Jonathan Leffert, MD

Recently, I went to my physician with left sided hearing loss, which I had been suffering from over the last several months. After appropriate auditory evaluation, I was diagnosed with unilateral high frequency sensioneural hearing loss. This prompted a diagnostic workup which included an MRI of the head with internal auditory canal evaluation for a possible acoustic neuroma. Because of my high deductible $6000 insurance plan that had not been met, and the cost of the MRI at over $3200, I was responsible for the entire bill. This test is the standard procedure to determine an important cause of my symptoms, and was perfectly appropriate for my care

My financial situation allowed me to pursue this evaluation, and as in many cases, a structural cause for my hearing loss was not found. However, for many people, the financial burden of $3200 might be prohibitive or require significant resource reallocation. What do people do if they cannot afford the out-of-pocket lump sum cost for a diagnostic test or treatment?

The obvious answer is that the test or treatment is not done, and the patient is not diagnosed. Insurance does not equal access, when the out of pocket cost is so high that the patient is unable to proceed with the workup. I cannot think of a more frustrating situation than paying insurance premiums, and having to meet a large deductible with an out of pocket cost that is unaffordable. Although deductibles are known at the time of the purchase of the insurance, like any unexpected cost in a fixed budget, getting hit with a bill for $3200 represents more than many people can afford at one time.

What is the solution to this significant barrier to care? I have not studied this issue in any detail, but I would guess this circumstance happens most frequently in diagnostic testing and with newer medications. Patients must be able to access care, particularly if they have insurance, or why have insurance in the first place? We have priced a certain group of patients out of the market, and as those numbers of patients grow, we will have many patients who paid for an insurance card but are unable to receive medical care.  

Articles

A physician receives a hefty out-of-pocket medical bill and ponders what other patients in his situation are forced to do.

Having Insurance Does Not Make Care Affordable

At the AMA meeting this week in in Chicago, a vigorous debate regarding physician response to in flight emergencies ensued. Many of the physicians in the room recounted emergencies that occurred while they were passengers on a plane. I got the sense that outside of a few physicians that were members of the Aerospace Medical Association, a group that had recently been involved in standard setting for the response to an in-flight emergency, most physicians were frustrated by the lack of understanding, expectation, and available medical supplies and equipment to help a patient in distress.

I learned from my Aerospace Medical Association colleagues that there are uniform rules among domestic airlines that define a medical bag with certain supplies, but not an Epi-Pen, or a blood glucose meter. I also learned that the stethoscopes on airlines generally are not adequate, and that the airline crew responds to physicians volunteering to help with a degree of skepticism about their credentials.

I have been involved in a few in-flight emergencies, one several years ago on a transatlantic flight and another couple of occasions recently on domestic flights. These "emergencies" were minor but in all of these situations, I felt my ability to act as a physician was severely compromised by the lack of training, communication, experience of the crew, and the equipment on the airplane. Ironically and very sadly, as I returned home earlier this week, a passenger on a plane to Chicago died in flight.

The time has come to educate physicians and allied medical personnel about the most common in-flight emergencies, the expectations of the physicians and crew, and the availability of the diagnostic equipment and treatments. These guidelines for medical personnel involvement should be standardized and publicized across the airlines industry, both domestic and international. This will assure responses from physicians and flight crew are uniform and effective.

We will never be able to prevent every in-flight tragedy, but we can be better prepared to act within our training and recognized guidelines to deal with emergencies in an appropriate manner. 

It's time to better educate, and equip physicians and flight crews for common in-flight emergencies, according to this doc. 

In-flight Emergencies: Is There a Doctor On Board?

In 2013, the American Medical Association (AMA) House of Delegates determined, based upon the scientific evidence, that obesity should be considered a disease. For physicians and their patients with obesity, the effect of this statement would provide the first steps toward destigmatizing a disease that can affect every organ system in profound ways. Over the last four years, clinical practice guidelines have been written by multiple specialty societies describing the correct approach to patients with obesity in terms of diagnosis and treatment. 

There remains a great deal of frustration among clinicians who treat patients because of the lack of availability of reimbursement for evaluation and management codes, obesity-related medications on the formulary of payers, and medical school curriculum that includes the scientific and clinical aspects of obesity. Finally, despite the AMA's declaration, there is ongoing stigma among many physicians, and the public in our conversation surrounding obesity.

To address the negativity associated with obesity, one simple way to make a difference would be to use patient-first language. Many clinicians refer to an "obese patient" or a "diabetic patient" rather than using the favorable terminology of a patient with obesity or a patient with diabetes. In 

, patients with obesity have reported over half of doctors making inappropriate comments about their weight. In addition, patients with a body mass index greater than 55 report delays in seeking care because of disrespectful treatment and inadequate healthcare facility accommodations.

In the next few weeks, the AMA will again debate an issue related to obesity while considering a resolution to formally destigmatize obesity by requiring patient-first language in all formal communications. Terms such as "obese," "morbidly obese," and "fat" would be replaced by "weight" and "unhealthy weight," and facilities would be encouraged to provide a comfortable environment with proper sized furniture, equipment and gowns. Obesity and its complications affect 30 percent of adults in the US.

All of our patients deserve the respect of patient first language, adopting the AMA resolution is a first step to tackling the epidemic of obesity in our country. 

Four years after declaring obesity a disease, the national doctor's group is urging new terminology for physicians to use in exam rooms.

AMA Urges Patient-first Language to Destigmatize Obesity

The rise in ERs not directly attached to a hospital is a relatively new phenomenon in the healthcare system. Recently, I have spoken to many patients about their thoughts on these ERs, which has prompted me to consider the reason they have popped up on many street corners in affluent neighborhoods.

Most patients tell me they would not use these ERs for "true" emergencies such as severe chest pain, abdominal pain or significant trauma, but would go to an unaffiliated ER facility for more typical ambulatory care problems such as a cough, fever or nausea. People I've talked to like the convenience of an ER in the neighborhood, and the advertised wait times that give the patient quick access to medical care. However, at what cost do these ERs deliver on this convenient, quick access?

A consistent experience of my patients are the exorbitant bills they receive for a co-pay or deductible from these free-standing ERs. Patients think that because these facilities are located in their neighborhood, they are just "glorified" urgent care centers that will treat their minor medical complaints conveniently and quickly. Patients may feel better initially after their treatment but the real pain is coming in the form of their dreaded ER bill. 

Should patients be aware that a designated ER facility delivers, by definition, a higher level of service, and therefore is contracted with Medicare and other third-party payers to be reimbursed at significantly higher rates than urgent care centers? Do free standing ERs fill a significant medical gap in our delivery system? Or, do they represent medical opportunism designed to lure people into a facility that delivers a higher profit margin to its owners?

Since many patients only consider in-hospital ERs, "real" ERs, and because of the similarity between neighborhood ERs and urgent care centers, I believe the rise of the neighborhood ER was intended primarily to increase the profit margin for owners at the expense of patients who lack the knowledge of the medical billing system. I also believe that the same greed that established these facilities will lead to their demise in the near future. 

Unaffiliated ERs are becoming popular due to their convenience, but are the high prices worth the level of care?

Are Free-Standing ERs a Rip-Off?

For the last two weeks, House Republicans have been rolling out their repeal and replacement plan for Obamacare. First and foremost, Obamacare intended to decrease the number of uninsured people in the US from around 15% of the population, or about 45 million people, to a much smaller number. By most accounts, about 10-15 million Americans ultimately gained health insurance as a result of Obamacare, far less than hoped for, but a significant number nonetheless. Two questions regarding the proposed bill that must be answered are will it maintain or decrease the number of uninsured Americans and will the result of the bill improve the quality of healthcare for those citizens?

The Obamacare insurance subsidies with the individual mandate provided a mechanism for an increased number of insured patients. Most of these patients were lower income individuals and families. Because there were limited choices in the individual marketplace, and a required benefits package, patients that did not qualify for subsidies paid high premiums and higher deductibles for their required health insurance. For these patients, healthcare premiums were very expensive, and services were mostly paid for out of pocket because deductibles were so high. Obamacare was broken for people in this group.

In the proposed GOP Healthcare bill, tax credits determined by age and geography substitute for the income related subsidies in Obamacare. The individual mandate is no longer present, so the beneficiaries of this plan are mostly older individuals from rural areas. The estimate by the Congressional Budget Office (CBO) is that if the bill passed as currently constructed, 24 million people would be left uninsured over the next 10 years. In addition, the CBO estimates that premiums would go up, however, there would be a substantial decrease to the federal budget deficit over the next 10 years.

This brings us back to the two important questions. The answer to the first is that if the American Health Care Act passed as constructed, it would increase the number of uninsured, and intuitively, the expectation would be a decreased level of care for those uninsured patients. The second question regarding quality of health care is more difficult to quantify, but it is becoming abundantly clear that the House Republicans are more interested in decreasing the federal deficit than improving the health of the American people. 

A lot has been said about the proposed GOP healthcare bill, but, if implemented, would it be beneficial?

Would the American Health Care Act Benefit Patients?

Over the last few days, two large insurance company mergers between Aetna and Humana, and Anthem and Cigna lost antitrust suits brought up by the Justice Department. The result of one these suits is that Aetna and Humana called off their $37 billion dollar merger with a payout of $1 billion from Aetna to Humana for backing out of the agreement. The other one is in legal entanglements with Anthem being sued by Cigna for a termination fee and breaches of the merger agreement.

I would assume that most physicians are pleased with the decisions in these cases and the ultimate failure of these mergers. However, there is more to this than just trying to keep a semblance of competition in the healthcare insurance marketplace.

To me, the $1 billion payout by Aetna is the key fact to take away from this fiasco. For a company to be able to lose $1 billion for just the opportunity to merge speaks volumes about the potential revenue that this merger would have produced for this combined entity. This payout also communicates the obscene pot of cash that Aetna must be sitting on to afford this astronomical sum of money without batting an eyelash.

The next time that you are negotiating a contract or have received a denial for a more expensive medication from Aetna, you might want to remind them that they gave a $1 billion payout for nothing more than the opportunity to dissolve a merger agreement with another insurance company.

Physicians are the other hand, actually provide desperately needed medical services to benefit real people. I wonder if that argument will get the insurance companies attention when reimbursements are slashed and patient services are denied. Any responsible person should certainly consider that a reasonable idea.

Humana and Aetna's merger didn't work out - but the real story is how much Aetna was willing to pay to just back out of the agreement. 