After several failed attempts the California legislature has passed a bill which aims to protect patients from balance billing. Gov. Jerry Brown has until the end of September to sign or veto the legislation. He is expected to sign it into law.
When it comes to navigating the intricacies of health insurance, Cassie Ray considers herself a pro. She actually reads her policy, including the fine print.
So when the 57-year-old from Fairfield, California, needed routine follow-up surgery after a mastectomy, she did her homework. "I looked up on my insurer's network and made sure the outpatient facility that I was being referred to was in my network," Ray said.
A month later, she received an unwelcome surprise: a $580 bill for an out-of-network anesthesiologist.
"I called the facility back, and at first, I felt like, this has to be a mistake. They'll fix it," Ray said.
Instead, the clinic said her only option was to negotiate the bill directly with the doctor. Ray's experience illustrates the surprise of balance billing.
The unexpected charges come when patients are treated by an out-of-network provider at an in-network facility.
After several failed attempts in recent years, the California legislature passed AB-72, which aims to protect patients' pocketbooks when they're hit by these surprise bills. Gov. Jerry Brown has until the end of September to sign or veto the legislation. He is expected to sign it into law.
A 2015 Consumers Union survey suggests the surprise bill phenomenon is fairly common. It found nearly 1 in 4 Californians who'd had hospital visits or surgery in the prior two years reported receiving an unexpected bill from an out-of-network provider.
"They can range in price from a hundred dollars to many thousands," said Betsy Imholz, special projects director for Consumers Union. "So it's a big financial burden on consumers."
In Ray's case, she said she tried to speak with a manager at the outpatient clinic, but no one returned her repeated calls. Then the bills stopped coming, so she figured all was resolved. Soon after, however, her bill was sent to collections.
"I was so frustrated," she recalled. "I was just in tears as I was dealing with it."
Ray said it took about seven months of wrangling before her insurance company finally paid the bill and she was able to clean up her credit rating.
"My immediate response was, there does need to be a law to fix this," said Ray. "This is so wrong."
The legislation, by Assemblyman Rob Bonta (D-Oakland) and six colleagues, would limit a patient's financial obligation to no more than what he would have owed if the provider had been in-network.
While agreeing that "patients should never have surprise bills," Dr. Karen Sibert, president-elect of the California Society of Anesthesiologists, said her organization and a number of other specialty medical groups oppose AB-72.
At issue, Sibert said, is the bill's formula for paying doctors who fill the gap left when insurance companies don't have enough providers in their networks. The legislation would set the payment rate at either the amount the insurer normally pays a doctor on contract for such services or 125 percent of the Medicare rate, whichever is greater.
That's insufficient, argued Sibert. "It's a problem because it removes any incentive for insurance companies to reach fair contracts with physicians."
Without such an incentive, she said, insurance companies will continue to have inadequate provider networks.
The powerful California Medical Association agrees with Sibert about the bill's payment formula, but it has shifted its position on AB-72 from opposed to neutral, said Janus Norman, the Association's vice president of governmental affairs.
There are a few reasons for the change of heart, he said. First, the bill would create stricter oversight of how in-patient services are delivered, and it would allow for tougher regulations on insurers if the state finds their provider networks to be inadequate.
The provision regarding tougher regulations, "is one improvement that AB-72 included that prior legislation did not," he said.
In addition, the measure would give out-of-network doctors the chance to appeal payment disputes with insurers through an independent third party, and the decision would be binding, another important change from previous versions of the bill, Norman said.
The California Association of Health Plans and the Association of California Life and Health Insurance Companies don't have a formal position on AB-72, according to an analysis by the Assembly Health Committee. Instead, they have expressed "concerns" about the measure, the committee said.
"While they laud the authors' efforts to protect consumers from balance billing," the analysis said, the insurer groups worry that the legislation might lead to higher premiums and cost-sharing, and that the bill's dispute resolution process might spark more lawsuits between providers and health insurance firms.
Anthony Wright, executive director of Health Access California, a consumer health care advocacy coalition, said Gov. Brown took an interest in the legislation.
"The governor's office did provide input during the negotiation process and we are hopeful that he will sign it," he said.
Consumers Union's Imholz said the California Medical Association's neutral position on the legislation was key in getting AB-72 across the finish line.
She predicts that if Brown signs the measure, a number of other states now considering similar protections against surprise bills will likely follow suit next year.
Researchers found stroke patients living in the Northeast states had more than twice the odds of receiving tPA — a powerful anti-coagulant that can break up the clot causing the stroke — than those living in the Midwest and the South.
In the United States, one out of every 20 deaths is caused by stroke. And yet, based on new research, race and geography prevent some of the most vulnerable from obtaining effective treatments.
The findings come from a report published Wednesday in the journal Neurology. Researchers found stroke patients living in the Northeast states had more than twice the odds of receiving tPA — a powerful anti-coagulant that can break up the clot causing the stroke — than those living in the Midwest and the South.gracias
The researchers also found race played a role in determining the patients who received treatment. African-Americans who were evaluated for stroke severity were 26 percent less likely to get the medication. Other minorities faced 17 percent higher odds of not securing the drug.
Overall, a quarter of patients eligible for the medication did not receive it.
Researchers analyzed data from nearly 62,000 patients tracked from 2003 to 2011 in a voluntary national hospital database set up by the American Heart Association. The group of patients all experienced ischemic strokes — those caused by blood clots in the brain and not those caused by burst blood vessels — and arrived at a hospital within two hours after their symptoms began. The drug is most effective when used within the first three hours after the onset of symptoms.
Lee Schwamm, vice-chairman of the neurology department at Massachusetts General Hospital and the lead author of the report, said he is not sure why so many people are not given access to tPA. But, he speculates the issue may lie in doctors not recognizing stroke in the first place.
"Some of this may be a failure of recognition rather than a failure to provide treatment to a person who presents these symptoms," he said.
According to the latest data from the Centers for Disease Control and Prevention, stroke is the fifth leading cause of death in the United States. The condition afflicts more than 795,000 people each year and kills nearly 130,000 of them.
African-Americans and Hispanics are more likely to have a stroke and die from the condition than whites.
High blood pressure, cholesterol and smoking raise the risk of having a stroke. And while half of the American population lives with one or more of these risk factors, a CDC survey in 2005 revealed less than 40 percent of respondents could name all of the symptoms of a stroke. Those include sudden numbness, lack of coordination and slurred speech
Mike Wacholder, 74, had a stroke while walking into his office in Troy, New York, four years ago. He first noticed himself leaning to the left as he walked. Although he went to the doctor within four hours of his first symptoms, his physician sent him back to work. He finally received a diagnosis nearly 11 hours later after collapsing and being rushed to the emergency room. While his brain function remains largely intact, the stroke disabled the left side of his body.
Wacholder said his experience taught him stroke patients need to advocate on their own behalf. Many patients are not educated enough about stroke to talk about their care, he said.
"The patient has to be able to express what's on their mind," he said.
Wacholder's long wait before arriving at the hospital eliminated his chance to obtain tPA.
Yet, even those who meet the recommended window of opportunity to obtain treatment fall through the cracks. Patients who arrived at the hospital more than 45 minutes after the onset of their symptoms had a 21 percent higher chance of not receiving tPA. At the hospital, those who waited more than 25 minutes for a CT scan were 41 percent less likely to receive the treatment.
Susan Gaunt, stroke program coordinator and stroke clinical nurse specialist at Gwinnett Medical Center outside of Atlanta, said providers in her facility are frustrated because so few patients arrive at the hospital in time to qualify for tPA.
Less than half of them use an ambulance for transport, she said, which means physicians and nurses must use up some initial care time doing routine medical protocol like placing an IV instead of pinpointing a diagnosis.
"Time is really drained," she said.
Georgia is located in America's "Stroke Belt," the region of the nation where stroke rates are high. According to the Georgia State Department of Health, stroke is the fourth leading cause of death in the state. In 2013 alone, the condition led to 21,000 hospitalizations and more than a billion dollars in medical costs.
Gaunt has worked on community outreach across the Peach State since 2004, educating the public about stroke and its risks.
"We do do a lot of community events," Gaunt said. "But it doesn't seem to be enough."
ATLANTA — It was a call that public health officials were dreading, but for which they had prepared. An elderly man in Salt Lake City died after contracting the Zika virus, the first fatality from the disease in the continental United States. His son, who had been a caregiver, also had become sick, but health officials did not know how.
Dr. Shannon Novosad was on a plane to Utah the next day, one of 10 detectives looking for answers about this case to help other professionals deal with this rapidly growing health problem.
Novosad is a critical care pulmonologist by training, but she is also in a two-year fellowship at the Centers for Disease Control and Prevention's Epidemiological Intelligence Service. Her colleagues in the program include about 80 medical and scientific professionals who study disease prevalence, patterns and control. The group includes dentists, doctors, veterinarians and entomologists.
For many years CDC has sent epidemiologists, or scientists who analyze disease outbreaks and study ways to prevent future ones, to major disease outbreaks. That work continues, said Kristen Nordlund, a communications specialist with the CDC.
But building on its experiences with Ebola in 2014, the agency also has created new rapid response teams, called CDC Emergency Response Teams (CERT), that bring expanded expertise to contain an outbreak as quickly as possible.
The teams include not only epidemiologists but also scientists with backgrounds in a particular disease itself, such as Zika. Entomologists, vector technicians, communications specialists and public health scientists have been part of the Zika teams.
They rush to areas where the disease is reported and help with local efforts to identify other patients and health care workers who may have been in contact with an infected person. They also provide extra hands in the collection and analysis of blood samples. And, in the Salt Lake City case over the summer, two entomologists who are vector-borne disease specialists helped local authorities trap mosquitoes to see if they were transmitting Zika.
These medical SWAT teams have also deployed to Texas and the Miami area. Nearly 800 people have been diagnosed in Florida with Zika, at least 64 of them having been infected locally. The size of the teams varies.
Novosad said that she hopes people know "that we have these mechanisms in place" to send in experts to deal with these outbreaks. "That's why public health is there … and we do have a strong public health workforce."
CDC Plan For Outbreak
Zika, which can be transmitted by mosquito bites, sexual contact or from mother to fetus, typically causes mild symptoms, including a rash, fever, joint pain and bloodshot eyes. It has also in rare cases been associated with Guillain-Barre syndrome, which includes temporary muscle weakness and paralysis.
However, the effect that has brought the greatest concerns involves pregnant women. The infection sometimes causes microencephaly, a birth defect in which a baby's head is unusually small. That can result in developmental delays, intellectual disabilities, problems with balance and with swallowing, according to the CDC.
CDC officials developed a detailed, 57-page plan for handling Zika outbreaks, which called for epidemiologists to study outbreak patterns; doctors to interview and treat health care workers and other who may have been in contact with people who had the disease; entomologists to trap and study mosquitoes in the outbreak area; and communications officers to coordinate getting information out to the public.
The Zika plan drew from lessons in the Ebola outbreak, in which health care workers who contracted that deadly virus at first were not interviewed about their exposure to Ebola and precautions for their health and those of others not taken. That led to sharp criticism of the CDC. The agency broadened its teams of epidemiologists normally sent to investigate disease outbreaks to include other experts, such as the vector-born specialists sent in response to Zika.
Behind the scenes in Miami, the disease detectives are interviewing people, collecting data and trapping mosquitoes, all the while working not only to contain the disease but also to quell growing concerns about its reach, said Nordlund.
"Our teams have been well-received and helped contribute to the response. The states and local health departments have done a lot of work to get prepared for Zika and are putting in tremendous effort in the Zika response," the CDC's director, Dr. Thomas Frieden, said in an email.
The much-publicized logjam in Congress over emergency spending to fight Zika has not hampered the CDC efforts, Frieden said, but he added that a shortage of funding could impair response efforts going forward.
Frieden said money for the teams has come from $222 million in repurposed funds. The administration earlier this year redirected funding for Ebola research and prevention to help pay for its efforts on Zika.
"We're in peak mosquito season right now and if more states see local transmission, CDC's resources will be stretched thin as we help respond in multiple areas," Frieden wrote in the email. "But it's not too late, and we are hopeful that Congress will do the right thing, as they have with Ebola, for example."
An Urgent Call
The call from the Utah Department of Public Health to the CDC came in on July 12. "We were all on a plane July 13," said Novosad. "We took whatever plane that could get us there fastest."
Once there, Novosad said the first job was to identify all health care workers who had come into contact with the patient.
"We started by contacting the employees, and we administered surveys," she said. "I think people were just really interested in helping, given the unusual nature of this outbreak."
The team of epidemiologists talked to family members to see if any others were infected.
A lab team helped make sure all necessary blood samples had been taken and were accounted for. A communications group coordinated information among the teams. Each morning at 6 a.m., the entire crew assembled to talk with experts in Atlanta.
The team issued its report Tuesday. It did not name the man or his son. Although they did not determine how the son became ill, the investigators noted that he had close contact with his father, who had a very high virus level. The son had hugged and kissed his father, as well as assisted medical workers in caring for him. The report noted that health care workers and family members "should be aware that blood and body fluids of severely ill patients might be infectious."
Nordlund said she understands why people become unnerved and impatient when disease outbreaks occur.
People typically do not pay attention to the work of public health agencies when no immediate outbreaks are occurring, she said.
"When public health is doing its job, you don't see it," she said. When a crisis occurs, it's suddenly news, she said.
On average, insurers spend $3,435 a year on an individual patient, but for those with an opioid dependence or abuse diagnosis, that amount jumps to $19,333. Those numbers reflect what insurers actually paid.
The nation's ongoing opioid problem comes with staggering physical and emotional costs to patients and families. But the dollar cost to the health system has been harder to peg. Now a new report shows a more than 1,300 percent rise in spending by health insurers in a four-year period on patients with a diagnosis of opioid dependence or abuse.
From 2011 to 2015, insurers' payments to hospitals, laboratories, treatment centers and other medical providers for these patients grew from $32 million to $446 million — a 1,375 percent increase.
While that's a small portion of the overall spending on medical care in the United States, the rapid rise is cause for concern, says Robin Gelburd, president of Fair Health, a nonprofit databank that provides cost information to the health industry and consumers.
"That really shows the stress on the health system and the impact on the individuals," said Gelburd.
The Fair Health study found a sharp difference in how much insurers spend on individual patients with such a diagnosis.
On average, insurers spend $3,435 a year on an individual patient, but for those with an opioid dependence or abuse diagnosis, that amount jumps to $19,333. Those numbers reflect what insurers actually paid. The report also includes data on what providers charged, amounts that are lowered by their contracts with insurers.
The study, set to be released Tuesday, builds on one Fair Health released in early August that found a 3,000 percent increase in the volume of insurance claims related to opioid dependence diagnoses between 2007 and 2014.
The latest study — part of a series — offers amounts associated with claims billed by providers and paid by insurers for the types of medical services used.
Both studies use de-identified claims data from insurers representing more than 150 million insured Americans who either have insurance through work or buy coverage on their own.
There have been other efforts by several researchers to quantify the cost of the opioid problem on the overall economy, estimated in the tens of billions of dollars. The new report adds to the available data "that it's not just the human cost associated with the opioid crisis that is enormous, but also that the economic costs are staggering," said Dr. Andrew Kolodny, senior scientist at Brandeis University. He did not work on the study.
The surge in spending on patients with opioid diagnoses is likely a combination of factors, the report notes. As media attention focuses on drug dependency, more people may be seeking treatment. At the same time, prescription and illegal use of narcotics may also be increasing.
The study found that emergency room visits and laboratory tests accounted for much of the spending.
Based on claims volume, the fastest-growing set of services in terms of utilization were for alcohol or drug therapy. Lab tests, including checks for barbiturate or opioid use, were not far behind.
Researchers did not use 2015 data for lab test costs, noting that a change in billing codes was made that increased the number of categories — and, in some cases, appear to generate higher payments by insurers. It is too early to estimate the long-term effects of the change, Gelburd said.
The report gives some examples of the changes, however. For example, one billing code for a test on opiate use commonly brought in a $31 payment from insurers prior to the change. The two billing codes that replaced it now are commonly paid at $78 and $156.
The new billing codes may reflect new technology in testing, said Gelburd. She said some observers speculate that the rapid increase in lab spending might reflect that, with more patients in therapy, the tests are being used to ensure they are taking their proper medications and not abusing narcotics.
But the spending might also reflect a growing use of very expensive urine and blood tests when less expensive ones would be sufficient, said Kolodny.
"I worry about profiteering," said Kolodny. "We do need tests, but not the expensive ones. A lot of clinics are making extra money off these lab tests."
The overall increase in spending across all types of medical services "is a societal issue," said Gelburd, who says policymakers need to ensure that changes are made to address the problem.
"Are medical school curricula adjusting to recognize the growing need for these services? Are insurers increasing the number of providers in their networks to ensure sufficient access? Are consumers being educated? It's an issue that has to be dealt with in all quadrants."
It isn't news that in rural parts of the country, people have a harder time accessing good health care. But new evidence suggests opposition to a key part of the 2010 health overhaul could be adding to the gap.
The finding comes from a study published Wednesday in the journal Health Affairs, which analyzes how the states' decisions on implementing the federal health law's expansion of Medicaid, a federal-state insurance program for low-income people, may be influencing rural hospitals' financial stability. Nineteen states opted not to join the expansion.
Rural hospitals have long argued they were hurt by the lack of Medicaid expansion, which leaves many of their patients without insurance coverage and strains the hospitals' ability to better serve the public. The study suggests they have a point.
Specifically, the researchers, from the University of North Carolina Chapel Hill, found that rural hospitals saw an improved chance of turning a profit if they were in a state that expanded Medicaid — while in city-based hospitals, there was no improvement to overall profitability. Across the board, hospitals earned more if they were in a state where more people had coverage and saw declines in the level of uncompensated care they gave.
To put it another way: All hospitals generally fared better under the larger Medicaid program, but there's more at stake for rural hospitals when the state expands coverage.
The study looked at how expanding Medicaid affected hospital revenue, how many Medicaid patients they discharged, levels of uncompensated care the hospitals provided and how well the institutions did financially overall. It compared those effects in rural versus urban areas, across more than 14,000 annual cost reports from hospitals between January 2011 and December 2014, or a year after eligible states could have expanded their Medicaid programs.
In states expanding Medicaid, rural hospitals saw a greater increase in Medicaid revenue than urban hospitals did. City-based facilities save a higher percentage than rural hospitals with the reduction in uncompensated care, though that change "did not translate into improved operating margins for urban hospitals," the study notes.
How much these differences matter, though, remains up in the air.
"There is a disparity in the impact of Medicaid expansion, and probably the [law] overall," said Brystana Kaufman, a doctoral candidate at the university's department of health policy and management and the study's first author. "There needs to be more exploration into why we're seeing this."
One likely factor: Rural hospitals serve more low-income people — who weren't eligible for insurance before, but who got covered after the health law took effect. And rural hospitals are historically more likely to operate at a loss than are urban ones. So the chance to see increased revenue is greater than in a city-based hospital.
That said, these are preliminary figures, looking at barely a year's worth of evidence when it comes to the Medicaid expansion. But the effect merits further scrutiny, experts said.
It's important because hospital finances matter for consumers, too. In rural communities, hospitals are often among the largest employers, and the main source of health care. Financial duress can affect what kind of services the facility offers.
"If you're [a hospital] in a state that did expand Medicaid, obviously you're going to be experiencing lower amounts of uninsured. Your bad debts and charity care have gone down," said Brock Slabach, senior vice president at the National Rural Health Association. He was not involved in the study, although he is familiar with the research team's work. "Has [that expense] gone to nothing? No. But it has helped."
That's especially true for rural hospitals, Kaufman said, because they have narrower profit margins than do urban ones. Any squeeze on the budget "is going to be more influential" and may limit a hospital's offerings or quality.
Hospitals are "still really trying to anticipate and assess the shakeout from all the changes that are happening," said Kristin Reiter, an associate professor at UNC-Chapel Hill's Department of Health Policy and Management and another study author.
How Medicaid affects rural and urban hospitals could influence other debates, the study authors said. For instance, the health law also is expected to cut so-called disproportionate health spending payments – cash infusions that support hospitals that treat low-income people, often in rural areas.
Those cuts haven't taken effect yet, but the researchers suggest, the paper could make a case for indefinitely postponing them.
"The hospitals rely on that funding to address uncompensated care," Kaufman said. In rural states that declined the expansion, uncompensated medical treatment poses a significant financial hurdle for hospitals.
But others cautioned against drawing hard conclusions yet. It's unclear how meaningful the rural-urban difference will be, especially over time, said Doug Staiger, a professor of economics at Dartmouth who has researched rural health access but was not involved with this study.
"I'd be really cautious interpreting," he said.
Plus, Slabach added, researchers must examine how the findings actually affect consumers.
And, it's possible the effects seen here aren't just thanks to Medicaid, said George "Mark" Holmes, an associate professor at UNC and director of the university's North Carolina Rural Health Research and Policy Analysis Program. Expansion states may have taken other steps meant to help hospitals and consumers. If so, it's worth figuring out what those are.
"Medicaid expansion is not a random event. That's very important to consider here," said Holmes, another author of the study. "These are states that have decided to do it. There could be other elements" at play.
Under a new California law, insurance companies — and health care providers — must comply with requirements to keep physician directories updated at least every quarter.
SACRAMENTO, Calif. — State Sen. Ed Hernandez and his wife, Diane, are optometrists.
Diane handles some insurance matters for their practice, and she recently told him that a health plan had emailed to request more information: It wanted confirmation that they were both participating providers, he says.
"I didn't say anything because I was afraid she'd be mad at me," says Hernandez, D-West Covina.
That's because the additional paperwork was probably his doing.
Hernandez, who chairs the California Senate Health Committee, is author of a newly enacted state law that aims to improve provider directories, long riddled with out-of-date and inaccurate information.
Under the law, insurance companies — and health care providers like the Hernandezes — must comply with new requirements to keep directories updated at least every quarter.
The law, which took effect July 1, also provides patients with some firepower to fight surprise medical bills that result from directory errors.
The law's reach is broad: It applies to Covered California and private market plans, as well as Medi-Cal managed care and most job-based insurance policies.
The inaccuracy of directories, Hernandez says, "has been and … seems to continue to be a problem that needs to be rectified."
Several other states, from Georgia to Maryland, have passed similar legislation or are considering doing so, says Claire McAndrew, private insurance program director for Families USA, a national health care consumer advocacy group. In some states, insurance commissioners have adopted new rules through the regulatory process.
But California's law "is the most comprehensive," she says. "The level of detail in California goes beyond any other state." Federal officials also instituted a rule this year requiring directories be updated monthly for all plans sold on the 37 state marketplaces run by the federal government.
And they set new rules for Medicare Advantage plans, requiring that the companies contact doctors every three months and update their online directories within 30 days. A recent study in the journal Health Affairs found that provider directories for some health plans sold through Covered California and in the private market are so inaccurate that they create a "disheartening" situation for consumers trying to find doctors.
That finding was confirmed this month when the state Department of Managed Health Care (DMHC) announced that Anthem Blue Cross and Blue Shield of California — which were previously fined for inaccuracies in their Covered California provider directories — still had "disappointing" directory problems.
"We are optimistic and hopeful that the law … will help," says department director Shelley Rouillard.
Among the law's new rules:
Health plans must update their printed directories at least every quarter and their online directories at least every week if providers report changes.
Provider directories must be posted online and be available to anyone, not just enrollees. Print directories must be available upon request.
The directories must "prominently" display directions for consumers who want to report inaccuracies. Upon receiving complaints, plans have 30 business days to makes changes, if necessary.
Providers must inform plans within five business days if they are no longer accepting new patients — or, alternately, if they will start accepting them.
Health plans can delay payments to providers who fail to respond to attempts to verify information.
The California law also gives consumers recourse. Let's say you use a provider directory to find a doctor but you're billed the out-of-network price because the directory was wrong. In that case, health plans must reimburse you the amount beyond what you would have paid to see an in-network doctor.
If you find yourself in this situation, first take your complaint to your plan, advises DMHC's Rouillard. You will have at least 180 days from the date you received the bill to file a grievance.
"You'll probably have to make a case" to the plan, Rouillard says. "You should explain what you did, when you looked at the directory, and that you relied on that information."
Documentation could help your case.
That's something to consider when you're searching for a provider in the first place. It wouldn't hurt to save a screen shot from the online directory showing the doctor is in-network, or take detailed notes if you call your plan's customer service line.
"Keep copies of everything, and note the date, time and name of anyone you speak to," says Nancy Kincaid, spokeswoman for the state Department of Insurance.
Plans have 30 days to investigate and respond to your complaint. If the situation isn't resolved to your satisfaction, your next step is to take your grievance to your health plan's regulator.
Since the law went into effect, the DMHC has helped one consumer get reimbursed as a result of this law.
But, "I'm hoping consumers don't have to go through process. I'm hoping the directories are accurate," Hernandez says.
It might take time to get there, as health plans implement the new requirements — as well as others that will take effect in the coming months — and work with providers to update the information.
"This is so early and there are so many errors," Rouillard says.
Paper suggests that "implicit bias"—doctors and nurses subtly or subconsciously treating some patients differently than others—or patients' perception of it could have consequences for patients' health.
Racial minorities and lower-income people typically fare far worse when it comes to health outcomes. And figuring out why has long been one of health care's black boxes. Forthcoming research may help shed light on what's driving those inequities — and how the system can fix them.
What is needed? Better bedside manner, so patients actually trust their doctors. Communication that is easily understood by everyday people. And transparency about what medical care costs, plus a willingness to discuss how price points fit into consumers' health decisions.
Those ideas were highlighted in a white paper presented last week at a health communication conference sponsored by the Centers for Disease Control and Prevention. The findings, which will be published in full later this fall, are based on interviews with 100 health professionals and 65 "disadvantaged patients," along with a nationally representative survey of 4,000 consumers. The examination is part of a larger project funded by the Robert Wood Johnson Foundation, a health-focused nonprofit. It was conducted by the Altarum Institute, a research and consulting organization.
The paper suggests that "implicit bias" — doctors and nurses subtly or subconsciously treating some patients differently than others — or patients' perception of it could have consequences for people's health. Patients who felt that they had experienced bias based on factors like race, income or insurance were less likely to follow advice about medication, for instance, and ended up sicker in the long run.
"We for a long time have neglected the human element," said Chris Duke, director of Altarum's Center for Consumer Choice in Health Care, and the white paper's author. "The number one predictor of patient satisfaction is if your nurse listened to you. We neglect this at our great peril."
Duke stressed that the research isn't enough to draw conclusions about causality — that feeling disrespected causes worse health. But the study builds on years of investigation that suggests implicit bias and how patients perceive it could contribute to differences in health outcomes.
Insurance status was the largest predictor of how patients viewed their doctor-patient interaction, Duke said. People on Medicaid, the state-federal health insurance program for low-income people, or who were uninsured, were more likely to perceive disrespect than those with private insurance or Medicare, which provides coverage for senior citizens and some disabled people. Income was the next predictor for how well people felt they were treated. After that came race.
Meanwhile, racial minorities and low-income people also were more likely to be sensitive to concerns about a doctor's bedside manner, and to seek out someone they thought would treat them well, Duke noted.
Often, these patients cue in on subtle behaviors, such as the doctor not making eye contact or not asking questions about their symptoms and health conditions, their lifestyle or their preferences on how to manage a disease. But that can be enough, Duke said, to keep people from seeking care, or following through on medical advice.
He recalled one interviewee: a lower-income black woman with high blood pressure. She said her physician never asked her meaningful questions about her health, instead just writing her a prescription. She was so dissatisfied she ignored the recommendation, meaning her condition only worsened.
"There's a huge need for provider training in communication and warmth, and the understanding that how you interact with your patients can have an implication … on their health," he said.
That interaction could have major consequences for patients with chronic diseases, like diabetes or heart problems, noted Ben Handel, an assistant professor of economics at the University of California, Berkeley, who has researched health consumer decision-making. These patients need regular follow-up, but they are less likely to seek it out, because they aren't in significant pain. But if they don't get regular treatment, they could develop severe medical complications.
"If you feel like your doctor doesn't respect you, you're not going to go the doctor unless you have to — and preventive care is something you don't get unless you have to," he said. "And that kind of stuff is in some ways the most important."
To address that, both Duke and Handel said it's worth examining how Medicaid pays doctors, so that they see more value in treating low-income patients. Currently, Medicaid reimburses physicians at a lower rate than do other insurance programs.
Encouraging more diversity in medical professions — from a racial and a socioeconomic standpoint — could also help, they said. That idea tracks with other suggestions researchers have made when brainstorming ways to tackle gaps in health care and to make the system more responsive to people who are typically overlooked.
"If you are a lower-income racial minority, and you walk into a hospital and none of the pictures of people look like you, and none of the staff looks like you, you may not feel welcome," Duke said. "People need to feel welcome for them to trust information, and trust guidance."
The paper also highlighted consumers' concerns about understanding their medical recommendations and how much their care costs. Expense in particular "is a big sticking point," Duke said, and it's something doctors have long been discouraged from discussing. But for patients, avoiding the subject means they're more likely to go without.
That's true across the board, but likely even more so for lower-income people, Handel said. "That's basic economic theory. If you're low-income and the marginal value of income is higher, you're going to be more price sensitive," he said.
The findings underscore a need for inclusivity, Duke said. "We heard many patients say, 'The system is for them and not for us,'" he said. "The fact that we have large disparities along the lines of income and race — it shows there's a lot of ground to be covered."
Aiming to make picking a health plan easier, the federal government, which runs the marketplaces in roughly two-thirds of states, is encouraging insurers to offer "simple choice plans" as an option this fall.
Despite much hand-wringing about health insurers exiting the marketplaces where people buy individual coverage, in many areas consumers will likely still have a choice of plans when the 2017 open enrollment starts in November. Aiming to make picking a plan easier, the federal government, which runs the marketplaces in roughly two-thirds of states, is encouraging insurers to offer "simple choice plans" as an option this fall.
The six new standardized plan designs will eliminate many of the moving parts that have bedeviled consumers trying to make apples-to-apples comparisons between plans. The government is providing guidelines for a simple choice plan at each of the bronze, silver and gold levels, and three more silver options for people who qualify for cost-sharing reductions based on their income.
In these plans, the deductibles and annual limits on out-of-pocket spending will be standardized, as will many of the consumer payments for medical services.
In the simple choice silver plan, for example, the deductible will be $3,500 and the maximum amount that someone will owe out-of-pocket for the year will be $7,100. For many specific services, consumers will have flat dollar copayments for services up front rather than having to meet their deductible before the plan picks up any of the tab. Some of these include primary care visits ($30), specialist visits ($65), urgent care ($75) and generic drugs ($15).
Insurers won't be required to offer standardized plans on the federal marketplace, just as they aren't required to do so in most of the state-based marketplaces that offer such plans.
Offering both standardized and non-standardized plans can present a challenge for consumers, say experts. Both need to be clearly differentiated online or consumers will have no easier time comparison shopping than before, said Sabrina Corlette, research professor at Georgetown University's Center on Health Insurance Reforms who coauthored a recent report examining state efforts to offer standardized plans.
"It's really important to get the consumer shopping experience right, otherwise you might as well not bother" with standardized plans, she said.
When the administration announced the simple choice plans in April, Kevin Counihan, CEO of the healthcare.gov marketplace said the plans would "display prominently" on the website and have "clear visual cues" that would distinguish the simple choice plans from others.
A CMS official said there was no further information available at this time about how the plans will be displayed this fall.
In addition to potentially helping consumers wade through a bewildering array of options, standardized plans make it harder for insurers to design plans to be less attractive to people with expensive health care conditions, said Corlette. Insurers may be limited in their ability to make certain types of specialist care or drugs more expensive, for example.
Behavioral economics research tells us that simplifying consumer choices helps people make better ones. It makes sense that it will work with marketplace plans, too, but at this time that's an unknown.
"We don't yet know that standardized benefit design will help people make better choices and get into the plan that's right for them," Corlette said.
Baltimore officials presented a 10-year plan Tuesday that sharply highlights the poor health status of African-Americans and aims to bring black rates of lead poisoning, heart disease, obesity, smoking and overdoses more in line with those of whites.
"We wanted to specifically call out disparities" in racial health, said Dr. Leana Wen, who became the city's health commissioner early last year. "And we have a moonshot. Our moonshot is we want to cut health disparities by half in the next 10 years."
Black Baltimore leaders praised Wen for putting disparities squarely in the conversation even as they acknowledged the difficulty of achieving the plan's goals.
"It's a big challenge. There's no debating that," said Diane Bell-McKoy, CEO of Associated Black Charities, a Maryland nonprofit. "She takes a step forward more so than anybody else I've seen because she calls it out. Most of the time we find code words for it. We don't call it out."
Violence last year following the death of Freddie Gray, a black man who died after being injured in police custody, exposed Baltimore's health divide as well as its criminal justice differences, officials said. Gray's family had won a settlement for alleged lead-paint poisoning, which is blamed for low test scores and cognitive challenges among thousands of Baltimore children.
"What happened last year with Freddie Gray put Baltimore in the national media spotlight," said Helen Holton, a Baltimore councilwoman who represents a portion of the city's west side. "That made people stop and take notice of what had been going on and stop treating it as business as usual."
The health plan, called Healthy Baltimore 2020, was first reported by the Baltimore Sun. Officials plan to track blood-lead levels, overdose deaths, child fatalities, healthy-food availability and other indicators year by year. It's called Healthy Baltimore 2020 because officials have set ambitious goals to achieve before 10 years is up, Wen said.
Tentative targets include cutting youth homicides by 10 percent and disparities in obesity, smoking and heart-disease deaths by 15 percent — all by 2020.
Tactics include more programs to reduce street violence, expanded anti-smoking campaigns, more home visits for pregnant women and increased access to naloxone, which blocks the effects of heroin.
The blueprint is "an ongoing document" that will be amended with community participation and results closely scored, Wen said.
"Our community is sick of us overpromising and underdelivering," she said.
But as in many other areas, Baltimore is still divided by health. Residents of Gray's west-side neighborhood of Sandtown-Winchester live 10 years less on average than Marylanders in general. Poor neighborhoods have far higher rates of heart disease, diabetes, addiction, HIV infection and other illness than more prosperous parts of the city.
Black leaders emphasized that Baltimore's health won't improve unless policymakers address deeper causes of illness such as poverty, unemployment and poor housing.
"It is affirming to see someone in Dr. Wen's role address the uncomfortable truths behind health inequities," said Debbie Rock, CEO of LIGHT Health and Wellness, which offers health and other community services on Baltimore's west side. "This is a great platform to also address upstream factors" such as low incomes, she said.
Holton compared the health blueprint to a Justice Department report this month alleging a pattern of excessive force and violation of constitutional rights by the Baltimore Police Department.
Both documents address racial differences and offer challenges for improvement, she said.
"You can travel 5 miles from one neighborhood to another and it's like you are in two different communities" in health levels, Holton said. "Freddie Gray was like the tipping point. Let's take this and make it a teachable moment of how to be better moving forward."
SANTA MONICA, Calif. — Dominick Bailey sat at his computer, scrutinizing the medication lists of patients in the geriatric unit.
A doctor had prescribed blood pressure medication for a 99-year-old woman at a dose that could cause her to faint or fall. An 84-year-old woman hospitalized for knee surgery was taking several drugs that were not meant for older patients because of their severe potential side effects.
And then there was 74-year-old Lola Cal. She had a long history of health problems, including high blood pressure and respiratory disease. She was in the hospital with pneumonia and had difficulty breathing. Her medical records showed she was on 36 medications.
"This is actually a little bit alarming," Bailey said.
He was concerned about the sheer number of drugs, but even more worried that several of them — including ones to treat insomnia and pain — could suppress Cal's breathing.
An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects. Often the drugs are prescribed by different specialists who don't communicate with each other. If those patients are hospitalized, doctors making the rounds add to the list — and some of the drugs they prescribe may be unnecessary or unsuitable.
"This is America's other drug problem — polypharmacy," said Dr. Maristela Garcia, director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica. "And the problem is huge."
The medical center, where Bailey also works, is intended specifically for treating older people. One of its goals is to ensure that elderly patients are not harmed by drugs meant to heal them.
That work falls largely to Bailey, a clinical pharmacist specializing in geriatric care.
Some drugs can cause confusion, falling, excessive bleeding, low blood pressure and respiratory complications in older patients, according to research and experts.
Older adults account for about 35 percent of all hospital stays but more than half of the visits that are marred by drug-related complications, according to a 2014 action plan by the U.S. Department of Health and Human Services. Such complications add about three days to the average stay, the agency said.
Data on financial losses linked to medication problems among elderly hospital patients is limited. But the Institute of Medicine determined in 2006 that at least 400,000 preventable "adverse drug events" occur each year in American hospitals. Such events, which can result from the wrong prescription or the wrong dosage, push health care costs up annually by about $3.5 billion (in 2006 dollars).
And even if a drug doesn't cause an adverse reaction, that doesn't mean the patient necessarily needs it. A study of Veterans Affairs hospitals showed that 44 percent of frail elderly patients were given at least one unnecessary drug at discharge.
"There are a lot of souvenirs from being in the hospital: medicines they may not need," said David Reuben, chief of the geriatrics division at UCLA School of Medicine.
Some drugs prescribed in the hospital are intended to treat the acute illnesses for which the patients were admitted; others are to prevent problems such as nausea or blood clots. Still others are meant to control side effects of the original medications.
University of California, San Francisco researcher and physician Ken Covinsky said many doctors who prescribe drugs in hospitals don't consider how long those medications might be needed. "There's a tendency in medicine every time we start a medicine to never stop it," Covinsky said.
When doctors in the hospital change or add to the list of medications, patients often return home uncertain about what to take. If patients have dementia or are unclear about their medications, and they don't have a family member or a caregiver to help, the consequences can be disastrous.
One 2013 study found that nearly a fifth of patients discharged had prescription-related medical complications during their first 45 days at home. About 35 percent of those complications were preventable, and 5 percent were life-threatening.
UCLA hired Bailey about three years ago, after he completed a residency at University of California, Davis. The idea was to bring a pharmacist into the hospital's geriatric unit to improve care and reduce readmissions among older patients.
Speaking from his hospital bed at UCLA's Santa Monica hospital, 79-year-old Will Carter said that before he was admitted with intense leg pain, he had been taking about a dozen different drugs for diabetes, high blood pressure and arthritis.
Doctors in the hospital lowered the doses of his blood pressure and diabetes medications and added a drug to help him urinate. Bailey carefully explained the changes to him. Still, Carter said he was worried he might take the drugs incorrectly at home and end up back in the hospital.
"I'm very confused about it, to tell you the truth," he said after talking to Bailey. "It's complicated. And if the pills are not right, you are in trouble."
Having a pharmacist like Bailey on the team caring for older patients can reduce drug complications and hospitalizations, according to a 2013 analysis of several studies published in the Journal of the American Geriatrics Society.
Over a six-month stretch after Bailey started working in UCLA's Santa Monica geriatric unit, readmissions related to drug problems declined from 22 to three. At the time, patients on the unit were taking an average of about 14 different medications each.
Bailey is energetic and constantly on the go. He started one morning recently with a short lecture to medical residents in which he reminded them that many drugs act differently in older patients than in younger ones.
"As you know, our elderly are already at risk for an accumulation of drugs in their body," he told the group. "If you put a drug that has a really long half-life, it is going to last even longer in our elderly."
The geriatric unit has limited beds, so older patients are spread throughout the hospital. Bailey's services are in demand. He gets paged throughout the day by doctors with questions about which medications are best for older patients or how different drugs interact. And he quickly moves from room to room, reviewing drug lists with patients.
Bailey said he tries to answer several questions in order to determine what's best for a patient. Is the drug needed? Is the dose right? Is it going to cause a problem?
One of his go-to references is known as the Beers list — a compilation of medications that are potentially harmful for older patients. The list, named for the doctor who created it and produced by the American Geriatrics Society, includes dozens of medications, including some antidepressants and antipsychotics.
When he's not talking to other doctors at the hospital, Bailey is often on the line with other pharmacists, physicians and relatives to make sure his patients' medication lists are accurate and up to date. He also monitors patients' new drugs, counsels patients about their prescriptions before they are discharged and calls them afterward to make sure they are taking the medications properly.
"Medications only work if you take them," Bailey said dryly. "If they sit on the shelf, they don't work."
That was one of his main worries about Cal, the 74-year old with chronic obstructive pulmonary disease. Standing at her bedside, Bailey pored over the list of 36 drugs. Cal told him she only took the medications that she thought seemed important.
Bailey explained to Cal that he and the doctors were going to make some changes. They would eliminate unnecessary and duplicate drugs, including some that could inhibit her breathing. Then she should take as prescribed all of the medications that remained on the list.
Bailey said he's constantly weighing the risks versus the benefits of medications for elderly patients like Cal.
"It is figuring out what they need," he said, "versus what they can survive without."