• Menu
  • Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar

Before Header

  • About Us
  • Lexicon
  • Contact Us
  • Our Store
  • ↑
  • ↓
  • ←
  • →

Balloon Juice

Come for the politics, stay for the snark.

Let us savor the impending downfall of lawless scoundrels who richly deserve the trouble barreling their way.

And we’re all out of bubblegum.

We’ve had enough carrots to last a lifetime. break out the sticks.

Is it negotiation when the other party actually wants to shoot the hostage?

The party of Reagan has become the party of Putin.

But frankly mr. cole, I’ll be happier when you get back to telling us to go fuck ourselves.

I was promised a recession.

When I decide to be condescending, you won’t have to dream up a fantasy about it.

Teach a man to fish, and he’ll sit in a boat all day drinking beer.

Too often we confuse noise with substance. too often we confuse setbacks with defeat.

Second rate reporter says what?

Too often we hand the biggest microphones to the cynics and the critics who delight in declaring failure.

So it was an October Surprise A Day, like an Advent calendar but for crime.

Shallow, uninformed, and lacking identity

I didn’t have alien invasion on my 2023 BINGO card.

Russian mouthpiece, go fuck yourself.

Balloon Juice has never been a refuge for the linguistically delicate.

Tick tock motherfuckers!

Technically true, but collectively nonsense

We are builders in a constant struggle with destroyers. let’s win this.

After roe, women are no longer free.

Motto for the House: Flip 5 and lose none.

Accountability, motherfuckers.

Something needs to be done about our bogus SCOTUS.

Mobile Menu

  • Winnable House Races
  • Donate with Venmo, Zelle & PayPal
  • Site Feedback
  • War in Ukraine
  • Submit Photos to On the Road
  • Politics
  • On The Road
  • Open Threads
  • Topics
  • Balloon Juice 2023 Pet Calendar (coming soon)
  • COVID-19 Coronavirus
  • Authors
  • About Us
  • Contact Us
  • Lexicon
  • Our Store
  • Politics
  • Open Threads
  • War in Ukraine
  • Garden Chats
  • On The Road
  • 2021-22 Fundraising!
You are here: Home / Anderson On Health Insurance / Rotten PEARS

Rotten PEARS

by David Anderson|  July 25, 20178:33 am| 25 Comments

This post is in: Anderson On Health Insurance

FacebookTweetEmail

Consumerism and patient directed insurance design is predicated on the assumption that pricing is transparent enough and choices are clear enough that patients can make reasonable decisions about cost effective treatment. There are a number of problems with that assumption, but I want to look at one today regarding the Pathology, Emergency Medicine, Anesthesiology and Radiology specialties.

These PEAR specialties are known as “invisible” providers. Invisible providers are seldom chosen by the patient. Invisible providers were intermittently listed in provider directories when I maintained the provider directory at UPMC. Invisible providers are part of the care team but they may not be employed by the same group that employs the visible providers.

Visible providers are the doctors that a patient can choose. My primary care provider is a visible provider. My wife’s Ob-Gyn is a visible provider. My former orthopedist is a visible provider. My mom’s neurologist is a visible provider. The hospital down the street with an ER is a visible provider. These are the providers where clear in and out of network designations occur.

The New York Times had a great article a study that examined the deliberate business strategy of a PEAR staffing agency to increase the number of out of network ER bills:

the new Yale research, released by the National Bureau of Economic Research, found those bills aren’t randomly sprinkled throughout the nation’s hospitals. They come mostly from a select group of E.R. doctors at particular hospitals. At about 15 percent of the hospitals, out-of-network rates were over 80 percent, the study found. Many of the emergency rooms in that fraction of hospitals were run by EmCare.

It is a deliberate business strategy to exploit the rottenness of the PEAR billing arrangements for profitability. Patients don’t know that the hospital is in network and most of the docs who work there are in network but the ER doctors or anethesologists are not.

The thing that leaped out at me was the deliberateness of the business strategy:

n addition to its work in emergency rooms, EmCare has been buying up groups of anesthesiologists and radiologists.

This is an exploit of the inability of people to make informed decisions in order to jack up rates.

What is a solution?

There are two common solutions. The first is to have states adapt out of network pricing limitations and dispute resolution systems. If out of network charges are capped at a multiplier of Medicare or a multiplier of usual and customary, the incentive to exploit a crack like this goes down dramatically. The other solution is to adapt a general contractor model for all emergency room services where the hospitals’ contractual obligations cover all service providers working under that roof. If someone presents to the emergency room with a broken arm, anyone who treats that patient, under this model, is assumed to be in-network if the hospital is in network.

As we move to a shopping model of health care, we need to get rid of the amazingly and glaringly obvious exploits and hacks to the system that do nothing for patient care but add significant expense and frustration.

FacebookTweetEmail
Previous Post: « You know what to do
Next Post: Hello Juicers »

Reader Interactions

25Comments

  1. 1.

    gvg

    July 25, 2017 at 8:43 am

    The other solution is to adapt a general contractor model for all emergency room services where the hospitals’ contractual obligations cover all service providers working under that roof. If someone presents to the emergency room with a broken arm, anyone who treats that patient, under this model, is assumed to be in-network if the hospital is in network.

    This seems like an obvious thing to do. I had not actually thought this through before. I assume there are reasons this would be resisted?

  2. 2.

    Steeplejack

    July 25, 2017 at 9:03 am

    Mildly disappointed that your solution doesn’t involve lining up EmCare’s C-level suits against a wall and shooting them.

  3. 3.

    OzarkHillbilly

    July 25, 2017 at 9:08 am

    where the hospitals’ contractual obligations cover all service providers working under that roof.

    I have long raged about this. It is so simple, so obvious, ergo it will never be done.

  4. 4.

    Spanky

    July 25, 2017 at 9:17 am

    @Steeplejack: Cheer up! That scenario may be nearer than you think, if the Republicans get everything they want. They’re still a minority, yet seem to forget that that’s the case. When things go sideways there’s no telling where things will end.

  5. 5.

    SP

    July 25, 2017 at 9:19 am

    David, what do you recommend individuals do to protect themselves from this? Have the patient (or responsible party if patient is unresponsive) ask to only have treatment from in-network doctors? Ask for a modification before signing any agreement to indicate this demand?
    I had a minor outpatient surgery on a finger a couple years ago, and at check-in I specifically asked if all the providers were covered by my insurance, and the intake person had no idea and said she couldn’t make any statement about that. The system is not set up to deal with corporations who see people at their most vulnerable as another profit center.

  6. 6.

    raven

    July 25, 2017 at 9:24 am

    Boy Scouts disavow!

  7. 7.

    David Anderson

    July 25, 2017 at 9:26 am

    @SP: I don’t know what a patient can do… Get it written down that you only want to be treated by in-network docs might help but I don’t know….

  8. 8.

    Betty Cracker

    July 25, 2017 at 9:33 am

    @raven: Weak.

  9. 9.

    Betty Cracker

    July 25, 2017 at 9:34 am

    “As we move to a shopping model of health care…” — and that’s the problem, ladles and jellyspoons.

  10. 10.

    Steeplejack

    July 25, 2017 at 9:34 am

    @raven:

    Disavow, bullshit. As one commenter said, that statement is a ¯\_(ツ)_/¯.

  11. 11.

    zhena gogolia

    July 25, 2017 at 9:38 am

    @Betty Cracker:

    as the comments reflect.

  12. 12.

    rikyrah

    July 25, 2017 at 9:43 am

    @raven:
    Weak as phuck.

  13. 13.

    Hildebrand

    July 25, 2017 at 9:44 am

    @raven: Should I assume your tongue is firmly in cheek? Because that statement was utterly lacking anything that might even remotely be akin to a disavowal.

  14. 14.

    MattF

    July 25, 2017 at 9:51 am

    This goes for outpatient medical centers as well. I read the other day that 99.6% of eye surgery is done at outpatient centers– and chances are excellent that you will get a separate bill from an anesthetist for your cataract surgery. And yes, you need anesthesia for eye surgery, and no, you are not offered any choices about who performs it.

  15. 15.

    OzarkHillbilly

    July 25, 2017 at 9:54 am

    A little OT: The Conservative Case for Universal Healthcare

    The barrier to universal healthcare is not economic but political. Is profligate spending on health care really a conservative value? And what kind of market incentives are working anyway–it’s an odd kind of market transaction in which the buyer is stopped from negotiating the price, but that is exactly what Medicare Part D statutorily requires: The government is not allowed to haggle the prices of prescription drugs with major pharmaceutical companies, unlike in nearly every other rich country. (Both Hillary Clinton and Donald Trump pledged to end this masochism, but the 45th president has so far done nothing, and U.S. prescription drug prices remain the highest in the world.) Does anyone seriously think “medical savings accounts” with their obnoxious complexity and added paperwork are the right answer, and not some neoliberal joke?

    The objections to socialized healthcare crumble upon impact with the reality. One beloved piece of folklore is that once people are given free healthcare they’ll abuse it by going on weird medical joyrides, just because they can, or simply let themselves go because they’ll have free doctor visits. I hate to ruin this gloating fantasy of lumpenproletariat irresponsibility, but people need take an honest look at the various health crises in the United States compared to other OECD (Organisation for Economic Cooperation and Development) countries. If readily available healthcare turns people hedonistic yahoos, why does Germany have less lethal drug overdoses than the U.S. Why does Canada have less obesity and type II diabetes? Why does the Netherlands have less teen pregnancy and less HIV? The evidence is appallingly clear: Among first-world countries, the U.S. is a public health disaster zone. We have reached the point where the rationalist santería of economistic incentives in our healthcare policies have nothing to do with people as they actually are.

    If socialized medicine could be in conformity with conservative principles, what about Republican principles? This may seem a nonstarter given the pious market Calvinism of Paul Ryan and Congressmen like Reps. Scott Perry (R-Pa.) and Mo Brooks (R-Ala.), who seem opposed to the very idea of health insurance of any kind at all. But their fanaticism is surprisingly unpopular in the U.S. According to recent polling, less than 25 percent of Americans approve of the recent GOP healthcare bills. Other polls show even lower numbers. These Republicans are also profoundly out of step with conservative parties in the rest of the world.

    Strange as it may seem to American Right, $600 EpiPens are not the sought-after goal of conservatives in other countries. In Canada, the single-payer healthcare system is such a part of national identity that even hard-right insurgents like Stockwell Day have enthusiastically pledged to maintain it. None of these systems are perfect, and all are subject to constant adjustment, but they do offer a better set of problems–the most any mature nation can ask for–than what we have in the U.S.

    And virtually no one looks at our expensive American mess as a model.

    I think he is more than a little Pollyanna-ish in his forecasting of GOP acceptance of it, but he makes the argument in it’s favor.

  16. 16.

    Scott

    July 25, 2017 at 10:40 am

    This has been my dream scenario: Have a non-life threatening but bloody ER visit and while dripping conspicuously on the ER floor loudly demand that all providers be in-network.

    Some enterprising lawyer should draft up a card for patients to carry and present that says essentially that by providing any care, the hospital accepts that all charges are in-network.

  17. 17.

    Barbara

    July 25, 2017 at 10:57 am

    @OzarkHillbilly: He seems to think that Republicans will cave on single payer before Democrats. My assumption is that if some version of this monstrosity makes it into law, Democrats will stop trying to push technocratic solutions and go for the simple version of health care reform. I have some issues with that, but they are themselves technocratic and could be tinkered with over time.

    To the original post: The legislative solutions should not be either/or, but both. If the insurer does not have a contract, then a percentage of Medicare. If it does have a contract with the hospital, it should cover all service providers including anesthesiologists and other doctors who become parasites on their patients, who have no ability to control who provides services in those contexts. Hospitals have complete control over who they contract with. If they told anesthesiologists they have to have contracts with any payer that the hospital does, this practice would end, overnight. An alternative would allow insurers to deduct out of network fees paid to hospital based physicians from hospital compensation. I have actually seen this happen, prospectively, where a large insurer explains to a hospital that it would love to pay more, but they are going to deduct what they had to pay to doctors under contract with the hospital but not under contract with the insurer. Hard ball. In that case it worked out pretty well.

  18. 18.

    Villago Delenda Est

    July 25, 2017 at 11:22 am

    predicated on the assumption that pricing is transparent enough and choices are clear enough that patients can make reasonable decisions about cost effective treatment.

    This is a classic example of “assume makes an ass out of you and me”.

  19. 19.

    Villago Delenda Est

    July 25, 2017 at 11:47 am

    @OzarkHillbilly: If our “conservatives” were actually conservative, and not moralistic scolds who seek a return to a golden age that exists only in their twisted imaginations, they’d see that single payer/socialist health care is the most economical and morally correct model existing.

    But they’re moralistic, greedy scolds.

  20. 20.

    Snarki, child of Loki

    July 25, 2017 at 1:21 pm

    “Some enterprising lawyer should draft up a card for patients to carry and present that says essentially that by providing any care, the hospital accepts that all charges are in-network.”

    You need to get a tatoo with the EULA. “Stick a hypodermic here if you agree to these terms…”

  21. 21.

    Vor

    July 25, 2017 at 1:33 pm

    @MattF: yes, that was exactly my experience. I had cataract lens implants and got separate bills for the anesthesiologist. Out of network, of course. Another problem is getting the insurance wrong. I was in-patient at an in-network hospital and had a ultrasound done. Somehow the Radiology group got my insurance info wrong and they were about to send it to collections when I figured out that they never submitted it to my insurance.

  22. 22.

    Barbara

    July 25, 2017 at 1:45 pm

    @Snarki, child of Loki: And if the hospital tries to argue sue for an EMTALA violation. Hounding patients about money in the ER can be a violation of EMTALA.

  23. 23.

    burnspbesq

    July 25, 2017 at 2:12 pm

    @Steeplejack:

    Mildly disappointed that your solution doesn’t involve lining up EmCare’s C-level suits against a wall and shooting them.

    I’m sure you’ll be happy to name an actual crime of which they are guilty.

  24. 24.

    burnspbesq

    July 25, 2017 at 2:18 pm

    @MattF:

    This goes for outpatient medical centers as well. I read the other day that 99.6% of eye surgery is done at outpatient centers– and chances are excellent that you will get a separate bill from an anesthetist for your cataract surgery. And yes, you need anesthesia for eye surgery, and no, you are not offered any choices about who performs it.

    That is true in the vast majority of cases, but it is not inevitably true. I asked my opthalmologist’s office to make sure the anaesthesiologists were in-network, and they did. $74/eye.

  25. 25.

    Arclite

    July 25, 2017 at 4:00 pm

    Fuck. The gotchas we gotta deal with having this fucking system.

Comments are closed.

Primary Sidebar

Fundraising 2023-24

Wis*Dems Supreme Court + SD-8

Recent Comments

  • NotMax on Music and Last Night to Write Postcards for Wisconsin (Mar 27, 2023 @ 9:53pm)
  • Omnes Omnibus on War for Ukraine Day 397: A New Week Begins (Mar 27, 2023 @ 9:53pm)
  • Narya on Music and Last Night to Write Postcards for Wisconsin (Mar 27, 2023 @ 9:51pm)
  • Dan B on War for Ukraine Day 397: A New Week Begins (Mar 27, 2023 @ 9:51pm)
  • Jay on War for Ukraine Day 397: A New Week Begins (Mar 27, 2023 @ 9:50pm)

🎈Keep Balloon Juice Ad Free

Become a Balloon Juice Patreon
Donate with Venmo, Zelle or PayPal

Balloon Juice Posts

View by Topic
View by Author
View by Month & Year
View by Past Author

Featuring

Medium Cool
Artists in Our Midst
Authors in Our Midst
We All Need A Little Kindness
Classified Documents: A Primer
State & Local Elections Discussion

Calling All Jackals

Site Feedback
Nominate a Rotating Tag
Submit Photos to On the Road
Balloon Juice Mailing List Signup
Balloon Juice Anniversary (All Links)
Balloon Juice Anniversary (All Posts)

Twitter / Spoutible

Balloon Juice (Spoutible)
WaterGirl (Spoutible)
TaMara (Spoutible)
John Cole
DougJ (aka NYT Pitchbot)
Betty Cracker
Tom Levenson
TaMara
David Anderson
Major Major Major Major
ActualCitizensUnited

Join the Fight!

Join the Fight Signup Form
All Join the Fight Posts

Balloon Juice Events

5/14  The Apocalypse
5/20  Home Away from Home
5/29  We’re Back, Baby
7/21  Merging!

Balloon Juice for Ukraine

Donate

Site Footer

Come for the politics, stay for the snark.

  • Facebook
  • RSS
  • Twitter
  • YouTube
  • Comment Policy
  • Our Authors
  • Blogroll
  • Our Artists
  • Privacy Policy

Copyright © 2023 Dev Balloon Juice · All Rights Reserved · Powered by BizBudding Inc

Share this ArticleLike this article? Email it to a friend!

Email sent!