Hospital
emergency rooms are more likely to charge pricier levels of care than
a decade ago, generating bigger bills that consumers increasingly must pay with
their own money, according to a new report.
The
nonprofit Health Care Cost Institute (HCCI) examined insurance claims for a
decade’s worth of hospital emergency room bills,
analyzing millions of insurance claims for people under the age of 65
who get health insurance through an employer.
HCCI
found that hospital emergency rooms not only substantially increased
prices for care from 2008 through 2017. The hospitals and doctors also billed
for more complex care, which allows them to collect more lucrative fees from
consumers, employers and private insurers.
The
average emergency room visit cost $1,389 in 2017, up 176% over the decade.
That is the cost of entry for emergency care; it does not include extra charges
such as blood tests, IVs, drugs or other treatments.
“When
you look at the last 10 years, it’s really astonishing how this average cost of
admission to the ER has gone up,” says HCCI senior researcher John Hargraves,
who presented his report this week at the AcademyHealth meeting in
Washington, D.C.
Last
month, President Trump called on Congress to curb surprise medical billing,
which describes when a consumer gets an often-expensive bill from a
hospital or doctor that is not part of their insurance network. Many states
already have passed legislation to address these unexpected bills.
It comes down to the codes
But
less attention has been paid on how ERs bill patients.
Every
hospital emergency room visit is assessed on a scale of 1 to 5 – a figure intended
to gauge medical complexity and the amount a consumer will be billed.
An
insect bite might be assigned the lowest billing code, 99281. A heart attack,
the highest code, 99285.
The
difference in how an emergency room visit is coded might cost a consumer
hundreds more for simply stepping in the building.
In
2008, 17% of hospital visits were charged the most expensive code. That
surged to 27% of visits in 2017, the report said. The average price for the
most expensive code more than doubled from $754 in 2008 to $1,895 in 2017.
Hospitals
also increased billings for the second most expensive code, but they
billed the three least expensive codes less often compared to a decade
ago.
Are we sicker? Or just being billed like it?
Does
that mean Americans became sicker over the past decade, requiring more
intense and complex care at hospital emergency rooms? The report does not
address that question.
Americans
don't go to the hospital ER more often than they did a decade ago, the report
said. However, those visits cost more and are more likely billed with more
expensive codes.
"We
don't see a big rise in overall ER rates," Hargraves says. "Which is
what you'd expect if there's a large increase of people having heart attacks or
other (more severe) things. I think that's telling."
The
report combines the amount charged by hospitals and doctors, who often
bill patients separately.
Hospital
industry officials point to their own studies to explain the increased use
of more expensive codes at emergency rooms.
An
American Hospital Association report found the average number of emergency
room visits per 1,000 patients increased nearly 12% between 2006 and 2010. The
report also found those adults had a rising level of illness. The report
examined hospital use by older adults eligible for Medicare; HCCI reported on
hospital claims of people under the age of 65.
“Hospital
emergency departments treat many of our nation’s sickest and most complex
patients,” says Ashley Thompson, senior vice president of policy at the
American Hospital Association. “As hospitals serve as the front-door for
dealing with issues ranging from violence, mental health conditions and
the opioid epidemic, the
number and complexity of ED visits overall continues to increase.”
The
decade-long change in billing practices comes as hospitals have shifted to
electronic health records systems. These computerized systems might prompt
hospital staff to better document care, which might support the use of more
expensive codes, Hargraves said.
Others
aren't so sure.
Whistleblowers
Jeffrey
Newman is a Boston attorney who has represented whistleblowers under the
federal False Claims Act. The federal law allows individuals to bring
lawsuits on behalf of the government and collect a portion of any settlement.
The law is often used by ex-employees of hospitals, medical practices, drug
companies or medical-device makers when they suspect a former employer is
improperly billing federal health programs such as Medicare or Medicaid.
In
March, a nurse practitioner represented by Newman settled a False Claims Act
case for $2.1 million against CareWell Urgent Care Centers.
The
settlement said that CareWell managers directed doctors and other medical
providers ask patients about 13 body parts or systems and examine at
least 9 areas, even if the patient's symptoms that did not require such extra
attention.
If the
doctors did not ask the questions, the urgent care center's medical records
system registered a "no" answer. The robust queries were meant
to ensure the urgent care center could bill at a higher
level reimbursement code, the settlement said.
Newman
said he believes there are not enough checks and balances to guarantee medical
services are properly coded.
"They
can find reasons to say they were doing more complex things," Newman says.
"They often see this as an easy mark to pump the services and say, 'We're
being better doctors,' when it contravenes the rules."
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