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Consumers are well aware of companies with difficult customer service experiences in a variety of industries, and health care is not an exception. KFF Health News published a piece on how a woman went in for one procedure and the surgeon decided to complete a separate preventative procedure while she was unconscious. Although the entire operation completed in the original time allotment for the initial procedure, the surgery center billed her twice, once for each procedure.

Consumers are well aware of companies with difficult customer service experiences in a variety of industries, and health care is not an exception. KFF Health News published a piece on how a woman went in for one procedure and the surgeon decided to complete a separate preventative procedure while she was unconscious. Although the entire operation completed in the original time allotment for the initial procedure, the surgery center billed her twice, once for each procedure.

From a systems perspective, it makes sense that the surgeon completed the second procedure instead of having her undergo anesthesia again and to make another incision. However, the surgery center's decision to double bill -- even though the entire operation completed in the originally allotted time -- seems unreasonable. For a case like that, it feels that the patient should have some agency in deciding whether to incur the additional cost. Beyond that, the surgery center was unwilling to negotiate with the patient, handing her bill to a collections agency, which sued her in court. If cases like these persist, the general public might ask for additional regulations around medical billing.

Given that federal subsidies for Affordable Care Act (ACA) plans is around $1 trillion, one would expect find to attempts to defraud the system. For example, one area that recently came to light was that many insurance agents change enrollment of existing patients without their knowledge or consent. KFF Health News reported on another way that people may try to defraud the system: understating their estimated income to receive more generous subsidies.

Given that federal subsidies for Affordable Care Act (ACA) plans is around $1 trillion, one would expect find to attempts to defraud the system. For example, one area that recently came to light was that many insurance agents change enrollment of existing patients without their knowledge or consent. KFF Health News reported on another way that people may try to defraud the system: understating their estimated income to receive more generous subsidies.

The article discusses a study that concludes that too many people sign up and declare that their estimated income falls within a certain range: "We estimate that fraudulent enrollment at 100 percent to 150 percent FPL [federal poverty line] is likely upwards of four to five million people in 2024. We estimate, conservatively, that this cost will likely be upwards of $15 to $20 billion this year." Apparently, during open enrollment, patients only need to estimate their income for the following year in order to determine how much subsidy they are entitled to. Theoretically, differences between estimated income and actual income will balance out when those patients file taxes for the following year. For example, patients whose incomes are higher than estimates would owe the difference in subsidies as additional tax. However, patients whose income is less than 400% of the federal poverty line would have the difference in subsidies capped (e.g. $950 for those between 200% and 300% of the federal poverty line). On one hand, the limit seems helpful in protecting patients against the financial consequences of unexpected rise in income. On the other hand, these limits present a tremendous incentive for people whose income is less than 400% of the federal poverty line to underestimate their income to receive more generous subsidies and then to only pay back a limited amount. Essentially, the federal government is subsidizing health insurance plans more than it planned to.

By law, Medicare had been restricted from negotiating drug prices with pharmaceutical manufacturers. That is changing, but Medicare is currently still limited in the number of drugs that it can negotiate. In contrast, KFF Health News published an article about weight loss drugs, including how Denmark was able to secure pricing that is about 15% of the list price of Ozempic in the U.S. It seems highly unlikely that Denmark would have been able to get the discounted price if it did not have the ability to refuse coverage for the drug.

By law, Medicare had been restricted from negotiating drug prices with pharmaceutical manufacturers. That is changing, but Medicare is currently still limited in the number of drugs that it can negotiate. In contrast, KFF Health News published an article about weight loss drugs, including how Denmark was able to secure pricing that is about 15% of the list price of Ozempic in the U.S. It seems highly unlikely that Denmark would have been able to get the discounted price if it did not have the ability to refuse coverage for the drug.

Weight loss drugs present an interesting opportunity in that they may be considered optional medication -- that is, obese patients are not expected to suddenly die because of a lack of access to the medication. As such, the public is likely to be more understanding if a payer (the government, in Denmark's case) decides to not cover it, giving the payer more leverage.

Continuing on in the theme of questioning the appropriateness of the non-profit status of many hospitals, KFF Health News published a column highlighting some of the questionable facets of various healthcare systems in the US. The author called some of these systems "diversified businesses" and notes the lavish executive compensation at these institutions, with CEO salaries outpacing the CEO salaries of large philanthropic foundations. The author places at least some of the blame on the regulators who ought scrutinize whether these large health systems should continue to enjoy the benefits of a non-profit status. The author notes that these institutions spend large amounts of money on political lobbying, which likely allows them to avoid scrutiny.

Continuing on in the theme of questioning the appropriateness of the non-profit status of many hospitals, KFF Health News published a column highlighting some of the questionable facets of various healthcare systems in the US. The author called some of these systems "diversified businesses" and notes the lavish executive compensation at these institutions, with CEO salaries outpacing the CEO salaries of large philanthropic foundations. The author places at least some of the blame on the regulators who ought scrutinize whether these large health systems should continue to enjoy the benefits of a non-profit status. The author notes that these institutions spend large amounts of money on political lobbying, which likely allows them to avoid scrutiny.

For historical context, the article explains that hospitals "were accorded nonprofit status for doling out free care during an era in which fewer people had insurance and bills were modest." That arrangement reduces the transparency, both in terms of the benefit received, as well as the cost of that community benefit. An alternative would have been for hospitals to not be given non-profit status and to continue to charge to provide care, while the government could pay for medical care for the indigent. Under that alternative, hospitals would have a stronger incentive to attract and care for patients (even if the patients cannot pay the procedure costs), while the government would more clearly know how much it is spending on medical care. Despite the benefits of such an arrangement, however, it is likely that that visibility into actual costs makes the alternative less appealing politically.

For quite some time, non-profit hospitals have agreed to provide benefits to the community (e.g. free or reduced medical care for some patients) in exchange for not having to pay income tax. Over the last several years, however, members of the public have been arguing that the exchange no longer makes sense, primarily because the non-profit hospitals are not providing enough community benefit, and in some cases, are suing patients who are unable to pay. As healthcare prices have continued to escalate and some non-profit hospitals seem to provide less community benefit than taxes they would have been obligated to pay without the non-profit status, the industry has been receiving additional scrutiny. KFF Health News published an article about the state of Montana proposing new rules to oversee non-profit hospitals.

For quite some time, non-profit hospitals have agreed to provide benefits to the community (e.g. free or reduced medical care for some patients) in exchange for not having to pay income tax. Over the last several years, however, members of the public have been arguing that the exchange no longer makes sense, primarily because the non-profit hospitals are not providing enough community benefit, and in some cases, are suing patients who are unable to pay. As healthcare prices have continued to escalate and some non-profit hospitals seem to provide less community benefit than taxes they would have been obligated to pay without the non-profit status, the industry has been receiving additional scrutiny. KFF Health News published an article about the state of Montana proposing new rules to oversee non-profit hospitals.

Part of the context is that hospitals might have a financial assistance policy, but might make it difficult for eligible patients to find out what the details are. The current proposal appears to be mostly aimed at data collection (e.g. not yet mandating certain patient education policies). A researcher is quoted in the article as saying that the proposed rules are not meaningful. The article elsewhere explains that the Montana Hospital Association lobbied against "too many reporting rules" and that legislators responded by limiting the data requirements "to largely the information hospitals already provide to the federal government." Regardless, that there is more scrutiny in this area, following a 2020 report and a 2023 law, gives an indication of the extent to which people are looking for ways to push back on the overall cost of healthcare. The article also reports on some similar efforts in Oregon and California, demonstrating that the interest goes beyond a single state. Efforts will need to go far beyond merely collecting data, but having data is an important early step.