write in ‘AS LONG AS THE PROVIDERS ARE IN MY NETWORK.’…before you sign any hospital admission documents accepting financial responsibility for your care

 “No Surprise Charges” is one of the key Lessons Learned in Elisabeth Rosenthal’s fabulous new book AN AMERICAN SICKNESS (Penguin Press, 2017). “Hospitals in your network should also be required to guarantee that all doctors who treat you are in your insurance network.”

We have all harshly experienced or heard about under-the counter out-of-network hospital charges:

(A)   “A Kaiser Family Foundation survey finds that among insured, non-elderly adults struggling with medical bill problems, charges from out-of-network providers were a contributing factor about one-third of the time.  Further, nearly 7 in 10 of individuals with unaffordable out-of-network medical bills did not know the health care provider was not in their plan’s network at the time they received care.”

(B)   A new study that looked at more than 2 million emergency department visits found that more than 1 in 5 patients who went to ERs within their health-insurance networks ended up being treated by an “out-of-network” doctor — and thus exposed to additional charges not covered by their insurance plan.”

Here is a brief case study:

“When Janet Wolfe was admitted to the hospital near Macon, Georgia, a few years ago, her lungs were functioning at just one-fifth their normal capacity. The problem: graft-versus-host disease, a complication from a stem cell transplant she received to treat lymphoma. Over the course of three days she saw three different doctors. Unbeknownst to Janet and her husband, Andrew, however, none of them was in her health plan’s network of providers. That led the insurer to pay a smaller fraction of those doctors’ bills, leaving the couple with some hefty charges.” (C)

So what can you do to avoid out-of-network charges? (D)

– Speak with a practice representative before being seen to understand the costs of seeing your doctor on an out-of-network or a cash basis. (DOCTOR note: maybe you need to leave and go to an in-network physician instead)

– If you need additional services, such as surgery, imaging or physical therapy, ask your doctor to refer you to an in-network facility to keep your costs down.

A New York law is a great start toward transparency to reduce out-of-network surprises.

Under a recent New York law, Hold Harmless Protections for Insured Patients, “… patients are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services or on surprise bills.

A bill is considered a surprise if consumers receive services without their knowledge from an out-of-network doctor at an in-network hospital or ambulatory surgical center, among other things. In addition, if consumers are referred to out-of-network providers but don’t sign a written consent form saying they understand the services will be out of network and may result in higher out-of-pocket costs, it’s considered a surprise bill. (E)


(A)   Surprise Medical Bills by Karen Pollitz, kkf.org, http://kff.org/private-insurance/issue-brief/surprise-medical-bills/

(B)   Many get hit with surprise ‘out-of-network’ bill after emergency rooms: Study” by Dan Mangan, CNBC, http://www.cnbc.com/2016/11/16/many-get-hit-with-surprise-out-of-network-bill-after-emergency-rooms-study.html

(C)   When Out-Of-Network Charges Pop Up, Try An Appeal, by Michelle Andrews, NPR, http://www.npr.org/sections/health-shots/2011/06/21/137304710/when-out-of-network-charges-pop-up-try-an-appeal

(D)   What It Means If Your Doctor is Out of Network, by Sergio Viroslav, Angie’s list, https://www.angieslist.com/articles/what-it-means-if-your-doctor-out-network.htm

(E)    N.Y. Law Offers Model For Helping Consumers Avoid Surprise Out-Of-Network Charges by Michelle Andrews, KHN  http://khn.org/news/n-y-law-offers-model-for-helping-consumers-avoid-surprise-out-of-network-charges/ 


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EBOLA is back in Africa. Is ZIKA next? Are we prepared?

Lesson Learned from recent EBOLA and ZIKA episodes. We need to designate REGIONAL EMERGING VIRUSES REFERRAL CENTERS (REVRCs).

1. There should not be an automatic default to just designating Ebola Centers as REVRCs although there is likely to be significant overlap.

2. REVRCs should be academic medical centers with respected, comprehensive infectious disease diagnostic/ treatment and research capabilities, and rigorous infection control programs. They should also offer robust, comprehensive perinatology, neonatology, and pediatric neurology services, with the most sophisticated imaging capabilities (and emerging viruses “reading” expertise).

3. National leadership in clinical trials.

4. A track record of successful, large scale clinical Rapid Response.

5. Organizational wherewithal to address intensive resource absorption.

REVRC protocols will be templates for are other mosquito borne diseases lurking on the horizon, such as Chikungunya, MERS, and Dengue.

Fast forward to this weekend:  “There have been 17 suspected cases and two confirmed cases of Ebola in Congo’s Bas-Uele province,…. Of the 19, three deaths have been reported. …. health officials were trying to located 125 people believed to be linked to the cases.” (A)

What are we waiting for? DESIGNATE REVRCs NOW!


(A)   EBOLA RETURNS: WHAT YOU NEED TO KNOW ABOUT THE OUTBREAK IN CONGO, by BY CONOR GAFFEY, Newsweek, http://www.newsweek.com/democratic-republic-congo-ebola-609143


Background posts:

EMERGENCY ROOMS are not all created equal!   http://doctordidyouwashyourhands.com/2016/04/emergency-rooms-are-not-all-created-equal/

We don’t know what we don’t know”  http://doctordidyouwashyourhands.com/2016/04/we-dont-know-what-we-dont-know-about-zika-1-the-challenge-to-emergency-preparedness/

Former hospital prez says: Designate local Zika centers now.   http://doctordidyouwashyourhands.com/2016/06/former-hospital-prez-says-designate-local-zika-centers-now-medical-experts-do-not-know-if-or-where-or-how-much-or-on-what-trajectory-the-zika-virus-may-spread-across-the-united-states/

 “I got Zika. The US health care system had no idea what to do with me…”  http://doctordidyouwashyourhands.com/2016/08/i-got-zika-the-us-health-care-system-had-no-idea-what-to-do-with-me/

 “With little known about Zika virus, hospitals scramble to stay ahead.”  http://doctordidyouwashyourhands.com/2016/08/with-little-known-about-zika-virus-hospitals-scramble-to-stay-ahead/

Hospitals are developing their own Zika preparedness models. Compare the Central Florida and Johns Hopkins approaches! Which template makes more sense?    http://doctordidyouwashyourhands.com/2016/09/hospitals-are-developing-their-own-zika-preparedness-models-compare-the-central-florida-and-johns-hopkins-approaches-which-template-makes-more-sense/



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The only sure things are death and taxes and “PRE-EXISTING” CONDITIONS.

“PRE-EXISTING CONDITIONS” is a predatory insurance industry term, not a medical term.

“Think it can’t get worse? …..The ACA specifically protected against discrimination for pre-existing conditions that showed up through genetic tests. You might not be sick yet—in technical terms, the illness has not manifested—but if you, for example, test positive for one of the pathogenic variants (a less X-Manly term than “mutation”) in the BRCA gene that predisposes you to breast cancer, you could still get covered. If the House bill becomes law, that protection vanishes. “(A)

Here’s a primer:

“A pre-existing condition is a term insurance companies used before the Affordable Care Act, the healthcare law better known as Obamacare, to classify certain diseases or health problems that could cause a person to be denied coverage or make their coverage more expensive than that of people considered healthy.” (B)

 “So what qualifies as a pre-existing condition under the bill? Nobody knows. The bill lacks any specifications, allowing health insurers a spacious margin for deciding who gets to pay through the nose for coverage.….Each of us is vulnerable to the unchecked exclusionary power that the health care bill would restore to the health insurance sector — a power that insurance providers have wielded before and used to devastating effect.” (C)

“Before Obamacare…..the patchwork of state and insurance regulations allowed each state to define pre-existing condition in its own way….”

Before Obamacare, along with significant diseases that were considered to be pre-existing like cancer, diabetes and heart disease, there were a variety of fairly minor conditions…other possible situations falling under pre-existing condition clauses are chronic conditions as acne, hemorrhoids, toenail fungus, allergies, tonsillitis, and bunions, hazardous occupations such as police officer, stunt person, test pilot, circus worker, and firefighter, and pregnancy and/or the intention to adopt. (D)(E)

In summary:

“In the pre-Obamacare era, insurers were able to deny coverage outright to people with pre-existing conditions. The Affordable Care Act banned individual states from allowing insurers to charge people with pre-existing conditions at a higher cost.

Under the American Health Care Act, states can opt to allow individual insurers the discretion of deciding what does and not count as a pre-existing condition. While people with those pre-existing condition can’t be denied coverage, they can potentially be charged more.” (F)

 So once again we “don’t know what we don’t know.” But we can speculate that health insurance applicants with pre-existing conditions might be “red-lined” by insurance companies and be quoted higher premiums up to five-times that paid by others, rates coupled with deductibles and co-pays that make policies unaffordable. (G)



(A) The House Health Plan Makes Your Genes a Preexisting Condition by Adam Rogers, WIRED, https://www.wired.com/2017/05/house-health-plan-makes-genes-preexisting-condition/

(B) From acne to pregnancy, here’s every ‘preexisting condition’ that could get you denied insurance under Trump’s new healthcare bill, by Lydia Ramsey, Business Insider, http://www.businessinsider.com/what-counts-pre-existing-condition-ahca-trump-obamacare-2017-5

(C) Under The Republican Health Bill, We All Have Pre-Existing Conditions, by Miles Howard, WBUR,  http://www.wbur.org/cognoscenti/2017/05/05/under-the-republican-health-bill-we-all-have-pre-existing-conditions

(D) What Is A Pre-Existing Condition Anyway? by Linda Bergthold, Huffington Post, http://www.huffingtonpost.com/entry/what-is-a-pre-existing-condition-anyway_us_590f60c8e4b046ea176aec7e

(E) What the GOP health care bill really says about pre-existing conditions by Tami Luhby, CNN, http://money.cnn.com/2017/05/01/news/economy/obamacare-trump-pre-existing-conditions/

(F) Pre-existing conditions: How 130 million Americans may be affected by the Obamacare repeal, by Christina Gregg, AOL, https://www.aol.com/article/news/2017/05/05/pre-existing-conditions-american-obamacare-repeal-american-health-care-act/22071483/

(G) The Republican Health Care Plan Is a Nightmare for the Old and Nearly Poor by Jordan Weissmann, Slate, http://www.slate.com/blogs/moneybox/2017/03/13/republican_plans_could_raise_insurance_premiums_by_750_percent_for_some.html

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Repeal and DESTROY

“Republicans have promised for seven years to repeal the Affordable Care Act, under which around 20 million Americans gained health coverage. But they had no consensus on how much of the law should be repealed and had great difficulty devising a comprehensive replacement.” (A)

 “Republicans are often right when they point out Obamacare’s shortcomings, like too few insurers on the exchanges in some states. That absolutely ought to be addressed. But snatching coverage from 24 million of our nation’s most vulnerable people to give as much as $1 trillion back to its wealthiest ones doesn’t fix that.” (B)

“The American Health Care Act…. could transform the nation’s health insurance system and create a new slate of winners and losers. (C)

Winners: High-income earners; Upper-middle-class people without pre-existing health conditions; Young, middle-class people without pre-existing health condition; People who wish to go without insurance; People who want less comprehensive health coverage; Large employers; Medical device companies, indoor tanning companies and a few other medical industries

Losers: Poor people: Older Americans, in most states: People with pre-existing health conditions, particularly in some states; State governments; Hospitals; Planned Parenthood

Some key concerns: (D)

          Some of Obamacare’s signature features would be gone immediately, such as the tax on people who don’t purchase health care, known as the “individual mandate.”

          States would have the option to get waivers from two of Obamacare’s requirements: that insurers cover “essential health benefits,” and that they charge the same price to everyone regardless of their health history. That would get rid of a key protection for people with preexisting conditions.

          AHCA would end Medicaid expansion in 2020, cut the program by $880 billion

          States could also opt out of Obamacare’s essential health benefits requirement. This is the core set of medical services that the Affordable Care Act requires all insurers to cover.

          The AHCA would fund high-risk pools for those who lose coverage. Experts worry the bill doesn’t have enough money.

          The AHCA allows insurers to charge their oldest enrollees up to five times as much as their youngest ones.

The Senate goes next, all men on the Republican working Group. “Notably missing from the working group are any of the five GOP women senators, particularly Maine’s Susan Collins and Alaska’s Lisa Murkowski, two moderate votes Republicans will need to get a bill passed through the senate.” (E)



(A)   House Passes Measure to Repeal and Replace the Affordable Care Act, by Thomas Kaplan and Robert Peer, https://www.nytimes.com/2017/05/04/us/politics/health-care-bill-vote.html?rref=collection%2Fbyline%2Frobert-pear&action=click&contentCollection=undefined&region=stream&module=stream_unit&version=latest&contentPlacement=1&pgtype=collection

(B)   New American Health Care Act is snake oil, Newsday, http://www.newsday.com/opinion/editorial/american-health-care-act-problems-1.13567594

(C)   Who Wins and Who Loses in the Latest G.O.P. Health Care Bill, Margot Sanger-Katz, https://www.nytimes.com/2017/05/04/upshot/who-wins-and-who-loses-in-the-latest-gop-health-care-bill.html

(D)   The American Health Care Act: the Obamacare repeal bill the House just passed, explained, by, Sarah Kliff; https://www.vox.com/policy-and-politics/2017/5/3/15531494/american-health-care-act-explained

(E)    Here’s What You Need to Know About the Health Care Bill, by Benjy Sarlin, NBC News, http://www.nbcnews.com/politics/congress/here-s-what-you-need-know-about-health-care-bill-n754611



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I just got an urgent cold call from a Financial Advisor recommending I buy warrants  in UBER since it is about to announce the opening of  a system of  “gig” urgi-care, UBER HEALTH.

You will be able to get a doctor to make a house call within ten minutes using a new UBER HEALTH APP. . If the doctor prescribes an MRI an imaging van will be sent to your house within one hour. Read by a radiologist somewhere in the ethernet.

There will be surge pricing and competition from LYFTparamedic.

Further research disclosed:

IBM WATSON DX will enable you to self-diagnose your health problems and treatment plans through secret proprietary algorithms, while the doctor is on the way.

APPLE MEDICAL SCHOOL will have virtual clinical rotations in medicine, pediatrics, surgery and obs/gyn, where students will deliver virtual babies.

WALMART HOSPITALS will become the anchor hospitals in many communities, right across from Walmart stores.

BLACKROCKdoc will employ 75% of physicians, with practice purchases funded by creating clinical derivatives.

AMAZONrx will dominate the mail order prescription medicine market.

MICROSOFTcare will capture 50% of the health insurance market driving Aetna, United and the Blue Cross plans out of business.

YAHOOlitigator will be do malpractice trolling akin to reverse mortgages.

To quote President Trump “nobody knew that healthcare could be so complicated”…

So I am going to sell all these stocks short.







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“It’s okay to ask your doctor: “Did you wash your hands?”

Recently after a doctor’s appointment I went to a nearby lab to have blood drawn for routine tests. I asked the phlebotomist to wash her hands to which she replied she already had. She had washed her hands in another room after the last patient, done some other work, come into the room, put gloves on, then went and used a shared computer*, before finally drawing blood. When I asked, she refused to wash her hands in front of me. So I refused to let her proceed. The same with the second tech. Finally the third washed her hands correctly in front of me.

“Most patients wouldn’t dare to ask their doctor to wash his or her hands..” It’s a simple enough request, but for patients and families who feel vulnerable, scared or uncomfortable in a hospital room, the subject can be too intimidating to even bring up with a doctor or nurse…” (A)

Some hospitals post signs in each examination room encouraging patients to be vigilant about doctor hand-washing; one even gives patients a card stating “Your care provider should clean their hands: 1) Before contact with you; 2) Before a procedure; 3) After a procedure; and 4) After contact with you.” (B)


Some background on Hospital Acquired Infections:

Hospital infections affect almost two million people in the United States every year, 100,000 of whom die. Up to 70 percent of these infections could be prevented if health care workers follow recommended protocols, which include hand hygiene. (C)

“…this sobering truth. When bacteria lurking on, for instance, a medical device, a bed rail, a bandage or a caregiver’s hands find their way into a patient’s body via a surgical wound, a catheter, a ventilator, or some invasive procedure, the disturbingly frequent result is a serious, sometimes devastating, infection.” (D)

“Hospital-acquired infections (HAI) cost $9.8 billion per year, with surgical site infections alone accounting for one-third of those costs, followed closely by ventilator-associated pneumonia at 31.6 percent….” (E)

“Hands are the most common vehicle for transmission of organisms and “hand hygiene” is the single most effective means of preventing the horizontal transmission of infections among hospital patients and health care personnel. “ (F) (G)


Protect yourself! Start by asking your doctor, nurse, phlebotomist, physical therapist and others –



* “It turns out that your computer keyboard could put a host of potentially harmful bacteria — including E. coli and staph — quite literally at your fingertips.” (H) “A study… suggests that dangerous bacteria may be spread by health care workers’ clothing.” (I)



(A)    Why Hospitals Want Patients to Ask Doctors, ‘Have You Washed Your Hands?’ by Laura Landro  http://online.wsj.com/news/articles/SB10001424052702303918804579107202360565642?KEYWORDS=hospital&mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702303918804579107202360565642.html%3FKEYWORDS%3Dhospital

(B)   It’s okay to ask your doctor: “Did you wash your hands?”, by Paul Taylor, http://healthydebate.ca/personal-health-navigator/okay-ask-doctor-wash-hands

(C)   Hand Washing Stops Infections, So Why Do Health Care Workers Skip It? ,  by Sanjay Saint, http://labblog.uofmhealth.org/industry-dx/hand-washing-stops-infections-so-why-do-health-care-workers-skip-it

(D)   What Zero Looks Like: Eliminating Hospital-Acquired Infections, http://www.ihi.org/resources/Pages/ImprovementStories/WhatZeroLooksLikeEliminatingHospitalAcquiredInfections.aspx

(E)    Hospital-acquired infections rack up $9.8B a year, by Julie Bird, http://www.fiercehealthcare.com/healthcare/hospital-acquired-infections-rack-up-9-8b-a-year

(F)    Guidelines for prevention of hospital acquired infections, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963198/

(G)  Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene, http://www.jstor.org/stable/10.1086/677145

(H)   How dirty is your Qwerty? by Dan Childs   http://abcnews.go.com/Health/Germs/story?id=4774746&page=1

(I)     Do white coats, scrubs, stethoscopes, cell phones and computer keyboards collect dangerous hospital germs?, by Joe Graedon, https://www.peoplespharmacy.com/2016/11/03/are-doctors-and-nurses-transporting-deadly-hospital-germs/

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“DRUGS DO NOT WORK IN PATIENTS WHO DO NOT TAKE THEM” (Former Surgeon General C. Everett Koop) –The Challenge of Non-Adherence.

The last DOCTOR post was about overmedication with prescription drugs and how to talk to your doctor about “DESCRIBING”. “Describing” is tapering off of drugs no longer needed. *

This post is about a related problem, the non-adherence to prescription drugs and the often severe and adverse consequences of non-compliance.

Non-Adherence refers to those who: Failed to fill or refill a prescription; Missed a dose; Took a lower or higher dose than prescribed; Stopped a prescription early; Took an old medication for a new problem without consulting a doctor; Took someone else’s medicine; or Forgot whether they’d taken a medication. (A)

Physicians should confirm that each patient:
– Understands their medications by reviewing: brand or generic name; function; how, when, and length of time the medication is taken; possible side effects; foods, liquids and activities to avoid while on the medication; refills (if necessary); and medication storage.
– Physicians can ask: “This medication will be an additional expense, how does it fit into your finances?”
– Have family members or caregivers be part of the team to help with administration and provide reminders
– And finish with: “I have given you a lot of information, let’s review your understanding of the prescription(s). (B)

Here are some details on the non-adherence epidemic.

The numbers are staggering. “Studies have consistently shown that 20 percent to 30 percent of medication prescriptions are never filled, and that approximately 50 percent of medications for chronic disease are not taken as prescribed,” ….“This lack of adherence….is estimated to cause approximately 125,000 deaths and at least 10 percent of hospitalizations, and to cost the American health care system between $100 billion and $289 billion a year.” (C)

“Within two years of having a heart attack, nearly 1 in 5 people stop taking lifesaving cholesterol-lowering drugs known as statins, according to a new study. And nearly 2 in 5 end up taking the drugs in lower doses or less often than they should…” (D)

“Medications are dispensed with the expectation that they will be taken exactly as prescribed. However, most patients do not follow their doctors’ orders. Excuses take many forms: “The medication was too expensive,” “If 1 pill is good, then 2 pills should be twice as good,” or “I didn’t understand the directions on the label.”” (E)

“… Patients may be no adherent during different stages of their treatment. They may decide not to fill their prescriptions in the pharmacy and not start their treatment at all. Patients may use more or less than the prescribed treatment or use their medication at the wrong time. They may also discontinue treatment prematurely.” (F)

* “DEPRESCRIBING” – Is there an epidemic of prescription medicine overtreatment? Start CHOOSING WISELY http://doctordidyouwashyourhands.com/2017/04/deprescribing-is-there-an-epidemic-of-prescription-medicine-overtreatment-start-choosing-wisely/

(A) Medication Adherence in America:2013, http://www.ncpa.co/adherence/AdherenceReportCard_Abridged.pdf
(B) Teaching Patients about their Medications: The Keys to Decreasing Non-Compliance, https://healthcarecommunication.wordpress.com/2009/02/06/teaching-patients-about-their-medications-the-keys-to-decreasing-non-compliance/
(C) The Cost of Not Taking Your Medicine, by Jane Brody, New York Times, https://www.nytimes.com/2017/04/17/well/the-cost-of-not-taking-your-medicine.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0
(D) Many people stop taking life-saving drugs after heart attacks, by Andrew M. Seaman, Washington Post, https://www.washingtonpost.com/national/health-science/many-people-stop-taking-lifesaving-drugs-after-heart-attacks/2017/04/21/705a28e8-253e-11e7-a1b3-faff0034e2de_story.html?utm_term=.14225b93cfe6
(E) Medication Nonadherence: Finding Solutions to a Costly Medical Problem, by Harold Gottlieb, Medscape, http://www.medscape.com/viewarticle/409940
(F) Definitions, variants, and causes of nonadherence with medication: a challenge for tailored interventions, by Jacqueline G Hugtenburg et al, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711878/


Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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