7. Dangerous Friends- One day the phone will ring and it will be a favorite aunt or grandfather wondering about their test results. The matriarch of the family may have been admitted after a stroke and, for an hour, relatives from out of state are burning up the phone lines begging for information. Be sure the limits are known and posted throughout any areas of medical records and patient contact. Friends and family of patients mean well and can get frustrated at a lack of answers but, staying vigilant will only help your practice and show the empathy for the patient that you value and their loved ones should respect.

8. Protect Yourself- Physical security is just as important as data security. Have PPD ready and available when needed. Know what issues patients present when they arrive and whether or not they should be in an isolation room. The moment ignored often becomes lost time and illness (consider the recent Ebola outbreak). If you work evening hours, be aware of your surroundings in parking areas and other dark environments.

9. Protect Your Claims- “But I swear, it was a car accident.” Be sure to document everything that patient says and presents in terms of their condition. How often have they requested pain medications this month? Do visual symptoms match up with clinical findings? Insurance fraud is a common occurrence. Enact all possible measures to prevent this from happening in your practice and, when in doubt, document in detail.

10. Be Prepared- The audits will come. The Joint Commission will make announced and unannounced appearances. State and local inspectors will show up and your practice must be ready. Keep all parts up to code and stay on top of changes within the survey process. Nothing can derail patient service, profit, and satisfaction like a failing inspection. It is common sense and the quickest headline to make the news when an office fails for something that was an easy fix.

This list is only ten of many issues of compliance that are present on a daily basis. Do your best in all areas and you will find an increase of patient and employee satisfaction, a smoother workflow, higher profits and success.

Impact of Healthcare Underestimated by Many Advisors

There are some very good points raised in this article by Emily Brower Auchard. We agree that employees should approach healthcare with the same financial awareness they bring to buying a car or a home. The article is reproduced below….

The high cost of healthcare in the U.S. takes up an increasingly large portion of consumers’ financial resources, with health spending in the U.S. reaching $3.1 trillion—or nearly $10,000 per person per year, according to the Centers for Medicaid and Medicare Services. Even with long-term disability and health insurance, consumers who get sick can be hit with unexpectedly large out-of-pocket expenses.

Advisors say the unpredictable nature of healthcare costs requires creative planning and careful attention to the small print of health-related insurance. Over the course of his career, Anthony Domino, an advisor with Associated Benefit Consultants in Rye Brook, N.Y., with $2 billion under management, has seen big changes in how healthcare costs impact his clients.

“Today my clients can spend more on co-pays for drugs than they used to for their entire health insurance premium,” he says. While healthcare reform has changed the funding for health insurance it hasn’t impacted healthcare costs, he notes. With that in mind he encourages clients to shop carefully for their healthcare insurance. He also recommends they repeat the process for every annual enrollment period to be sure they are getting the best coverage possible. In addition to premium increases, other plan benefits and costs, such as drug benefits or coverage of out-of-network provider care, can change significantly from one year to the next. This can lead to what the healthcare industry now calls “surprise medical bills.”

Neal Slafsky, managing director of United Capital in Newport Beach, Calif., encourages clients to approach healthcare with the same financial awareness they bring to buying a car or a home.

Slafsky, whose firm has $15.4 billion under management, works with his clients to ensure they get the benefits they are due from their health insurance providers — which can mean taking a more active role in reviewing medical bills after a client’s hospital stay.

“Sometimes clients have to appeal their claim and go back more than once to get the benefits they are due,” he explains. If the process is too much for a client, he recommends they hire a medical claims processor.

“The fees are very reasonable and I’ve seen them get terrific results,” he says. The best way advisors can serve clients, he says, is to do a “deep dive” into the world of healthcare insurance.

Providers can be very opaque in their explanations of benefits and advisors can play a crucial role in translating that information for clients. “Where else is a client going to go to get that information?” he notes.

Long-term disability insurance is another element where clients typically need advisor guidance. “Clients need to plan well in advance to prepare for the possibility of being disabled,” explains Venita Zavidny, an advisor with Houston, Texas-based Kanaly Trust, which has $2 billion under management. Zavidny, who considers incurring a long-term disability to be one of her clients’ biggest risks, is well versed in the financial needs of long-term care. Zavidny works with clients to look closely and carefully at their long-term disability plans and to make sure they know exactly what coverage they are buying.

For instance, a plan that says it will provide 60 percent of a client’s income may look appealing on paper — but clients often neglect to factor in other costs. “Taxes will make that income considerably less,” notes Zavidny. Many plans include Social Security benefits in their formulas and will subtract any amount of long-term disability provided by Social Security from their payments. One piece of advice Zavidny offers her clients: avoid paying taxes on future long-term disability income by taking the benefit as imputed income. “This small decision on insurance choices can have big consequences for the future,” she notes.

Addressing quality in healthcare

For more than a year, top officials from Medicare, the nation’s largest health plans, medical societies and major employer and consumer groups hammered away at a dreadful task: Get everyone to agree to use identical quality measures for the treatment of heart disease, cancer and other common conditions. Here is a summary of the work from the Collaborative….click here

Evaluating health insurance plans can be daunting and confusing, and most people don’t get much guidance, research shows

The following is taken from an article written by Austin Frakt at the New York Times. It highlights the challenges around picking a health plan…….

It’s open enrollment season for almost every kind of health insurance in America. Millions of Americans using Medicare plans, employer-sponsored health insurance or Affordable Care Act marketplaces select health plans each fall. Many consumers face numerous options, and research shows that they make many mistakes, often paying more than they need to.

Some err by selecting deductibles that are too low. Lower deductibles can be a fine choice for some consumers, but trying to save money with a lower deductible can be a poor choice if a person pays even more in premiums. For instance, at one large American company in 2010, employees could reduce their deductible by $250 — to $750 from $1,000 — by paying $500 more in premiums. Trading $500 for $250 is clearly a bad deal for the consumer.

Yet a majority of the firm’s workers made bad deals like this, according to a study by Saurabh Bhargava, a Carnegie Mellon economist, and his colleagues. Workers were offered a choice of 48 plans that were identical except in cost sharing and premiums. Though no plan would have been optimal for every employee, a $1,000 deductible plan would have been better for many and at least a no-worse choice for 97 percent of employees who chose a lower deductible.

People make mistakes like this for a variety of reasons. Some don’t understand basic health insurance concepts. In an experiment accompanying Mr. Bhargava’s study, 71 percent of people couldn’t identify fundamental cost-sharing features of health insurance plans. This type of illiteracy was highly predictive of mistakes like overpaying for a lower deductible.

Another study, led by George Loewenstein, a professor of economics and psychology at Carnegie Mellon, found that people misunderstood plan features and costs. Even with plan details right in front of them, only 40 percent of privately insured Americans could identify how much they’d have to pay for anM.R.I. scan. Only 11 percent could report what a four-day hospital stay would cost them. Yet study subjects were overconfident. All said they understood what a “co-pay” was, but 28 percent could not correctly answer a question testing their understanding of the term; only 7 percent would admit to not knowing what “maximum out-of-pocket” meant, but 41 percent couldn’t define it.

Another study found that less than a third of respondents could correctly answer questions about coverage features of their own plan. Yet anotherfound that only a minority of workers at a large firm could answer questions about plan characteristics or their own, recent health care spending.

Without a doubt, choosing a plan can be daunting. A shopper in the Affordable Care Act marketplace can choose from 40 plans, on average. A typical Medicare beneficiary can choose from among nearly 20 Medicare Advantage plans and 30 stand-alone prescription drug plans.

In selecting plans, consumers are prone to mental shortcuts that often lead to poor choices. Plan labels — like the “gold,” “silver” or “bronze” — can fool people. To some, “gold” sounds better than “bronze,” even if it isn’t. In one study, people were asked to select hypothetical plans with these labels, but the researchers reversed the meaning of “gold” and “bronze” for half of them. It didn’t matter. Most people picked “gold” anyway.

The ordering of choices also matters. Consumers tend to select plans near the top of a list, a phenomenon that arises in other contexts: Economists download more papers from the tops of lists of new studies, as my colleague Neil Irwinreported; politicians at the top of ballots receive more votes.

Eric Johnson, a Columbia business professor, led a study that found that without substantial additional assistance, a consumer’s likelihood of selecting the lowest-cost plan is no better than chance. The researchers conducted a series of experiments on people similar to those who would shop for marketplace coverage. Each study participant was asked to presume he’d use a certain amount of health care and, based on that, to choose the lowest-cost plan from among eight choices, which varied by premium, doctor co-pay and deductible.Only 21 percent could accomplish this task, a figure not statistically different from chance. The annual cost of errors was about $250. A separate analysis showed that participants had a stronger aversion to an increase in costs in deductible or co-pay than to the same increase in premium. Because a dollar is a dollar, no matter how you spend it, this is another indication of irrational decision making.

But when study subjects were provided with a tutorial or with a calculator that revealed the full cost of each plan, or if they were placed in the lowest-cost plan by default (from which they could voluntarily switch), their chance of selecting the cheapest plan was much higher, upward of 75 percent in some experiments.

Though some Medicare beneficiaries switch to lower-cost drug plans over time, another way consumers get stuck with bad deals is by staying in plans as their premiums increase, a status quo bias. One study found that New Jersey enrollees in Medicare prescription drug plans paid an average of $536 more over three years because of this kind of inertia. Some insurers strategically enter marketswith low prices and increase them over time, exploiting consumers’ inertia. This “invest then harvest” pricing strategy has been observed in markets for Medicare Advantage planscommercial health insurance and others.

Providing consumers with easier access to cost comparison information can help. A study published in The Journal of Economics in 2012 found that when a random sample of Medicare beneficiaries got letters that compared prescription drug plan costs, they were more likely to switch plans and to save money, relative to nonrecipients. When pharmacy students helped California Medicare beneficiaries understand drug plan costs, 60 percent switched plans.

Few consumers get this much help. When researchers at the University of Pennsylvania examined the Obamacare online marketplaces last year, they found only a few that provided some of the tools consumers need. Most marketplaces presented plans in order of the cost of the premium, which doesn’t take other cost sharing into account. (However, California ranked plans according to total cost, Kentucky listed them randomly, and Minnesota ranked them based on best match according to a series of preference questions, similar in spirit to an approach recommended by University of California, Berkeley economists in a recent Brookings policy paper.)

Only three states offered cost estimators. The federal government’s site, HealthCare.gov, will offer more information about plans — like which physicians are in plan networks — and cost comparison tools.

If last year is any guide, once again few consumers will actively shop for a more beneficial plan. An analysis by the Department of Health and Human Services showed that more than 70 percent could have found a cheaper plan. The research is clear: Most won’t find that cheaper plan without a great deal more help.

Austin Frakt is a health economist with several governmental and academic affiliations. He blogs at The Incidental Economist, and you can follow him on Twitter at @afrakt.