Health care costs and documenting social needs

Prognosis
Doctors Propose New Diagnosis: ‘Unable to Pay for Prescriptions’

Outlier Health Care Spending- by John Tozzi published in Bloomberg

The U.S. spends less on social services, but makes up for it in medical costs

If you get struck by lightning or bitten by a pig, a physician can record that information with a code shorter than your phone number.

But if you can’t afford your bills, doctors and health plans have no consistent way to document that.

Now, the biggest U.S. insurance company and the country’s most influential association of doctors want to create new ways to better capture information about patients’ social conditions. It’s part of a shift in the health-care industry to address aspects of people’s lives that influence their well-being beyond medical care, so-called social determinants of health.

“Having a standardized diagnosis allows for everyone in the system to understand that there’s an unmet social need,” said Sheila Shapiro, a senior vice president at UnitedHealthcare. The company, a unit of Minnetonka, Minnesota-based UnitedHealth Group Inc., announced the plan Tuesday with the American Medical Association.

Just as medical diagnoses trigger prescriptions or referrals to labs and specialists, the proposed codes are meant to help clinicians refer patients to assistance for food, housing, transportation or other needs.

Since 2017, UnitedHealthcare’s Medicare Advantage plans have made more than 700,000 referrals to outside social-service programs. The insurer’s Medicare plans cover about 4.9 million people.

Among the more than 20 new codes under consideration:

• unable to pay for prescriptions
• unable to afford child care
• worried about losing housing
• unable to count on family and friends
• feeling unsafe in current environment

Having standard designations for such conditions would let doctors, hospitals and health plans share the information through medical records and insurance claims forms.

“Everyone can start reading from the same sheet of (medical!) music,” said Tom Gianulli, chief medical information officer at the AMA’s Integrated Health Model Initiative.

While the codes wouldn’t immediately lead to reimbursement changes, capturing data about patients’ social needs may be a step toward paying for interventions that address them.

“Collecting data is a big part of this right now, and trying to figure out what’s effective, and advocate for funding around that,” said Steve Nelson, chief executive officer of UnitedHealthcare.

Slowly Changing

Payments are still largely tied to the number of procedures clinicians perform, rather than the overall health of patients. 

That’s slowly changing, and the effort to treat social needs is part of the transformation.

For example, a diabetic who can’t get to the pharmacy to pick up medication may wind up in an emergency room with uncontrolled blood sugar. 

Traditionally, insurance would pay for the emergency room visit but not for the cab ride to the pharmacy that might have prevented it.

The taxpayers and employers who finance America’s $3.5 trillion medical system ultimately pay the cost of that hospital visit. The health-care industry and policy makers are struggling to figure out how to get people those cab rides, as well as other interventions that could make people healthier and reduce overall spending.

The industry has already taken steps in that direction. In 2016, the new codes were adopted to indicate whether a patient is homeless, poor or lacking adequate food, for example. The latest proposal would build on that effort. A federal committee will decide whether to adopt the proposal later this year.

New codes are a useful first step, but there are limits to what the health-care system can do, said Melinda Abrams, a vice president at the Commonwealth Fund, a foundation focused on health research.

Society also needs to properly finance the social-service system because inadequate funding contributes to high health-care costs, Abrams said.

“The health-care sector has had a blind eye to it.”

Health care costs are too high - many wait for tax refunds to seek care

Americans are delaying healthcare until tax refunds arrive- reported in Los Angeles Times by John Tozi (Bloomberg reporter)

More than 1 in 3 working-age Americans skipped a doctor’s visit or medical test or didn’t fill a prescription because of the cost, last year, according to a recent survey.

When Hayden Myer made an eye doctor’s appointment for the end of April, he told the clinic that he might not show up for the visit if his tax refund didn’t arrive in time.

The 27-year-old, who says his vision is bad enough that he avoids driving at night, has been wearing a 4-year-old pair of glasses since he ran out of contact lenses last summer. He’s expecting about $265 from his refund.

Myer and many other Americans rely on getting money back at tax time to pay for important health needs. It’s a result of thin household savings colliding with rising medical prices and high-deductible insurance plans that expose them to greater health expenses.

“I’ve never been able to use my return for anything that is a leisure or a pleasure,” said Myer, who earns about $40,000 a year running a peer-support line for a mental-health nonprofit in Richmond, Va.

The federal deadline for people to file income taxes was Monday, and some people’s refunds are still churning through the system. Out-of-pocket spending on healthcare jumps about 60% in the week after people get their refunds, according to an analysis of account data published last year by the JPMorgan Chase Institute, a research group that draws on the bank’s data. The bulk of that money is spent during face-to-face encounters at clinics, hospitals or other medical providers.

That suggests people aren’t merely using refunds to pay down old debts; they’re also waiting until they have cash in hand to get treated.

“It was surprising, and I’d go so far as to say alarming,” said Fiona Greig, director of consumer research at the JPMorgan Chase Institute. “Those are visits that would have taken place three weeks earlier, had the tax refund arrived three weeks earlier.”

Refunds trigger an approximately 10% increase in the number of people making in-person healthcare payments on weekdays, according to the group’s research. Other research from the institute has shown that refunds are also frequently followed by increased cash withdrawals, credit card payments and spending on durable goods.

Tax refunds — the difference between the money withheld from workers’ paychecks and the taxes they actually owe — are the biggest single payment many households receive all year. The average federal refund taxpayers received this spring was $2,873, according to IRS data on filings as of March 29.

More than 1 in 3 working-age Americans skipped a doctor’s visit or medical test or didn’t fill a prescription because of the cost last year, according to a recent survey by the Commonwealth Fund, a nonprofit health-research foundation.

Myer, who has insurance, has been forgoing weekly injections for low testosterone, getting them only once a month or less. “That prescription is also just sky-high,” he said; it’s about $75 per visit until he reaches his health plan’s deductible.

The medical costs add to a pile of student loans, credit-card debt and payments on his Nissan Rogue. He recently moved back in with his father after he couldn’t afford a rent increase. He also owes money to a psychiatrist who charges a sliding-scale fee. Getting a new prescription for his vision is Myer’s priority, though.

Dentists and physicians’ offices accounted for the greatest share of in-person health payments that followed tax refunds, the JPMorgan Chase Institute’s report showed. Mark Vitale, a dentist in Edison, N.J., said refunds always bring a surge of patients.

“Year after year, what patients will say to me is, ‘Let’s just wait until April 1 or May 1 when I get my tax refund,’” he said. Vitale has practiced for 35 years, and over time, he said, “the dollar has gotten tighter.’’

Three people who booked significant dental procedures such as implants or crowns around the beginning of April cited their tax refunds, he said. They’re typically employed, middle-class people. Sometimes they’ve delayed dental work for years.

The research group analyzed data from millions of Chase bank accounts, as well as credit and debit cards, looking for patterns in the movements of money.

The granular picture of how cash flow affects people’s ability to get medical care reveals problems that clinicians, health plans, employers and financial companies ought to grapple with, Greig said.

Doctors need to talk to patients about how to prioritize care if they can’t pay for it. That conversation now happens “in a very incomplete way” with finance staff, rather than with clinicians, she said. Employers and health plans should understand that trying to lower spending by pushing more expenses onto households could backfire if they delay care.

“Health problems don’t age well,” Greig said.