The fast-growing hospital system, which leases Colorado Springs’ Memorial Hospital, acquired the remaining 17 freestanding ERs and two boutique hospitals it operated in a partnership with Texas-based Adeptus Health, including Grandview Hospital in Colorado Springs and four of the freestanding ERs in El Paso County.
The move comes as part of Adeptus’ restructuring under a Chapter 11 bankruptcy. The company, based in a suburb of Dallas, was acquired in October by New York-based Deerfield Management Co.
UCHealth completed the deal this month, said Dan Weaver, UCHealth’s spokesman. Terms of the transaction were not disclosed.
The deal helps ensure a kaleidescope of services offered by UCHealth, which also has recently expanded its urgent care and primary care services.
“We’re focused on providing comprehensive care for our patients,” Weaver said.
The move solidifies UCHealth’s position on the controversial clinics, which have most of the amenities of an emergency room attached to a hospital.
Consumer advocates have for years raised concerns about billing practices at such facilities, because patients often are left with large medical bills for minor ailments that could be better treated at urgent care clinics. That’s because different billing rates can apply at such emergency rooms, and they can charge a “facility fee” that can increase the price of an appointment by more than $1,000.
Weaver said the hospital system has worked to educate patients on where best to seek help for their specific medical need.
Aetna will be the first national payer to waive copays for Narcan for its fully-insured commercial members – a move that will increase access and remove possible financial barriers to the lifesaving drug. In addition, Aetna will limit the quantity of opioids prescribed for acute pain and post-surgery to a seven-day supply for its commercial pharmacy members. Both changes will be effective Jan. 1, 2018.
Narcan delivers one dose of the opioid overdose reversing medicine naloxone through the nose of a person overdosing on opioids. Narcan is a preferred branded medication, which may currently require a copay for members. The current copay for Aetna members ranges from $0 to $150, depending on the plan selected, but is typically in the $30 to $40 range.
“Aetna is committed to addressing the opioid crisis through prevention, intervention and treatment,” said Harold L. Paz, M.D., M.S., executive vice president and chief medical officer of Aetna. “Increasing access to Narcan can save lives so that individuals with opioid abuse disorder can live long enough to get into evidence-based treatment.”
According to research from the drug manufacturer, nearly 35 percent of Aetna members prescribed Narcan between January to June 2017 did not pick up their prescription.
WASHINGTON —A recent article in Vox about hospital billing practices makes a number of assertions that rely heavily on data from the Health Care Cost Institute or HCCI, which receives millions of dollars from four of the largest health insurance companies. According to a statement from Paul Kivela, MD, FACEP, president of the American College of Emergency Physicians:
“Unfortunately, Vox’s data source is not independent, because the data used for the article come directly from a limited subset of claims from four major commercial insurers, which have a long history of denying emergency department claims. For example, the state of New York successfully sued United Health Care, one of the main contributors to HCCI, for fraudulently calculating and significantly underpaying doctors for out-of-network medical services using its Ingenix database. In 2014, only 34 percent of emergency department visits were under private payer coverage (of which employer-sponsored coverage is an even smaller subset). Basing an analysis such as Vox’s on data only from employer-sponsored health plans leaves out a major portion of the picture and skews the article’s findings. For example, Vox says it found that emergency department visits have dropped by 2 percent between 2009 and 2015–yet CDC data show that visits have actually increased overall by 3.9 percent from 2009 to 2014. Such a disparity calls into question the rest of the findings presented in the piece.
“Hospital emergency departments are legally required to be open 24 hours a day, seven days a week, which is not one of the characteristics of a ‘monopoly,” as the article claimed them to be. Unlike urgent care centers and physician office, they never turn anyone away. This has resulted in significant amount of uncompensated care over the years.
“The article correctly identifies hospital facility fees as one of the most expensive part of an emergency department bill. Doctors bill separately and are typically about one-fourth of a total emergency department bill.
“Emergency physicians are calling for transparency by insurance companies and use of independent databases, such as Fair Health (www.fairhealth.org), to calculate physician payments.”
ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.
The American College of Emergency Physicians (ACEP) is challenging a recent report that says spending on hospital emergency room fees is on the rise.
Vox and the Health Care Cost Institute analyzed more than 70 million bills for ER visits that were recorded between 2009 and 2015 and found that spending on the fees increased by $3 billion in that span.
However, ACEP President Paul Kivela, M.D., said in a statement that the institute’s data is limited, as it receives millions in funding from four major commercial payers, and bases its data on those sources.
Kivela said that as just 34% of ER visits are paid by commercial payers, that data set paints an incomplete picture of emergency care.
“Basing an analysis such as Vox’s on data only from employer-sponsored health plans leaves out a major portion of the picture and skews the article’s findings,” Kivela said.
Kivela noted that the HCCI indicated that ER visits dropped by 2% between 2009 and 2015, while CDC data suggested that the number of visits instead increased by nearly 4% between 2009 and 2014.
He did say, however, that the article was correct in its assertion that hospital facility fees are often the highest part of a patient’s ER bill. Emergency physicians bill separately, Kivela said, and generally account for a quarter or less of a patient’s bill.
Price-gouging in the ER is a problem across the country, particularly for minorities and the uninsured. A recent study, which was based on 2013 data, found that ERs charge on average between 1 and 12.6 times what Medicare pays for emergency care. The markups create total bills that were 340% more than what Medicare would cover; ERs were charging $4 billion versus $898 million in Medicare allowable amounts.
In the Vox piece, an emergency care researcher called emergency rooms monopolies, which gives them free rein to set their own prices. Kivela disputed that assertion as well.
“Hospital emergency departments are legally required to be open 24 hours a day, seven days a week, which is not one of the characteristics of a ‘monopoly,'” as the article claimed them to be,” he said. “Unlike urgent care centers and physician offices, they never turn anyone away. This has resulted in significant amount of uncompensated care over the years.”
There are 141 million visits to the emergency room each year, and nearly all of them (including Saifan’s) have a charge for something called a facility fee. This is the price of walking through the door and seeking service. It does not include any care provided.
Emergency rooms argue that these fees are necessary to keep their doors open, so they can be ready 24/7 to treat anything from a sore back to a gunshot wound. But there is also wide variation in how much hospitals charge for these fees, raising questions about how they are set and how closely they are tethered to overhead costs.
Most hospitals do not make these fees public. Patients typically learn what their emergency room facility fee is when they receive a bill weeks later. The fees can be hundreds or thousands of dollars. That’s why Vox has launched a year-long investigation into emergency room facility fees, to better understand how much they cost and how they affect patients.
Saifan’s bill was so expensive, it turns out, because the hospital used the facility fee typically reserved for complex, intensive emergency room visits.
Emergency room facility fees are usually coded on a 1 to 5 scale, to reflect the complexity of care delivered to the patient. Saifan’s visit where he received a muscle relaxant was coded by the doctor as a level 4 visit — the second highest — and came with hefty fees as a result.
The hospital billed a separate facility fee and chose level 3, typically reserved for moderately complex visits.
Saifan’s experience isn’t an anomaly: A new Vox analysis reveals that emergency rooms all across the country are increasingly using these higher-intensity codes, and that the price of these codes has increased sharply since 2009.
Vox worked with the nonprofit Health Care Cost Institute (HCCI) to analyze 70 million insurance bills for emergency room visits from between 2009 and 2015. We focused on the prices that health plans paid hospitals for facility fees, not the hospital charges (which can often be inflated well above what patients actually pay).
We found that the price of these fees rose 89 percent between 2009 and 2015 — rising twice as fast as the price of outpatient health care, and four times as fast as overall health care spending.
Overall spending on emergency room fees rose by more than $3 billion between 2009 and 2015, despite the fact the HCCI database shows a slight (2 percent) decline in the number of emergency room fees billed in the same time period.
“It is having a dramatic effect on what people spend in a hospital setting,” says Niall Brennan, executive director of the Health Care Cost Institute. “And as we know, that has a trickle-down effect on premiums and benefits.”
The HCCI data shows that prices are rising dramatically and that, increasingly, hospitals have gravitated to using the most expensive billing codes — the level 4 and 5 charges, typically reserved for the most complex visits.
The rising price of emergency room facility fees coupled with growing usage of the most expensive codes mean it’s significantly more expensive to go to an emergency room now than it was six years ago.
Hospitals argues that these increases are due to an aging, sicker population.
“The number and complexity of ED visits continues to increase — this trend is not surprising given current population and health care-related trends,” Ashley Thompson, senior vice president for public policy at the American Hospital Association, said in a statement.
But experts on emergency billing argue that this is evidence of hospitals taking advantage of their market power — charging high fees because they are often the only place, late at night or on the weekend, where Americans can seek health care.
“If you have a monopoly — and when it comes to the ER, it’s a monopoly — you can set any price you want,” says Robert Derlet, a professor emeritus in emergency medicine at the University of California Davis, who has been critical of ER billing in the past.
“What is going to deter me from increasing my price? Who can stop me? If I’m the financial officer for the hospital, I might even get a bonus for doing this.”
Hospitals increasingly code emergency room visits as complex
David Overton knows what strep throat feels like. He comes down with it once or twice every year. He typically goes to urgent care or a drug store clinic when his achy throat and fever symptoms start.
But his most recent strep throat infection flared up on Memorial Day, and those clinics were closed. So he went to Legacy Emergency Room & Urgent Care outside of Dallas.
Overton walked in the door for urgent care, but staff there said his case was severe enough to move him to the emergency room side of the clinic.
“I felt terrible, and I wasn’t up for debating it,” he says. “So I was like okay, I guess we’ll do this.”
The emergency room performed a CT scan and used IV medications to treat Overton. He immediately felt better, and left with a prescription for antibiotics. Three days, later he saw another doctor who confirmed it was a simple case of strep throat.
But because of the complex intervention — the CT scan, the IV drugs, the long visit — the hospital coded Overton has having the most complex visit possible, a level 5. They billed him a $1,900 facility fee. Because he has a high-deductible plan, he’s responsible for all of it.
“Did I need the CT scan? No. Did I need the IV antibiotics? No,” he says. “I could have been treated with oral antibiotics.”
He’s currently paying off the bill by $50 each month. So far, he’s paid $300.
Emergency billing guidelines offered by the American College of Emergency Physicians typically reward doctors for providing a higher level of medical care. They instruct hospitals to use the more expensive billing codes for cases where they have to perform multiple scans and examinations.
Two different hospitals trips for the same condition may be treated and billed quite differently. A case of strep throat treated with oral antibiotics — a simple visit — would likely be coded as a level 1 or 2 visit. But a visit with multiple scans and an IV drip could come out to a 4 or 5.
The HCCI data set suggests that Overton’s experience may not be atypical. It shows that more and more emergency rooms are billing the severe, expensive facility fee charges.
What’s more, there are no federal guidelines on how to code even the exact same visit. This is left up to a hospital’s billing staff, meaning that if two patients receive identical care in different emergency rooms, one may be coded as a level 3 and another as a level 4.
“There are charges that people could look at differently,” says David McKenzie, reimbursement director for the American College of Emergency Physicians. “Reasonable people could disagree on severity.”
These discrepancies can be expensive for patients, as emergency rooms charge hundreds of dollars more for the more severe codes.
The HCCI database shows that the average price of a level 3 facility fee (in medical coding, this is billed as 99283) is $576. Go up to the next severity code, level 4 (or, in medical codes, 99284), and the price rises to $810.
“Hospitals can make a lot of money charging for all the extras — CT scans, MRIs, laboratory fees, even starting an IV,” Derlet, the emergency physician, says.
In 2009, 50 percent of all emergency room facility fee charges were for level 4 and 5 codes. In 2015, that number rose to 59 percent.
How to interpret that trend isn’t fully clear. Some say it could signal hospitals charging higher rates for similar care. But the current data makes it impossible to rule out the fact that emergency room visits may just be getting more serious.
“At face value, it might suggest that patients are showing up at the ER sicker or with more serious injuries,” says Jonathan Mathieu, chief economist at the Center for Improving Health Care Value in Colorado. His group has documented similar, state-level trends to what the HCCI national data set shows. “This feels a little shaky, for a lack of a more elegant term, because it is the same trend year over year over year.”
Medical bills from the Emergency Room (ER) are a mystery to many patients in the US health system. From incredibly high, varying charges to surprise bills resulting from in/out of network confusion, many Americans have no idea what to expect when it comes to the cost of this necessary service. Recently, Vox reporter, Sarah Kliff, has begun collecting ER bills in an attempt to “bring transparency to these extremely common but little understood fees”. To further the discussion, HCCI is releasing its first freely available data download! Using HCCI’s vast commercial claims dataset, we examined the 5, successive Current Procedural Terminology (CPT) codes for an ER visit which are designed to capture the level of severity and complexity of the ER visit. Analyzed collectively, we used these codes to explore how spending, utilization, and prices for ER visits have changed from 2009 through 2015.
Spending per member on all ER visits increased 85% between 2009 and 2015, largely due to the more than 100% growth in spending on high severity cases. ER spending growth was driven by price increases. High severity visits had the highest prices and the greatest price growth; the price for the most severe ER visit rose over $400, from $498 in 2009 to $900 in 2015. While overall use of the ER remained constant, there was a significant shift in case mix from low to high severity visits – further magnifying the effects of high severity price increases on spending.
The average price of an ER visit increased in every state. Some states saw price increases well over 100%, while price growth was half the national rate in others. The downloadable dataset alongside this post allows for all types of state-level comparisons across years, severities, and measures.
Using insurance claims data, we show that in 22% of emergency episodes, patients attended in-network hospitals, but were treated by out-of-network physicians. Out-of-network billing allows physicians to significantly increase their payment rates relative to what they would be paid for treating in-network patients. Because patients cannot avoid out-of-network physicians during an emergency, physicians have an incentive to remain out-of-network and receive higher payment rates. Hospitals incur costs when out-of-network billing occurs within their facilities. We illustrate in a model and confirm empirically via analysis of two leading physician-outsourcing firms that physicians offer transfers to hospitals to offset the costs of out-of-network billing and allow the practice to continue. We find that a New York State law that introduced binding arbitration between physicians and insurers to settle surprise bills reduced out-of-network billing rates.
The report found that ER fees increased by more than $3 billion between 2009 and 2015 despite a 2% decrease in ER fees billed. There were only 9.4 million ER visits in 2015 compared to 10.5 million in 2009. So, payer efforts and patient education to get care at lower cost facilities are working. However, costs remain a problem.
In the past few years, payers have created policies that target reducing ER utilization and costs. Payers have moved care away from hospital ERs and to less expensive outpatient facilities or freestanding ERs. Health systems, in turn, have focused more on expanding outpatient care and major systems like HCA have invested in freestanding ERs and urgent care centers.
In one of the most controversial payer moves this year, Anthem announced a policy to not pay for “unnecessary” ER visits. The policy requires an Anthem medical director to review claims information and decide whether symptoms and diagnoses warranted the visit. The payer implemented the policy as a way to cut costs and reduce ER visits and wait times. Hospital leaders have spoken out against that policy, including Missouri healthcare executives who called the policy “unfair to policyholders, and downright dangerous for patients.”
Despite the opposition, Anthem’s policy is one that other payers are watching closely. Lea Halim, senior research consultant at Advisory Board Company, recently told Healthcare Dive that more payers will follow suit if Anthem’s policy cuts costs and reduces ER visits.
“Will Anthem get a lot of pushback from patients and employers? Will hospital lobbies succeed in getting state governments to force Anthem to roll back the policy? If Anthem does not face or successfully overcomes these types of challenges, other payers may very well follow suit,” Halim said.
When an unresponsive patient arrived at a Florida hospital ER, the medical staff was taken aback upon discovering the words “DO NOT RESUSCITATE” tattooed onto the man’s chest—with the word “NOT” underlined and with his signature beneath it. Confused and alarmed, the medical staff chose to ignore the apparent DNR request—but not without alerting the hospital’s ethics team, who had a different take on the matter.
As described in a New England Journal of Medicinecase report, the unnamed 70-year-old man was brought to the ER by paramedics in an unconscious state, and with an elevated blood alcohol level. The patient had a history of chronic obstructive pulmonary disease (a type of lung disease), diabetes, and an irregular heart rate. His condition began to deteriorate several hours after being admitted, and dramatic medical interventions were needed to keep the patient alive.
But with the “DO NOT RESUSCITATE” tattoo glaring back at them, the ICU team was suddenly confronted with a serious dilemma. The patient arrived at the hospital without ID, the medical staff was unable to contact next of kin, and efforts to revive or communicate with the patient were futile. The medical staff had no way of knowing if the tattoo was representative of the man’s true end-of-life wishes, so they decided to play it safe and ignore it.
“We initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty,” wrote the authors of the case study. “This decision left us conflicted owing to the patient’s extraordinary effort to make his presumed advance directive known; therefore, an ethics consultation was requested.”
But there was more too it than just the medical ethics. Gregory Holt, the lead author of the new case study, said the biggest question in his mind was the legal aspect of whether or not it was acceptable. “Florida has stringent rules on this,” he told Gizmodo.
While the DNR tattoo may seem extreme, the request to not be resuscitated during end-of-life care is most certainly not. Roughly 80 percent of US Medicare patients say “they wish to avoid hospitalization and intensive care during the terminal phase of illness.” Revealingly, a 2014 survey showed that the vast majority of physicians would prefer to skip high-intensity interventions for themselves. Of the 1,081 doctors polled, over 88 percent opted for do-not-resuscitate status. Indeed, measures to keep a patient alive are often invasive, painful, and costly. DNRs, which hospital staff refer to as “no-codes,” are an explicit request to forego high-intensity interventions like CPR, electric shock, and intubation tubes. More implicitly, it’s a request to not be hooked up to a machine.
Typically, DNRs are formal, notarized documents that a patient gives to their doctor and family members. Tattoos, needless to say, are a highly unorthodox—but arguably direct—means of conveying one’s end-of-life wishes. That said, this patient’s tattoo presented some undeniable complications for the hospital staff. Is a tattoo a legal document? Was it a regretful thing the patient did while he was drunk or high? Did he get the tattoo, but later change his opinion? On this last point, a prior case does exist in which a patient’s DNR tattoo did not reflect their wishes (as the authors wrote in this 2012 report: “…he did not think anyone would take his tattoo seriously…”).
In this most recent NEJM case, the ICU team did its best to keep the patient alive as the ethics team mulled over the situation, administering antibiotics, vasopressors (to reduce elevated blood pressure), intravenous fluid resuscitation, and other measures.
“After reviewing the patient’s case, the ethics consultants advised us to honor the patient’s DNR tattoo,” Holt told Gizmodo. “They suggested that it was most reasonable to infer that the tattoo expressed an authentic preference, that what might be seen as caution could also be seen as standing on ceremony [i.e. adherence to medical tradition and norms], and that the law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interests.”
Accordingly, the ICU team wrote up a DNR, and the patient died later that evening without having undergone any emergency DNR measures. Before he died, however, the hospital’s social work department discovered the patient’s Florida Department of Health “out-of-hospital” DNR order, which was consistent with the tattoo.
But as the authors of the new report point out, the whole incident “produced more confusion than clarity,” saying that, despite how hard it can be for patients to make their end-of-life wishes known, “this case report neither supports nor opposes the use of tattoos to express end-of-life wishes when the person is incapacitated.”
Kerry Bowman, a bioethicist at the University of Toronto, agrees that this incident was challenging.
“Advanced directives of any kind do not override most recent expressed capable wish,” Bowman told Gizmodo. “In other words, [the patient] may have changed his mind and there may be no way of knowing. Tattoo regret is not rare. [The ICU team’s] defense is erring on the side of life.”
At the same time, however, Bowman is sympathetic to the patient, saying the tattoo may be an expression of how often patients’ wishes are somehow overlooked and the system takes over. “My position would be if someone went to the great length of having DNR tattooed with a signature, it indicates a strong and clear wish,” he told Gizmodo.
Melissa Garrido, an Associate Professor at the Icahn School of Medicine at Mount Sinai in NYC, shares this sentiment, saying that even when a DNR order has been entered into a medical record, it is not always readily accessible in a health crisis. “A standardized tattoo may be a readily accessible method for communicating a strongly held care preference,” she told Gizmodo.
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