New Health Care Pricing Transparency Rules in 2021

The United States has the highest health care expenditures in the world, in terms of absolute dollars, dollars per person, and as a percentage of GDP 1.  The United States is also one of the few industrialized countries to have very limited government health coverage for working adults.  While insurance premiums are currently price transparent, many aspects of health care are not cost transparent at all.  Historically, it was not standard practice to publish prices of procedures or tests to patients prior to performing them.  Patients would not learn about the true cost until they received their bill later.  This was complicated by the various prices for the same test or procedure depending on the patient’s health care coverage, or lack thereof.  This made it very difficult even for informed patients to make financially informed decisions about where to obtain certain procedures or even if they were truly necessary.  One example from 2012 demonstrated, for mammograms in the Boston area, an average cost of $310 per mammogram but a range from $176-$529 2.  This information could have helped save a patient potentially hundreds of dollars had they had access to it.  Unfortunately, at the time of writing this entry, these prices are often only obtainable with persistence, if at all.

New Health Care Pricing Transparency Rules in 2021

The good news is that, as of January 1st, 2021, The Executive Order EO on Improving Price and Quality Transparency in American Healthcare to Put Patients First goes into effect 3.   This will mandate all hospitals and providers to provide the standard prices for procedures and services.  This includes both the gross price of all services and procedures, but also the amount charged to individual insurers 3.  The most immediate benefit will be that it will allow patients to make financially informed decisions about non-urgent services.  One big caveat is that while this executive order will provide information about cost, it will not include any information regarding the quality or value that any particular institution may provide.  Some information regarding quality of an individual organization can be found at Medicare.gov 4.  While competitive pricing is critical to help stabilize or even decrease the cost of health care, one should be careful to measure it carefully with the quality of the health care obtained.

For more information regarding health care transparency and medical reform, click here.

Bibliography:

  1. 1.”National Health Expenditures 2018 Highlights”. National Health Expenditure Data : Historical. Centers for Medicare & Medicaid Services. December 2019. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.
  2. “Provider Price Variation: For Mammography Services in the Commercial Market”. Center for Health Information and Analysis. October 2014. https://www.chiamass.gov/assets/docs/r/pubs/14/rp-mammography-chartbook.pdf
  3. Postma, Terri MD and Grimsley, Heather. “Hospital Price Transparency Final Rule”. Medical Learning Network. Center for Medicare & Medicaid Services.  December 2019.  https://www.cms.gov/files/document/2019-12-03-hospital-presentation.pdf
  4. “Hospital Compare”. HealthCare.gov. https://www.medicare.gov/hospitalcompare/search.html

Obesity And Inactivity During Pandemic Caused Greater Covid Infection

April 29, 2021 – On his latest podcast, Dr. Steven Goldstein told his audience that Americans gained a good bit of weight during the lockdowns caused by the Covid-19 pandemic. But that was not the only bad news. The sad irony that obesity increased the risk of hospitalization due to the Covid-19 infection was not lost on him or his listeners as obesity and inactivity during pandemic caused greater covid infection risk. The cruel combination of lockdowns that were supposed to help keep the American public safer created a situation that made the likelihood of infection and a difficult recovery more possible.

Fat people are at increased risk of morbid covidity
The vast majority—78%—of U.S. patients hospitalized with COVID-19 were overweight or had obesity according to the American Medical Association.

The Houston Healthcare Initiative podcast can be heard on: : Apple Podcasts, LibSyn, Spotify, Radio.Com, Listen Notes, iHeart Radio, Podcast Addict, Podbay, Backtracks, Player FM, Stitcher, and SoundCloud. There is a way to repair this and many other weight related health risks if individuals change their eating habits.

The Consequences of Obesity & Covid-19                                                                              

The vast majority—78%—of U.S. patients hospitalized with COVID-19 were overweight or had obesity according to the American Medical Association. The numbers for intensive care, invasive mechanical ventilation and death were nearly the same.  In short, the quarantine was and is associated with stress and depression leading to unhealthy diet and reduced physical activity. “The main culprit in all of this was what we choose to eat before and during the pandemic,” Dr. Goldstein said.

This Century’s Dietary Downward Spiral

The obesity rate in the U.S. steadily increased since the initial 1962 recording of 23%. By 2014, figures from the CDC found that more than one-third of U.S. adults and 17% of children were obese.  The National Center for Health Statistics at the CDC showed in their most up to date statistics that 42.4% of U.S. adults were obese as of 2017-2018 (43% for men and 41.9% for women).

Americans in general consume more calories than needed. “We eat out way more than we ever did before,” Dr. Goldstein commented. “School systems encouraged unhealthy eating practices among children by accepting soft drink and fast-food contracts because they provide large commissions for financially strapped schools. The increase in energy intake or calories has been paralleled by a decrease in physical activity. Not moving is the norm. And that was especially the case during the pandemic.”

Discouraging but Curable

Rather than be discouraged by this news Dr. Goldstein was hopeful because the treatment for this is known and within the reach of all Americans; that they all make better decisions about what they eat.  “Everyone in the USA can literally take control of their own health and well-being with better choices at the table, store and restaurant and that can start right now, for everyone,” he said.

The pandemic and lockdown brought a lot of significant change to American society. The tendency to sit and eat was exacerbated considerably. “With more people moving less than ever while snacking constantly it is no wonder that our collective weight is so far up,” Dr. Goldstein concluded. “This is an easy fix for us all if we will just make the changes.”

About the Houston Healthcare Initiative

The Houston Healthcare Initiative podcast with Dr. Steven Goldstein is an information vehicle for people who want to know all medical options for themselves and are interested in reforming the healthcare industry. To learn more about the Houston Healthcare Initiative please visit www.houstonhealthcareinitiative.org.

What you need to know in Health Care.

The right to health was initially recognized by the World Health Organization (WHO) in 1946. According to WHO, the enjoyment of health is a fundamental right of every human being regardless of race, political belief, or religion. The debate over whether health care is a right or privilege has been raging for more than a century. Here is a look at the definition of health care and health care providers and whether health care is a right or  privilege.

What you need to know in Health Care.

Health Care and Health Care Providers

Healthcare is the provision of medical care to individuals and communities. Healthcare careers are not limited to doctors and nurses but also include chiropractors, administrators, therapists, and technology professionals.

According to federal regulations, a health care provider is a doctor of medicine, dentist, podiatrist, clinical psychologist, nurse, or any medical personnel, authorized to practice by the State and working according to the standards laid out by State law. A healthcare provider is; therefore, anyone who is legally permitted to administer healthcare to patients.

Is Health Care A Right or Privilege?

The right to health care is internationally recognized but this does not mean this right is enforced worldwide. In the U.S., health care was included in the Second Bill of Rights that was drafted by Franklin Delano Roosevelt. His wife took his work to the UN which led to the clarification of health care as a human right in the Universal Declaration of Human Rights (UDHR).

After the adoption of the UDHR, all industrialized countries implemented universal health care programs to make sure their citizens enjoyed the right to health. However, in 2015, the U.S. report to the UN does not acknowledge health care as a human right. The U.S. does not have a health care system but only a health insurance system in the form of Medicare and Affordable Care Act. It is; therefore, reasonable to claim that in the U.S. and many developed countries health care is more of a privilege than a right.

The Houston Health Initiative is a group of health conscious patients and physicians who have come together to maintain and improve the health of each member of their group. The goal of HHI is to change the way Americans pay and receive medical care. If you want to learn about the state of health care in the country, or to make a change to the health care system in the U.S., Houston Healthcare Initiative has got your back.

Contact us

Proper health care when you can’t afford health insurance.

The number of uninsured people in the United States has slowly been rising for the past few years. A KFF analysis of the data gathered by the U.S. Census Bureau shows that 10.9% or 28.9 million people under the age of 65 were uninsured in 2019. This problem is only made worse by the fact that many people who are uninsured avoid medical attention until they are experiencing a medical emergency. Preventable or manageable conditions are made worse and much more expensive when this is done. The U.S. Census Bureau tabulated the reasons why those people were uninsured, and the overwhelming majority, 73.7%, said that coverage was simply not affordable for them.

Proper health care when you can't afford health insurance.

If you find yourself in the same or a similar situation where medical insurance is unaffordable, you need to know that there are options for you to receive proper medical care. One such option is a community health center. These health centers can also be referred to as Federally Qualified Health Centers (FQHCs) or community clinics, but they all operate similarly. They are non-profit clinics that provide quality health care to people at a very low cost regardless of income or insurance status. Today there are over 1,400 community health centers across the U.S., making them not only affordable alternatives to for-profit hospitals but also very accessible no matter where you live.

Despite the fact that you may be asked to pay only a small fee, you’ll always receive comprehensive, quality care at one of these clinics. That’s because their quality of care is heavily tracked to ensure that they are always providing good care to their patients. These health centers can provide primary preventative care, ongoing care, coordination with specialty care, and much more. For those with severe financial struggles, some of these clinics have on-site social workers who can coordinate benefits through connections they have in your community.

Almost every state has a network of community health centers that can provide low cost or free health care to people regardless of their insurance status or level of income. If you’d like more information about this or like topics, visit Houston Healthcare Initiative (HHI). We are an organization of like-minded physicians and other medical professionals who are looking to help change the nature of our public health in the U.S.

Healthcare by the Numbers

Where Does the Money Go When Paying for Healthcare; Prices, Costs, and Value…

Healthcare by the Numbers

March 23, 2021 – On the latest edition of the Houston Healthcare Initiative podcast, Houston based neurologist and the founder of the Houston Healthcare Initiative Dr. Steven Goldstein, describes the numbers and dollars associated with health insurance and hospitalization costs. This to inform us all where the money that individuals and employers contribute goes and who really profits most.

Dr. Seven Franklin
Where does your money go when paying for health insurance?

The answers are surprising when it comes to cost, price, and the ultimate value those with health insurance derive from the premiums they and their employers all pay. Ultimately, did the public purchase more benefits or receive a better value as a result of what they were charged? “There is nothing wrong with making a profit, but most people will want to know what they bought and was it worth it,” Dr. Goldstein told his listeners.

Additionally, Dr. Goldstein describes the profits hospitals and health insurance companies accrue, what percentage of their payments actually go to help pay for their healthcare and how much the insurance companies keep. All this to help the public decide if this money was well spent or if it could be better managed.

Where To Listen

The Houston Healthcare Initiative podcast can be heard on: Apple Podcasts, LibSyn, Spotify, Radio.Com, Listen Notes, iHeart Radio, Podcast Addict, Podbay, Backtracks, Player FM, Stitcher, and SoundCloud.

About the Houston Healthcare Initiative

The Houston Healthcare Initiative podcast with Dr. Steven Goldstein is an information vehicle for people who want to know all medical options for themselves and are interested in reforming the healthcare industry. To learn more about the Houston Healthcare Initiative please visit www.houstonhealthcareinitiative.org.

What’s increasing the cost of your healthcare?

A popular opinion in the United States is that the current health care system is broken. Health care in the United States costs more than that of comparable countries but does not provide greater or even equal quality of care when compared to those same countries. Many people and organizations are actively attempting to fix this problem, but without the people’s approval, they cannot effect real change. Unfortunately, most people don’t understand the problem or where it stems from. This article should give you a little more understanding of the problem.

What's increasing the cost of your healthcare?

The healthcare industry used to be just like any other industry in a free market. People would judge care by its quality while contrasting that to its price. Now, insurance allows people to ignore the price of care by introducing a copay that is much smaller than the actual cost of their care.

Since the price is not of much concern, hospitals no longer need to show their prices in order to get patients. As hospitals improve the quality of their care by upgrading technology and techniques, prices go up. At the same time, patients now are more likely to get unnecessary treatment because they are only expected to pay a small copay.

These two factors contribute to the price of insurance increasing. The increase in insurance price increases both your copay and the amount your employer is expected to contribute. Because employers do not gain from contributing more, cuts have to be made somewhere to maintain profitability, this is usually your pay. Unfortunately, now you cannot afford to opt-out of your employer’s insurance because the cost of healthcare has risen too high.

In addition to these problems raising the cost of healthcare, uninsured people also raise the cost of healthcare for everyone. This is because people who do not have insurance are likely to not seek medical attention until a problem goes from bad to worse to emergency. In these events, prices go up for everyone because the hospital has to make up for their loss.

To further add to the problem, affordable health care legislation can backfire by raising the price of healthcare depending on the provisions within. There are many more factors that play into the cyclical nature of this problem, such as pre-existing conditions, managed care plans, insurer networks, and businesses simply going bankrupt. For more information on this topic and many more related to the health care industry, contact Houston Healthcare Initiative (HHI) today.

Imagining a patient centered healthcare system

Many complain about our current healthcare system but little has been accomplished to make it patient centered. I believe that a patient centered healthcare system can be accomplished by using a patient owned healthcare cooperative model that is free from the constraints of the CPT codes used for billing and by providing financial incentives to patients to be compliant and lead a healthy lifestyle. Physicians rather than insurance companies and administrators should be responsible for care and would be compensated based on results. Profits from the cooperative would belong to the patients rather than an insurance company. One vision of  healthcare in the future is described below. Changes could begin incrementally, starting out with a conventional healthcare cooperative. Utilization of these changes should be voluntary on the part of the patient.

Imagining a patient centered healthcare system

Screening for disease.

An annual physical examination including physical and mental fitness, weight, vital signs and age appropriate screening tests would be performed. If disease is found, appropriate treatment is begun.

Acute Illness

Rather than making an appointment to see a doctor or go to the ER/ Urgent Care, the patient can tap an app on the smartphone and talk to a physician in a few minutes. The patient would grant access to the physician to his/her medical record. The patient would report the symptoms as well as vitals signs – Blood pressure, pulse and temperature. (every patient would have the means of measuring these.) The physician could take the history and do a telemedicine exam; order lab tests and imaging; summon an ambulance; supervise the EMT’s; order transport to the hospital as necessary and treat the patient during transport.

If patients are well enough, they can go to the imaging center that also has a drawing station for blood work by car or  “cabulance”. Alternatively, blood work, EKG, plain x ray and ultrasound can be performed at home. This would all be performed the same day or night.

Most patients will not be very sick and simply need a diagnosis, reassurance, oral medication or first aid instruction. If necessary, diagnosis can be aided by AI.

Simple procedures e.g. suture of laceration can be provided by skilled technicians that come to the home and supervised by the physician

Sicker patients can be cared for at home with an aide to help with routine care and food preparation. Nurses can administer intravenous treatment; oxygen therapy and medication.

They can draw blood and help physicians perform telemedicine exams. The original doctor can call in specialists that can consult via telemedicine or if necessary in person. If necessary, treatment can be guided by AI.

Patients with unstable vital signs will still need transport to hospital for treatment of major trauma, heart attacks, GI bleeding, pulmonary emboli, acute stroke. Hospitals will be better equipped to handle these patients in the ER by avoiding the clutter of patients that do not have a life threatening emergency.

Chronic illness  e.g. diabetes, obesity, hypertension, seizure disorder, mental illness

A treatment team supervised by a specialist would care for the patient. Members of the team would consist of the patient, dieticians, physical therapists, psychologists, social workers, clergy, personal trainers, medical assistants, nurses or other skilled people necessary to care for the illness. A physician designed algorithm would help guide treatment. Problems with treatment compliance could be addressed by team members as well as the physician. Visits to the physician office would be rare. Results of treatment would be measured in terms of end organ damage e.g. to the heart, kidney, brain,musculoskeletal system.

Diagnostic Problem Cases.

When a patient has a symptom that is not resolving with initial treatment or where the diagnosis

Is not clear e.g. cause of dizziness, cause of anemia, breast lump found on mammogram, a diagnosis should be arrived at in a few days and appropriate treatment begun. This can best be accomplished if the patient goes to a facility where tests and specialty consultation can be performed in a few days. This facility would not provide nursing care or overnight stay. But would have a quiet space for patients to study and read; other space for a gym, TV, video games or other entertainment. There would be Exam rooms for specialists. Laboratory and imaging would be available on site with a 24 hour turnaround. Specialists would see the patient the same day or next day. This is similar to a hospital without beds, nursing care and bedside food service. Once the diagnosis is made, a treatment should be established and begun in 24-48 hours. The center would be judged on accuracy of diagnosis as well as efficiency.

To learn more, visit our website.

A Brief Look at the Numbers

A Brief Look at the Numbers: Average cost of hospitalization in 2018 was about $10K; the average charge with private insurance was about $20K (The average charge to the uninsured ranges from $40K to $60K) Average number of hospitalizations per year was about 9/100 for ages below 64.

A Brief Look at the Numbers

Total annual payments for hospitalization/100 people= 9x20K= $180K

Annual outpatient charges are estimated at $500

Total annual outpatient charges/100 people= $500×100=  $50K

Annual drug costs across the population estimated at $1200. We can reasonably assume

that drug costs are higher for the over 65 population. We would estimate this to be $500

In the under 65 population.

Total annual drug charges/100 people =$500×100= $50K

Total costs of reinsurance with $50K deductible+purchase of PPO discounts=$20K

If we add these costs together, we find the total charges/100 people= $300000

Notice this is the total cost. Insurance typically pays about ⅔ of the cost; ⅓ of the costs are paid out of pocket in the form of copays and deductibles.

The very cheapest Blue Cross policy for a 31 yo male in zip code 77096 was $257/month or

$3084/yr. The cost for 100 people would be $308K annually but would have a $7400 deductible.( At age 50, the cost was $4000 annually.) The high deductible means that outpatient care is not paid for and that the insurance only pays for the reinsurance and hospitalization costs of $200K.

The gross profit for the insurance company is at least $100K (income per 100 patients of at least $300K less claims of $200K)

For more information, check out our website!

Healthcare: The high cost you’ll never see

The United States has taken an important step in reducing the cost of health care by mandating price transparency. Unfortunately, people are not incentivized to care about the actual cost of health care under the current system of insurance and care plans. This lack of incentive is one of the major reasons why the cost of health care has risen to its current height. People are allowed to focus solely on the price of their deductible, copay, and out-of-pocket maximum for their insurance instead of the actual cost of care. However, focusing on these things doesn’t change the price of their care or the fact that someone needs to pay it in full. Let’s discuss the effect this has on people who require care.

Healthcare: The high cost you'll never see

There are typically two types of people who use the health care system, those who avoid the system until they need it, and those who rely on it regularly. Both types of people are relatively insensitive to the actual cost of their health care.

Those who avoid it until they need it usually have very little experience with the health care system, and typically only rely on it for emergencies. They may have little knowledge of how it works and what everything costs, but prices are of little concern to most people in an emergency. These people focus on insurance premiums, deductibles, and their copay rather than the actual price of the emergency care they’ll receive, and they rarely will (or can) shop around for the best price.

Those who rely on the health care system regularly are people who need care for extended periods of time or have chronic illnesses. These people have much more experience with the health care system but are still relatively insensitive to the actual price of their care. This is because instead of focusing on the price of care, they only have to focus on their deductibles and the out-of-pocket maximum of their insurance plan. After paying the out-of-pocket maximum, their care is paid for entirely by their insurance for a period of time.

In both cases, the health care system doesn’t incentivize people to care about what the actual cost of care will be. Price transparency can be very helpful for people (mostly those who fall somewhere between the two types of people described above), but it can only go so far in helping the problem. Creating coordinated health systems that stop the fragmentation of care for chronically ill patients can drastically reduce the actual cost of care for each patient. In addition to this, proper preventative care can reduce the overall cost of care for those who avoid the health care system.

Houston Healthcare Initiative (HHI) is an organization of physicians and other medical professionals that is actively trying to fix this problem by increasing coordination, being transparent about our pricing, and much more. Contact HHI today for more information.

Did The Covid-19 Pandemic Cost You Your Job and Health Insurance?

In a time when so many lost their jobs because of the Covid-19 Pandemic….

Job & Health Insurance Loss Come and Go Together; How To Find Affordable Coverage

March 2, 2021 — In December 2020, 66% of Americans who answered a survey said they fear they won’t be able to afford health care this year. Of the 41% of respondents who are very or moderately concerned about health-care costs, 53% are parents with children. The amount of people who were and remain unemployed because of the Covid-19 pandemic remains high. Since most individuals get their health insurance with their jobs, those same folks are also in need of medical coverage.

On his regular podcast, Houston based neurologist and founder of the Houston Healthcare Initiative Dr. Steven Goldstein has immediate and affordable medical insurance solutions for those who need coverage. To hear the podcast visit: Apple Podcasts, Radio.com, iHeartRadio, SoundCloud, and the Houston Healthcare Initiative web site. Job & Health Insurance Loss Come and Go Together.

Use the Obama Care National Marketplace

People who lost their jobs due to the pandemic have the burden of finding work and paying for healthcare. As most people’s healthcare is tied to their jobs. “There are alternatives for people who lost both their jobs and accompanying health insurance,” Dr. Goldstein told his audience. “The key for those people to get covered is to act quickly.”

One reason for this is that job loss qualifies Americans for a special enrollment period in the health insurance marketplace regulated by the U.S. government, but it only lasts 60 days. “Normally the enrollment period for this is in the month of November, but job loss allows an exception. Just remember the 60-day deadline,” Dr. Goldstein said.

Private Health Insurance

Private health insurance will sometimes offer more flexibility than standard coverage. For example, short-term policies lasting up to one year are available in many states. There are differences between health insurance and private health insurance. People buy private health insurance many times because their place of employment does not offer it. In the case of people who lost their employer provided health insurance, purchasing it like this is an option. Private health insurance is often an option for those who work part time, are self-employed, or own a small business.

Health Co-Ops

Health insurance co-ops are private health insurance plans that serve a small group of people and are owned and operated by the members of that group. The health co-operative or co-op is a member owned not for profit corporation. They are run democratically by the members.

The real benefit of health insurance co-ops are they are significantly cheaper than regular health insurance. “The monthly fees are called membership fees, not premiums, Dr. Goldstein said. “The average cost of a co-op membership is about $40 to $90. To put that into perspective, regular COBRA insurance premiums can cost as much as $650 per month.”

Job loss is unnerving enough at any time. Losing health coverage during a pandemic makes that level of anxiety even higher. Because no one wants to be without medical insurance when a previously unseen virus is spreading.  It could make you or a loved one sick at the worst possible time. Fortunately there are reasons to be optimistic about getting health insurance that is affordable and obtainable if action is taken sooner than later.

The amount of information about this and other similar issues grows ever higher at the Houston Healthcare Initiative web site and its social media sites. To learn more about the Houston Healthcare Initiative go to www.houstonhealthcareinitiative.org.

Job & Health Insurance Loss Come and Go Together.