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Kaiser Health News reported on a couple's difficulties with a medical bill when their newborn twins required neonatal intensive care. The No Surprises Act requires insurance companies and providers to work out payment when patients end up at an out-of-network provider for an emergency. However, this article details some difficulties that can arise when the insurer denies that medical services were provided in response to an emergency.

Kaiser Health News reported on a couple's difficulties with a medical bill when their newborn twins required neonatal intensive care. The No Surprises Act requires insurance companies and providers to work out payment when patients end up at an out-of-network provider for an emergency. However, this article details some difficulties that can arise when the insurer denies that medical services were provided in response to an emergency.

It is unclear why the hospital in this case appears to have been reluctant to have billed the services as emergency services. The article seems to suggest that the hospital might have been following some internal protocol, given that the infants were not literally checked in via the emergency department (but rather through a doctor). However, once the couple alerted the hospital, it is unclear why they refused to amend their claims. It also seems odd that the insurance company seemed so ready to deny that neonatal intensive care immediately after birth was for emergency purposes. Regardless, it is unfortunate that patients find themselves needing to turn to consultants to navigate such billing challenges.

Kaiser Health News published an interesting article about how some hospitals that are recognized as "five stars" (highest quality) are also some of the very same ones that are penalized for poor performance on patient safety. This seeming paradox appears to stem from the Centers for Medicare & Medicaid Services (CMS) basing its star rating on a variety of metrics, but using a sharper focus on patient readmissions to determine penalties.

Kaiser Health News published an interesting article about how some hospitals that are recognized as "five stars" (highest quality) are also some of the very same ones that are penalized for poor performance on patient safety. This seeming paradox appears to stem from the Centers for Medicare & Medicaid Services (CMS) basing its star rating on a variety of metrics, but using a sharper focus on patient readmissions to determine penalties.

While the situation might make sense, it seems that it could be confusing to patients. CMS could adjust its star rating, for example, so that hospitals that are penalized are not eligible for the highest rating.

Tangentially, it appears that many academic medical centers (which many might assume to provide excellent care) are penalized, and one professor noted that measurement relies on self-reporting from the hospital. Some hospitals might be under much higher financial pressure to not be penalized and thus have a strong conflict of interest. It does seem that relying on self-reported numbers is problematic.

More broadly, CMS noted that the penalty for underperforming hospitals is fixed by law. While the intention may have been good, crafting a coherent policy (and corresponding incentives) can be difficult, and it seems that the program might need some refinement to be useful. According to one professor cited in the article, "the program [to reduce patient readmissions] has been a failure."

Kaiser Health News reported on a deal signed by California and Kaiser Permanente with regards to Medi-Cal enrollment. The agreement raised questions because the terms were negotiated privately and not offered to other Medi-Cal insurers. The agreement has some interesting facets, mostly stemming from Kaiser's dual role as both an insurer and a provider, and also from Kaiser's size in the state.

Kaiser Health News reported on a deal signed by California and Kaiser Permanente with regards to Medi-Cal enrollment. The agreement raised questions because the terms were negotiated privately and not offered to other Medi-Cal insurers. The agreement has some interesting facets, mostly stemming from Kaiser's dual role as both an insurer and a provider, and also from Kaiser's size in the state.

Half of Medi-Cal insurers subcontracted care for a subset of their patients to Kaiser, which is not only an insurer, but also a provider. Those insurers enjoyed a small markup on Kaiser's services, but this new deal allows Kaiser to enroll those patients (formerly customers of competing insurers) as its own. Additionally, Kaiser is allowed to limit enrollment to its previous patients, a special term that other insurers do not get to enjoy. The ability of Kaiser to limit enrollment has raised questions of whether or it it can effectively game the actuarial odds for its own benefit.

State leadership cited the risk of losing Kaiser's participation altogether if the state did not grant Kaiser's request for special terms. Given Kaiser's size and that they are reportedly losing money on Medi-Cal, the state might not have had great alternatives. This situation highlights a challenge with having only a few large healthcare providers that serve much of the state's needs.

Regardless, the optics for this no-bid contract are not great, given that other insurers had to undergo a bidding process, the governor's no-bid contracts during the earlier parts of the pandemic, and Kaiser's previous partnership with the governor.

People generally think positively of a health system expanding health access by opening up clinics closer to its patients. However, Kaiser Health News reported on Massachusetts' Health Policy Commission, which released analysis that indicates that it believes otherwise in the case of a proposed expansion.

People generally think positively of a health system expanding health access by opening up clinics closer to its patients. However, Kaiser Health News reported on Massachusetts' Health Policy Commission, which released analysis that indicates that it believes otherwise in the case of a proposed expansion.

As background, the state's most expensive health system -- and the one best known for quality -- has sought to expand its footprint, including opening three ambulatory care centers. Previously, a number of state regulators had expressed concern over health systems expanding by acquiring or merging with other practices. Given the antitrust scrutiny, it appears that some health systems have been investing heavily in hopes of achieving organic growth. Critics say that this particular expansion will lead to the same eventual outcome as mergers: that a large health system will grow even bigger, to the detriment of its competitors.

The criticism seems plausible: a health system can expand, promising low prices with the same level of quality that everyone has come to expect. As patients switch doctors, other institutions might face deteriorating financial situations and some might even close their doors. The fear is that at that point, the large health system can freely raise its prices, knowing that it will be difficult for competitors to re-establish themselves. While the health system might couch the expansion as being able to better serve its patients, it is not hard to imagine the health system delaying the expansion if there were no possibility of additional profit.

Even if the critics are correct, however, the solution is not exactly clear. Some previous monopolies ended up being broken up to help engender competition. However, such a move could be disruptive to operations and will likely only be pursued rather unwillingly. Another approach would be to subject the health system to some sort of price controls (e.g. price increases must be approved by a regulatory body), but that likely comes with some market distortions of its own. Theoretically, if the health system raises prices too much, competitors will be able to grow their market share. However, barriers to entry might be rather high in terms of getting patients to switch their primary care physician, and there is likely a third-party payer problem, where the party making the decision (the patient when selecting which system to be treated at) is different from the party making the immediate payments (the insurance company). That disconnect might end up reinforcing the health system's market share.

Kaiser Health News published a reporter's personal account of difficulty in acquiring insulin, a common hormone used to treat diabetes. The main difficulty appears to be that the reporter's employer recently changed insurance providers, and the new insurance company required "prior authorization" (approval from the insurance company, usually requiring justification from the doctor). Compounding this issue was that the reporter also changed doctors around this time period, having to wait months for the first appointment with the new doctor. Additionally, the new insurance company did not cover the previously used brand of insulin, but rather a different one. While the reporter does eventually acquire insulin, the account ends on a funny (and sad note) about getting a call informing him that his new insurer was again waiting on a prior authorization (presumably for the next month's refill).

Kaiser Health News published a reporter's personal account of difficulty in acquiring insulin, a common hormone used to treat diabetes. The main difficulty appears to be that the reporter's employer recently changed insurance providers, and the new insurance company required "prior authorization" (approval from the insurance company, usually requiring justification from the doctor). Compounding this issue was that the reporter also changed doctors around this time period, having to wait months for the first appointment with the new doctor. Additionally, the new insurance company did not cover the previously used brand of insulin, but rather a different one. While the reporter does eventually acquire insulin, the account ends on a funny (and sad note) about getting a call informing him that his new insurer was again waiting on a prior authorization (presumably for the next month's refill).

The reporter commented on how doctors oppose the practice of prior authorization, while insurers say they believe that the practice is useful for patient safety and for saving money. While prior authorization probably makes sense for some procedures, insulin does not seem like a great candidate for prior authorization. First, it seems unlikely that people would abuse insulin. Second, insulin requires a doctor's prescription (that is presumably time-limited and needs periodic refreshing) and I suspect that once people start taking insulin on a regular basis, it is fairly rare that they would stop; even if this point is not generally true, there is still the first point about why people would still buy insulin if they did not need it. Third, the price of insulin seems fairly small relative to a number of medical procedures, and perhaps even compared to the administrative cost of upholding the requirement for prior authorization. I suppose that an argument could be made for the opposite side that prior authorization might somehow reduce the possibility that someone who no longer needs insulin might be continuing to buy insulin in order to sell it for profit -- that seems unlikely to be happening too generally, but perhaps insurers have some data about this point. One point that is likely missing from the insurers' calculus is the administrative cost on providers' office staff to comply with prior authorization requirements.

There is also probably a smaller story about how electronic communication between providers' offices and insurance companies could reduce administrative costs on both sides (e.g. a provider's electronic medical record to send a request for prior authorization to the insurer). Another angle would be that ideally, a patient's medical record would be portable enough from one provider to another such that an insurer could accept it for prior authorization in cases like this one.