JustCare

Tag: Outpatient

  • Save money, avoid hospital-owned outpatient facilities

    Save money, avoid hospital-owned outpatient facilities

    One of the ways hospitals are generating more revenue is through ownership of doctors’ practices, outpatient surgical clinics and diagnostic centers. Hospitals can charge far higher fees for care you receive at these hospital-owned providers, even though they have no evident tie to the hospitals. You literally can save thousands of dollars on an outpatient service by seeing physicians who are not part of a hospital system; Medicare could save billions by paying outpatient facilities the same rate as independent facilities.

    What’s going on? Hospitals are permitted to add a “hospital facility fee,” to your doctors’ charges or the charges at an outpatient facility that they own. The hospitals consider these facilities “outpatient hospital departments.” And, the charges can be $154.52 for a visit to the doctor to get a flu test or $15,000 for some services at some hospitals, reports Jessica Glenza for The Guardian.

    United States of Care, a non-profit organization, just released a report, Behind the Bill, on these hospital upcharges. It’s one way that consolidation in the health care sector is driving up costs.

    The American Hospital Association (AHA) supports facility fees and has helped to ensure they remain part of a patient’s bill at an outpatient facility owned by a hospital. The AHA argues that hospitals have a lot of unfunded costs, such as emergency room care they provide, regardless of whether patients are insured. The facility fee helps offset these costs.

    As recently as two years ago, more than four in ten doctors were connected with a hospital. A decade earlier, three in ten doctors had hospital ties. Charges for physician services keep rising. One researcher found that hospitals charge 150% more for the same outpatient services as ambulatory surgical centers in the same region that are not hospital-owned.

    Another study found that when a physician group merged its practice with a hospital, charges increased 14.1 percent on average. But, don’t think you can predict them; no one discloses them. They depend entirely on the hospital adding them to the bill and bear no relation to the cost of a service. 

    Medicare payment policy has fueled hospitals’ purchase of outpatient facilities. Medicare pays the same price for a service performed in hospital as in an outpatient facility owned by a hospital, even though the outpatient facility service should cost a lot less. Though some in Congress want to address this issue, nothing has been done to date.

    The AHA blames insurers for health care cost increases. But, hospitals are also responsible. Politics clearly has kept Medicare from adjusting its payments for outpatient services at facilities owned by hospitals down to the same level as it pays for outpatient services at facilities that are independent.

    Here’s more from Just Care:

  • Which outpatient drugs are costing Medicare the most?

    Which outpatient drugs are costing Medicare the most?

    In a little more than a month, we will know which ten outpatient prescription drugs will be subject to Medicare price negotiation under the Inflation Reduction Act in 2025. (That’s if the pharmaceutical companies do not prevail in their lawsuits aimed at stopping Medicare drug price negotiation.) The drugs whose prices will be negotiated will be those, covered under Medicare Part D, that are costing Medicare the most.

    In 2026, Medicare will negotiate prices for 10 additional drugs. In 2027, Medicare will negotiate prices for 15 additional Part D drugs. In 2028, Medicare will negotiate prices for yet another 15 Part D drugs.

    Beginning in 2029, Medicare will negotiate prices for 20 drugs covered under Part D and Part B, which covers inpatient drugs. Under the law, Medicare can only negotiate the prices of single-source brand-name drugs, which have been on the market for at least seven years, or biologics that do not have biosimilar options, which have been on the market for at least 11 years.

    A small number of drugs are responsible for a significant portion of Part D prescription drug spending. Medicare spent $48 billion on the ten drugs with the highest spending in 2021. Half of those drugs are treatments for diabetes: Trulicity, Januvia, Jardiance, Lantus Solostar, and Ozempic. The other half include Imbruvica, a cancer treatment and Humira Citrate-free (Cf) pen, a treatment for rheumatoid arthritis.

    Prescription drug prices are soaring, especially for the drugs that Medicare is spending the most on. In the three years between 2018 and 2021, the price of these ten drugs more than doubled. Spending jumped from $22 billion to $48 billion. Total Medicare Part D spending rose from $166 billion to $216 billion.

    Twenty-two percent of Medicare Part D spending results from just ten drugs out of a total of 3,500 (0.3 percent) that Medicare covers under Part D. Sixty-one percent of total spending results from just 100 drugs (3 percent of covered drugs).

    In 2021, Medicare spent $2.6 billion on Ozempic, to treat diabetes for 500,000 Medicare patients, $5 billion on Revlimid, to treat multiple myeloma, and $12.6 billion on Eliquis, a blood thinner.

    Not all of these drugs will be eligible for drug price negotiation: Ozempic, Revlimid, Humira and Lantus are not eligible. Ozempic has not been on the market long enough and the other three have biosimilars.

    The Congressional Budget Office estimates that, as a result of drug price negotiation, Medicare will save $100 billion on prescription drugs costs in the five years beginning in 2026. That’s a beginning, but hardly enough. If Congress would only permit prescription drug importation from verified pharmacies abroad, it would help drive down drug prices considerably.

    Here’s more from Just Care:

  • Escort requirements keep people from receiving medical procedures

    Escort requirements keep people from receiving medical procedures

    Paula Span reports for the New York Times on outpatient procedures that require patients to have someone to escort them out of the doctor’s office. Consequently, sometimes patients must forego important care because they have no one to escort them out of the doctor’s office afterwards. These escort requirements are a particular challenge for people living alone, without friends and family to assist them.

    There are a range of outpatient procedures for which some physicians require you to have an escort. For example, if you need a colonoscopy or cataract surgery, to name two procedures that require anesthesia, you might not be able to get an appointment if you don’t have an escort to pick you up after the service. Without the name and contact information for your escort, doctors might not allow you to schedule these procedures.

    Easy access to transportation home after a procedure is not enough. Some physicians require people to have someone to get them from the doctor’s office to the taxi or car and then from the taxi or car into their homes. The concern is that the patient might have a bad reaction to the anesthesia and end up in a stupor or vomiting or totally disoriented.

    Not every doctor requires an escort. But, some doctors do. One person enrolled in an Aetna Medicare Advantage plan could not find a doctor to perform a procedure he needed unless he had an escort. But, he did not have one, and Aetna won’t cover the cost of the medical escort.

    An escort requirement is a big issue for many people who live alone and don’t have people to turn to for help. They might need a procedure to stay healthy. But,  if they also need an escort for their safety, they are in a quandary.

    Is there a way to avoid having an escort? If you do not have an escort to accompany you to a procedure where an escort is required, you should ask your health care providers that require escorts whether they would allow you to wait in their offices for several hours after a procedure in lieu of having an escort. Sometimes they will.

    How to get an escort? You might try contacting your local church or religious institution. Or, if you’re up to it, look into volunteering in your community for credits. Organizations like TimeBank allow you to bank credit from your own volunteering to enable you to get a volunteer to escort you home from the doctor.

    Here’s more from Just Care:

  • More hospitalized Medicare patients will qualify for nursing home care

    More hospitalized Medicare patients will qualify for nursing home care

    For many years now, Medicare has not always covered nursing home care for patients post-hospitalization. Hospitals that treated patients as outpatient–even when the patients stayed overnight–had no right to Medicare coverage of their nursing home or rehab care upon discharge. Susan Jaffe reports for Kaiser Health News that this might finally be changing, in some cases.

    More than ten years after a class-action suit was brought challenging Medicare nursing home coverage policies, a federal appeals court in Connecticut has ruled that patients should be able to challenge a Medicare coverage denial of their nursing home care if they were admitted to the hospital as an inpatient and the hospital switched their status to outpatient or observation, which is covered under Part B of Medicare. Complicated? Yep.

    For reasons that are surely financial, hospitals sometimes admit patients as inpatients, which is covered under Medicare Part A, and then switch them to outpatient or observation status. What’s most insane is that a hospital can change a patient’s status even when the patient has stayed overnight for three nights and even after the patient has been discharged. The decision is completely unrelated to the care the patient received in hospital.

    From the patients’ perspective, so long as they have Medicare Parts A and Part B and supplemental coverage, there is generally no difference how Medicare pays for their hospital care. But, if patients need rehab or nursing home care post hospitalization, there’s a big difference. Medicare generally only covers nursing home and rehab care for people who have been hospitalized as inpatients for at least three days.

    Patients who receive outpatient care in hospital never qualify for skilled nursing or rehab coverage. It doesn’t matter if they received exactly the same care as an outpatient as they would have as an inpatient.

    Consequently, tens of thousands patients who would have qualified for Medicare nursing home care had their hospital treated them as inpatients are denied Medicare nursing home or rehab coverage. If they need to be in a nursing home or rehab facility after discharge, they have to pay the full cost out of pocket.

    If you are admitted to hospital, you want to speak with your doctor and make sure that the hospital admits you as an inpatient. Hospitals did not have to disclose this information until recently, when a federal law was enacted in 2017. Since then, they must give you written notice, but, until this latest ruling, you weren’t able to appeal the hospital’s decision to treat you as an outpatient.

    The government has not said whether it will appeal this latest ruling. For now, patients who are admitted to the hospital as inpatients have the right to appeal a hospital decision to switch them to outpatient status. And, the tens of thousands of patients who have had to pay for their nursing home care because their hospitals switched their status can file a claim seeking reimbursement. For more information, visit the Center for Medicare Advocacy site.

    Here’s more from Just Care:

  • Should you get inpatient or outpatient care? It matters

    Should you get inpatient or outpatient care? It matters

    In December 2020, the Trump administration changed payment policy for hundreds of procedures that Medicare had previously covered on an inpatient basis only. To save money, over the next three years, Medicare will begin covering these procedures on an outpatient basis, where appropriate. What does that mean for people with Medicare?

    This payment policy change should reduce Medicare spending, as the government pays less for outpatient services than for inpatient services. How the change in coverage will affect people with Medicare is not yet clear. It can be beneficial to receive care for many surgeries on an outpatient basis. Sometimes, however, inpatient care is preferable.

    Here’s the catch: Hospitals can keep you overnight for several nights and still treat you as an outpatient. If you have Medicare supplemental coverage, it might not matter. You should have few if any out-of-pocket costs for your care. But, if you don’t have supplemental coverage, you could be liable for as much as 20 percent of the cost of your care and, depending upon where you live and the physician billing you, another 15 percent on top of that.

    If you are planning to go to the hospital for a procedure and to stay overnight, it’s smart to speak to your doctor about your potential needs after you are discharged from the hospital. In particular, will you need home care, nursing home care or rehab services after your discharge?

    You will only be eligible for coverage of rehab or nursing services if you are in the hospital three nights and treated as an inpatient. If you will need rehab or nursing services post discharge, you should  confirm with your doctor that the hospital treats you as an inpatient. If you will need home care, Medicare comes home care for people meeting the eligibility criteria without a prior hospitalization requirement, but it could be harder to get an agency to take you as a patient if you have not been a hospital inpatient.

    Keep in mind that if the hospital treats you as an outpatient, you will not qualify for covered rehab or nursing services should you need them.

    The change in Medicare payment policy stems from technological advances that allow many more procedures to be done on an outpatient basis and significantly higher Medicare  payments to hospitals for inpatient care relative to outpatient care for the same procedure. That makes no sense. Of course, moving to a new policy should be done in a way that does not hurt patients, either by depriving them of coverage for needed care or shifting more costs onto them.

    Here’s more from Just Care:

  • Medicare outpatient hospital care may not be what you think it is

    Medicare outpatient hospital care may not be what you think it is

    Visit NBCNews.com for breaking news, world news, and news about the economy

    Visit NBCNews.com for breaking news, world news, andnews about the economy

    For financial reasons, hospitals around the country are increasingly classifying overnight hospital stays for people with Medicare—even stays that last more than three days—as outpatient visits.  The problem is that unless the hospital treats you as a hospital inpatient, Medicare will not cover your skilled nursing facility care post-hospitalization.  And, the hospital often has the discretion to classify even lengthy stays as Medicare outpatient hospital care.