Who protects consumers of healthcare?
Two recent emails from readers got me thinking about that question. I don't mean consumers in their role as patients whose medical well-being is looked after by state medical boards and health departments that police doctors and hospitals. Those organizations don't always do a perfect job protecting patients from harm, but at least they are in place.
But who protects patients when things go wrong on healthcare's financial side? What happens when you receive a bill you didn't expect and can't afford to pay? What happens when insurers send unintelligible explanations of benefits you can't understand? What about questionable loan arrangements to avoid medical bankruptcy?
Consumers of healthcare are pretty much on their own. From the 1960s though the 1980s when people complained, they got action from consumer organizations, government and even businesses that set up departments to handle complaints. That consumer movement is now but a flicker.
"We don't have as many public-interest minded regulators, and officials who try to grab these issues by the horns and deal with them," says Chuck Bell, director of programs for Consumers Union.
The emails I received show that although it's an uphill battle to get redress, fighting back as an individual can get attention and may ultimately lead to better protections for everyone.
John Rutledge, a retiree, got snared in Medicare's three-day rule by a hospital near his hometown Wheaton, Illinois. At the end of March he took his wife, who was having breathing problems, to the hospital where she was held for three nights of "observation." Patients must be in a hospital for three days as an in-patient before they are entitled to Medicare benefits for 100 days of skilled nursing home care as I noted in a recent column.
Thousands of families have been caught when hospitals decide their loved ones are admitted for "observation," a tactic that allows them to avoid repaying Medicare if government auditors find patients should not have been classified as "in-patients." Playing the "observational" game is worth millions to hospitals but costs families tens of thousands of dollars when someone doesn't qualify for Medicare-covered skilled nursing care.
Rutledge knew about the three-day rule. Both his doctor and a pulmonologist at the same medical practice recommended an in-patient stay, and Rutledge refused to sign a hospital document saying his wife was admitted for observation.
Still, the hospital prevailed, claiming a consultant made the decision to keep her for "observation." Rutledge was stuck with a bill that, so far, totals over $15,000 for the skilled nursing care his wife did need. He said he had been a "significant donor" to the hospital foundation, and "I have told the foundation that what I spend as a result of "observation" will come out of what I planned to give them, starting with the annual gift."
The second email came from Kathryn Green, a college history professor who lives in Greenwood, Mississippi. Green is fighting an air ambulance company, which transported her late husband to a Jackson hospital after he suffered a fatal fall in their home. This "nightmare," as she calls it, is a bill from the transport company that claims it's outside her insurance network, and says she owes them $50,950.
"I am 63 and will have a devastated retirement if this is upheld," Green told me.
Blue Cross & Blue Shield of Mississippi, the administrator for her insurance carrier the State and School Employees' Health Insurance Plan, paid $7,192 of the $58,142 the transport company billed. Blue Cross has told Green that she should be held harmless and should not be charged for the "balance after payment of the Allowable Charge has been made directly to that provider."
Green is raising a ruckus and has taken her case to state and national media, members of Congress, the state attorney general, and the Mississippi Health Advocacy Program. The company has told her it will begin collection efforts.
In both cases there's a legislative solution. The three-day rule can be fixed by counting all the time a patient spends in the hospital whether they're classified as an "in" or as an "observational" patient. The ambulance problem can be fixed by changing the 1978 airline deregulation law that prevents states from interfering with fares, services, and routes. But money and politics block the federal changes that would help people like Rutledge and Green.
"It's like playing a game of health insurance roulette," Bell says. "Your coverage exposes you to these gaps that have been normalized. It's become the way of doing business."
A resurgent consumer movement could change all that.
What consumer problems have you had with balance billing? Write to Trudy at email@example.com.