JustCare

Tag: Emergency room

  • Private equity is destroying ER care

    Private equity is destroying ER care

    With private equity, profits always come first. ER care is no exception. Keren Landman, MD reports for Vox on how private equity is destroying ER care. It’s good reason you should choose your hospital emergency room carefully.

    One ER doctor Landman spoke with described how, when he started out, there were plenty of physicians in the ER, hospitals made sure that the physicians’ needs were met when the emergency rooms were at their busiest, and physicians delivered most of the care people needed in emergencies. Then, private equity bought his practice and everything changed very fast. In short, private equity saved money by cutting the number of physicians in the ER, reducing their hours and replacing them with nurse practitioners and physicians’ assistants.

    This ER doctor quit his job once he was working for a private equity firm and moved to another hospital. Shortly thereafter, the same private equity firm bought the ER practice at this hospital. It happened again and again so that the ER doctor couldn’t find an ER that wasn’t private equity-owned.

    With private equity ownership, the ER doctor reports that he and his colleagues were given little time to do their jobs and staffing was inadequate. As a result, patients were not getting the care they needed, whether they had a simple need or were at risk of dying from a heart attack. Consequently, patients were dying, perhaps not directly because of these cuts, but, if not, very likely indirectly.

    What is private equity doing exactly? Private equity is buying ownership of ER doctors’ groups and other staff rather than buildings or equipment. Buying doctors’ groups allows private equity firms to charge patients whatever they please. People needing ER care can’t comparison shop. Private equity-owned ERs also tend to be out of insurer networks in order to boost ER profits. Once private equity takes over an ER department, on average, patient costs rise more than 80 percent.

    As of March 2024, private equity now controls 25 percent of all emergency rooms in the US. It became easy for them to take over in the late 20th century early 2000’s after doctors’ groups contracted with hospitals to run their ERs . These “contract management groups” or CMGs centralized processes, were entrepreneurial, and focused on profits, which made it easy for private equity to buy them out.

    In the early 21st century, private equity began its takeover of ER care. It saw profit opportunities from charging patients high prices for their care and from cutting ER staff. There’s no limit to what they could charge. In one case, a private equity firm charged a patient thousands of dollars for wound care for a half-inch wound to which glue was applied in the ER.

    By 2010, private equity owned about nine percent of ER doctors’ groups. And, private equity ownership of hospital ERs continued to grow even after Congress passed its No Surprises Act law that kept private equity firms from gouging patients.

    The No Surprises Act, which took effect in January 2022, prohibits physicians from billing patients in the ER for out-of-network care. Patients are only responsible for deductibles and copays associated with in-network care. The law also prohibits an in-network hospital from billing patients above the in-network rate for routine care they receive from an out-of-network physician if they don’t consent to receiving it.

    People are still wrongly billed in violation of the No Surprises Act, but they are often unaware of it. Moreover, the No Surprises Act doesn’t cover out-of-network ambulances or urgent care facilities.

    Here’s more from Just Care:

  • Hospitals delay care for older adults in ERs, causing them needless harm

    Hospitals delay care for older adults in ERs, causing them needless harm

    Judith Graham reports for KFF Health News on the plight of older adults in hospital emergency rooms. Hospitals often keep older adults in their ERs for extended periods before getting them admitted to the hospital. Hospitals could benefit financially from these delays, but patients can suffer.

    The evidence shows that older adults often can wait more than a day to be admitted to the hospital, although their doctors have recommended a hospital admission long before. In the ER, patients often are not getting their care needs met. They are prevented from moving much, and they are usually not well fed or hydrated.

    The problem is only getting worse, according to ER physicians. And, older adults appear to be kept in ERs longer than most other people. But, there’s little data to understand how common ER boarding is and which hospitals are the worse offenders. Hospitals do not need to report this data. It’s also not clear which hospitals do not have adequate space for patients.

    Why are some people spending so much time in ERs? In some cases, hospitals are short-staffed. In other cases, people needing care that is highly profitable get preferential treatment and are moved out more quickly than those who need less profitable care. In still other cases, hospitals don’t have enough beds because they are unable to discharge patients for home health care or to a nursing facility as quickly as they should be able to.

    In an ER, older adults can quickly see their conditions worsen. They lose muscle from sitting or lying all day. They may not be taking their medicines. They may become delirious.

    Unnecessary stays in the ER can mean longer hospital stays and more health issues for older adults. Patients generally don’t get proper care in the ER, except to address an immediate crisis. They can fall, get hospital-acquired infections, bedsores and worse. They are more likely to die in the hospital if they spend the night in the ER needlessly.

    What to do if you’re admitted to the ER? Don’t go alone. Make sure you have a family member or friend or caregiver with you to speak out on your behalf, ensure you are fed properly, and otherwise well cared for. Bring a list of your medicines and bring a bag with the medicines you take, if possible.

    Also, protect yourself against delirium. Bring your hearing aids and glasses to avoid being disoriented and some food and drink. If you can get up and move around, do so.

    Here’s more from Just Care:

  • Patient safety at risk in private-equity controlled emergency rooms

    Patient safety at risk in private-equity controlled emergency rooms

    Gretchen Morgenson reports for NBC News.com on a medical director fired after exposing the risks of emergency treatment at his hospital in Kansas City. Inadequate staffing jeopardized patient safety. But, his private-equity employers, Kolberg Kravis (KKR) and, before that, Clayton, Dubilier & Rice, like other for-profit owners of medical groups, were focused on maximizing profits.

    Ray Brevont, the medical director and independent contractor, complained about the fact that, at times, understaffing in the emergency department meant no physician was present when a patient’s life was at risk. Brevont was let go. How often does this happen? For sure, many other doctors in Brevont’s position fear speaking out against their employers and putting their jobs at risk.

    Today, four in ten emergency departments are controlled by for-profit entities, which are responsible for the staffing. KKR, which owns Envision Healthcare, and Blackstone, another private equity group, which owns TeamHealth, are two big companies in this space.

    Private equity firms are generally in the business of buying up companies, finding ways to increase their profits, often through cutting costs, and selling them off a few years later at a profit. Because emergency departments are big profit centers, private equity firms are buying up control of these departments and have been charged with interfering in the practice of medicine to the detriment of patients.

    Private equity firms implement policies in hospital emergency departments that are often unavailable for public scrutiny. But, Brevont claimed that KKR’s “code blue” policy put patients’ lives in danger. Emergency room physicians were expected to care for patients outside the hospital’s emergency department. The consequence: No emergency room physician in the emergency department.

    Brevont sued Emcare, the company that hired him, which is a subsidiary of Envision, saying he had been wrongfully let go. Under federal law, the emergency department was required to have a physician present at all times. Brevont’s boss told him that profits explained the failure to have a physician present but “Profits are in everyone’s best interest.”

    This is not the first suit against KKR for interfering wrongly in the practice of medicine. Recently, ER physicians in California sued KKR’s Envision Healthcare for wrongful interference in the practice of medicine.

    Brevont won $26 million in damages. Envision blamed a hospital policy for the understaffing and took no responsibility. The appellate court ruling stated that Envision “makes a physician the owner of these subsidiaries to comply with the regulations, which prohibit a publicly traded company from providing medical services.” Of note, the named physician owner had nothing to do with the emergency departments he allegedly owned.

    Most states require physicians to be owners of these companies as nonphysicians cannot be practicing medicine or directing decisions about treatment. But, for-profit companies find ways around the issue. When they are found to violate the law, they tend not to be penalized in a way that would deter future activity of the same sort. The penalty too often does not fit the crime.

    Why is the profit motive so dangerous? Companies might decide how much time a physician can spend with a patient, what tests the physician can administer and whether the patient needs to see a physician at all, with little focus on evidence-based medical practice or patient needs.

    For reasons that are impossible to justify, the federal government often continues to allow these companies to continue their businesses after they have been found guilty of fraud and other wrongs if they say they will commit to behaving appropriately down the line. Curious how we throw people in jail for the rest of their lives for far less serious crimes.

    Here’s more from Just Care:

  • Beginning January 2022, HHS bans surprise bills from out-of-network providers

    Beginning January 2022, HHS bans surprise bills from out-of-network providers

    HHS has issued an interim final rule that bans surprise bills for patients who receive care from out-of-network providers at in-network hospitals. The rule applies to both emergency and non-emergency care, reports Joyce Frieden at Medpage Today.

    Many patients find, even when they are careful to see in-network doctors at in-network hospitals, that they receive care from a range of 0ut-of-network providers as well. Radiologists, anesthesiologists and emergency doctors are three types of specialists that often do not provide in-network care. With this new HHS rule, patients will only pay the in-network copay for out-of-network services in in-network hospitals.

    The HHS rule builds on Trump administration policy. It bans surprise medical bills as well as high charges from out-of-network providers for non-emergency care for which people have no advance notice. These are unexpected charges because they are either buried in the fine print from an insurer or are left out.

    People who receive out-of-network services in non-emergency situations need to have notice and give their consent. As it is, when patients are billed for out-of-network care, their out-of-pocket payments generally do not count towards their deductible or their out-of-pocket cap.

    The HHS interim final rule also forbids insurance companies from retroactively denying emergency room visits, reports Robert King for Fierce Healthcare. In essence, insurers cannot second guess individuals as to whether they experienced an emergency after they receive emergency services. Insurers must pay these claims.

    HHS plans to issue a series of other interim final rules in the next several months. It will be requiring better price transparency for consumers as well as better tools for comparing provider charges. HHS Secretary Xavier Becerra wants these rules to be crystal clear and understood by all parties so that they actually work in practice and not simply in theory. Time will tell.

  • ER coverage: Private health insurers control our coverage

    ER coverage: Private health insurers control our coverage

    If you think you like your private health insurance, watch out. Private health insurers control the terms of your coverage. What they cover today can be very different tomorrow. Do not count on anything other than having your policy cancelled if you don’t pay your premiums. Reed Abelson reports for the New York Times on United Healthcare’s move to restrict coverage for emergency room visits.

    Yes, it’s true that the federal government defines the minimum benefits private insurers must offer. But, there’s a difference between benefits, such as hospital care and physical therapy, and services covered. Insurers have virtually free rein to decide when services are medically necessary and to delay and deny care, even when your treating physician deems it medically necessary. In theory, insurers must follow generally accepted medical standards. But, their decisions are usually not subject to public scrutiny. So, watch out!

    United Healthcare’s move on emergency room visits is just one among hundreds of changes to its coverage policies that received some public attention and some pushback. Imagine all the coverage policy changes that no one is aware of–e.g., increases in copays, narrowing of provider networks, more restrictive medical necessity protocols, and new administrative hurdles. All of these “innovative” insurance designs can jeopardize access to critical care.

    Coverage denials for emergency room visits that United Healthcare deems non-urgent received attention mainly because it hurts the doctors and hospitals’ pocketbooks. So the providers’ lobbying arms organized and spoke out against the policy change. Even still, United Healthcare is saying that it’s delaying implementation of its restrictive ER coverage policy, not reversing it. When an insurer’s policy changes affect patients, without reducing revenue for doctors and hospitals, the policy change often does not get the same attention.

    As it is, millions of Americans are taking grave health risks in emergency situations. They stay home to avoid responsibility for huge out-of-pocket costs associated with emergency room care. In some cases, staying home can lead to heart attacks and other deadly health conditions.

    United has profited handsomely as a result of people using the emergency room less. During 2020, the novel coronavirus pandemic led to a 27 percent drop in the number of emergency room visits. United’s proposed ER coverage policy change would help ensure that its costs for emergency room care do not creep back up, eating into its new-found profits.

    Recent data suggests that United’s profits likely came at the cost of the premature loss of life of thousands of its members, who ended up dying of heart disease, diabetes and other illnesses because they went without emergency care. Anthem tried a similar policy change several years ago. Emergency room physicians sued the company on the ground that Anthem was violating consumer protections under federal law.

    Here’s more from Just Care:

  • Legalization of marijuana without safeguards creates large public health risks

    Legalization of marijuana without safeguards creates large public health risks

    Medical marijuana is now legal in 33 states and Washington D.C. Recreational marijuana is legal in 11 states and Washington D.C. And more than 37 million Americans use marijuana. Without safeguards, marijuana legalization creates large public health risks, writes Rosalie Liccardo Pacula for Stat News.

    States benefit significantly from legalizing marijuana by way of increased tax revenue. And, legalizing marijuana creates more jobs. Americans who use marijuana, in turn, don’t have to fear criminal prosecution in their states.

    But, there are also considerable risks for Americans. Marijuana can be harmful. Like vitamin supplements, most marijuana products are unregulated, so drug safety is a serious issue. The Food and Drug Administration does not ensure their safety, unless they are prescribed. In fact the federal government still considers possession and use of marijuana products a crime.

    States are left to oversee the safety of marijuana products. And, for the most part, they have neither the skills nor the resources to do so, even if they have the will. Lack of oversight can present serious problems.

    Already, four states have recalled marijuana products found to be unsafe. They contained dangerous pesticides. We don’t know how many other marijuana products are unsafe.

    People using marijuana legally in their states are increasingly ending up in hospital emergency rooms. Their ER visits have doubled. They may experience uncontrolled vomiting or acute psychosis. And, some develop vaping-related lung injuries, such as burns from butane hash oil.

    Americans need greater protections in states where marijuana use is legal. One way to protect Americans from overuse of marijuana products would be for states to establish non-competitive markets, permitting the sale of marijuana only from government or non-profit agencies, rather than for-profit businesses.

    States could then better guarantee the safety of marijuana products. States could control their marketing and promotion, reducing their overuse. Today, businesses selling marijuana products are focused on driving revenue and not on public health or safety.

    States could also set stiff financial penalties on producers, dispensaries and companies that provide inaccurate information to people about marijuana products.

    Given the cost involved, it’s unlikely that states will step in to ensure accurate labeling of marijuana products or that they are tested for safety, though states should. (States don’t generally do testing for vitamin supplements, even though several have been found to be unsafe.) States might, however, prevent the sale of high potency waxes and oils.

    States could also require that marijuana dispensaries have someone on staff who can advise people accurately about products. New York, Connecticut and Minnesota require this.

    Here’s more from Just Care:

  • Bi-partisan bill in Congress would prevent surprise medical bills

    Bi-partisan bill in Congress would prevent surprise medical bills

    Millions of insured Americans go to the hospital, thinking that their bills will be covered only to be surprised by unexpected medical bills. Too often, they end up in medical bankruptcy. Out-of-network doctors and other health care providers may charge people tens of thousands of dollars. Finally, there’s a bipartisan bill in Congress that would prevent surprise medical bills.

    Senator Cassidy (R-LA), Michael Bennet (D-CO), Chuck Grassley (R-IA), Tom Carper (D-DE), Todd Young (R-IN), and Claire McCaskill (D-MO) have introduced S._____  The bill would forbid out-of-network care providers from billing patients for their services over which the patients have no control. These bills usually are a result of patients needing emergency hospital care and having no ability to ensure  the hospital they are taken to or the providers who treat them are in-network.

    The bill would protect patients from having to pay out of pocket for out-of-network care any more than they would pay for in-network care. Their health insurance would pay any additional charges up to a designated limit.  This bill would make a major difference for thousands of patients. Kaiser Health News has reported that people have received surprise bills for a $17,850 urine test and for $109,000 after a heart attack.

    The Senate bill would also protect emergency room patients in an out-of-network hospital once they are stabilized. At that point, the hospital would have to notify them in writing that they will be billed for its out-of-network services. The patients could sign a waiver agreeing to pay privately for that care. Or, they would have the right to move to an in-network hospital.

    More than half of all workers with health insurance through their employers (61 percent) are in self-funded plans. The employers pay claims directly rather than through insurance. And, out-of-network hospitals and doctors today can charge these plans what they will. This bill would no longer allow this type of balance billing.

    For now, here’s how to protect yourself from surprise medical bills.

    Here’s more from Just Care:

  • How to protect yourself from surprise medical bills?

    How to protect yourself from surprise medical bills?

    Watch out for huge medical bills if you visit the emergency room and are enrolled in a commercial health plan. They are common, and Kaiser Health News reports that these bills are often permissible. What should be done to end surprise medical bills? Medicare for All, of course. How can you protect yourself from surprise medical bills?

    In today’s commercial health care system, you want to avoid out-of-network emergency care if at all possible. Plan ahead and identify the emergency room in your health plan’s network and the in-network ambulance that will take you there. If not, here’s one example of what can happen: In the Spring of 2017, St. David’s Medical Center charged a teacher $108,951 for his four-day emergency stay after a heart attack. St. David’s, in Austin, Texas, is operated by HCA Healthcare, the nation’s largest for-profit hospital chain. The teacher’s insurance had paid $56,000 for his out-of-network care. But, the hospital billed the teacher for the difference.

    Fortunately, the story got a lot of media attention. And, shortly after Kaiser Health News and NPR reported it, St. David’s  cut its bill down first to $782.29 and then to $332.29. But, what about all the people with exorbitant medical bills that do not get major media attention?

    What’s particularly noteworthy is that the reduced bill does not reflect St. David’s acknowledgement of billing errors on its part. The hospital’s original bill was intentional. Indeed, the hospital claims it “did everything right in this particular situation.” How? The hospital had let the teacher know that he might be able to get a “discount” on his bill based on his income. 

    The issue, of course, is the legitimacy of St. David’s charges. It stretches credulity that the teacher’s four-day stay could have cost the hospital anything close to the amount it billed. The fact that it slashed the additional charge down to a few hundred dollars immediately after it came to public view also suggests the bill should not have been sent.

    But, in this case, the teacher had insurance through his employer’s self-funded health plan. And, according to Kaiser Health News, ERISA, the federal law concerning self-funded health plans, allows hospitals and doctors to charge patients receiving out-of-network care seemingly whatever they please on top of what their employer plan pays. About six in ten people with employer coverage are enrolled in an ERISA plan.

    Surprise hospital bills are pervasive, particularly when people are seeking emergency care. Some states have stepped in to protect their residents from surprise bills in a limited way. But, not enough. And, Congress has yet to address this serious issue. According to Congressman Lloyd Doggett, “This is a nationwide problem, and we need a nationwide solution.” 

    If your health care coverage is not from your employer through a self-funded ERISA plan, you should be protected from some of these exorbitant surprise bills. The Affordable Care Act permits out-of-network hospitals to bill patients only what they would have paid in an in-network hospital. That said, the ACA still allows out of network ambulances, doctors and hospitals to charge patients for whatever their health plans do not pay.

    If you get surprise medical bills, you should appeal to your health plan to pay them. And, if that does not work, contact your Congressman and Senators as well as your local newspaper and Kaiser Health News to report your story. It’s important to keep the pressure on Congress to address this issue.

    No one should be forced into extreme medical debt or bankruptcy because of a medical or hospital bill, or for that matter, a prescription drug bill. Medicare for All would put an end to these bills. Not surprisingly, the majority of Americans support Medicare for All and an ever increasing cohort of Democrats in Congress do as well.

    If you support Medicare for All, please let Congress know. Sign this petition.

    Here’s more from Just Care:

  • Anthem keeps people from getting ER care simply by claiming it may not pay for it

    Anthem keeps people from getting ER care simply by claiming it may not pay for it

    The New York Times has a follow-up story on Anthem, the insurer that unconscionably denied some of its enrollees coverage for emergency care if it did not believe their diagnosis warranted it. According to a new congressional report, Anthem has reversed its policy. Still, Anthem likely has deterred its enrollees from seeking ER care.

    In 2017, Anthem denied coverage for more than 12,000 emergency room visits, stating that they were unnecessary and “avoidable.” However, the patients who appealed Anthem’s denials were successful in most cases. The benefit to Anthem is that most people do not know they can challenge an appeal and that it can be worth it to do so. So, they ended up stuck paying ER bills that they likely should not have had to pay.

    Anthem says it has now changed its policy, limiting its denials for ER visits. And, there is some evidence that it is now approving ER care in most instances. But, there is also a fear that its enrollees are worried about being denied coverage for their ER visits and not seeking ER care when they need it.

    Anthem has been sued by doctors’ groups, who allege that Anthem violated the law with its ER policy since it forced patients to determine whether they needed ER care when they did not know their diagnoses. Let’s get real. People generally do not know whether they are having a heart attack or heartburn.

    Anthem says that it is simply trying to keep its costs down since ER care is so expensive. Of course, the less it spends on care, the more profits it makes. Rather than penalizing patients who think they need ER care because ER costs are so high, Anthem should be arguing for Medicare for all, which would include rational prices for care.

    Congress, for its part, should step in and support Medicare for All. Senators and House members should recognize that commercial insurers are unable or unwilling to rein in excessive and unsustainable provider costs. Instead, they shift responsibility onto their enrollees

    If you support Medicare for all, please sign this petition.

    Here’s more from Just Care:

  • Gawande to lead new Amazon health care company

    Gawande to lead new Amazon health care company

    Amazon’s Jeff Bezos is building a new health care company in partnership with Berkshire Hathaway and JP Morgan Chase. They have hired Dr. Atul Gawande to lead it.  Will he able to improve care for the companies’ one million employees and, better still, for our health care system?

    The new health care company, as yet to be named, is charged with finding smart ways to improve health care for company employees. There are so many smart things companies can do, if they want to, including eliminating copays and deductibles that keep people from getting needed care, applying evidence-based medical protocols and paying for best value drugs.  The issue is always how to drive these improvements.

    Without a federally administered plan to drive health system improvements, systemic improvements tend not to happen. For one, lots of learning is not shared publicly. And, even when it is, hospitals and doctors are often set in their ways. Peter Pronovost, MD, became famous for his protocols/checklist for reducing hospital infections. But many hospitals have resisted applying them.

    How much power will these three companies have to effect change? They are big. But insurers and hospitals are also powerful and have their own agenda. And, what changes will Gawande focus on? Leana Wen, Baltimore’s Commissioner of Health, makes an important point about the value of Gawande focusing on social determinants of health—good housing, nutrition, safety, transportation—if he wants to get to the root driver of health care use, But, it’s hard to believe he’ll focus on those issues given the demographics of the workers at Amazon, Berkshire Hathaway and JP Morgan Chase.

    Megan Ranney, an associate professor of emergency medicine at Brown University Medical School smartly suggests Gawande look at how emergency rooms can link patients to the array of services and resources they need. Right now, emergency rooms are huge cost centers. But, emergency rooms could do a lot more to keep patients out of hospital.

    Andy Slavitt suggests Gawande avoid the road traps created by commercial interests and stay focused on public health issues. Will he be able to do that given his employers?

    Here’s more from Just Care: