Here is the scenario that started Part 1 of this series, the one on insurance that appeared in the March/April 2017 issue of Online Searcher starting on page 30. I have repeated it to use the same example in making all the decisions necessary to heal.
Walking home from work, paying more attention to the text from your granddaughter about her first days at college than you are to the pavement, you accidentally step on a small rock. It rolls, your foot slips out, and suddenly the sidewalk cement is greeting your body full force. The crack you hear in your right arm, near your shoulder, is intimidating. You hear a voice asking if you are OK, as darkness takes over.
The next few days are a blur. There’s an ambulance, a few X-rays (or was that an MRI?), a minor surgery to stabilize your arm, and you are sent home with some opioid drugs, which make you oblivious to the pain. A week later after the check-in visit, the doctor says you need to have a total reverse arm surgery at a price tag of $18K for the surgery and $20K for the implant … and he’d like to schedule it for 3 weeks from now, Thursday at 9 a.m. All you need do is to set up the appointment with the front desk.
At home, the walls close in on you. Who will pay for this? Will insurance cover anything? Medicare? Do you really need the surgery? How do you get another opinion? Can you talk to a specialist? What if you need home care afterwards, maybe physical therapy? Your spouse passed away last year, and your entire family lives four states away.
Don’t panic. Close your eyes, breathe deeply, and take it one step at a time. You can figure it out.
Getting a Second Opinion
Regardless of the insurance plan you have, many people may want to think twice before scheduling a surgery without a second opinion. While the U.S. Affordable Care Act (ACA) will cover a wellness visit for free, almost everything else requires a co-pay for the next visit.
If you have a health maintenance organization (HMO) plan, a basic Medicare plan, or are on Medicaid, call your primary care provider (PCP) and ask for a referral. This may be tricky if your PCP is the doctor who suggested the surgery, as it may seem that you are second-guessing the opinion, which you are. However, a good PCP should have already referred you to a specialist in the field (in this example, it would be an orthopedic surgeon, who is almost never a PCP).
If you had already been referred once, it’s OK to ask your PCP for a second referral. This is your body; be aware of what you are doing to it. And if the second opinion is completely different, call the PCP yet again and ask for a third opinion. However, you may want to call your insurance provider to explain why you are asking for a third opinion, just to be sure that the payer will indeed cover it, not assume it’s an irrelevant cost, and bill you for the full amount.
Be aware of the possible costs before the visit. If it’s not 100% clear from the documentation given to you each year with the new sign-up process, then call the toll-free number on the insurance provider website—it should also be marked clearly on your insurance card.
If you have a preferred provider organization (PPO) or an advanced Medicare plan with certain benefits, a referral will not be needed. However, it still would not be a bad idea to check on costs. While you have the ability to see any physician without getting a referral, be careful that the physician you choose is still in the network. Most plans cover, at best, from 5% to 20% of out-of-network costs. It is up to you to check on the network status since you are the one deciding which physician to see.
If the physician chosen is out of network and the overall visits are $180 plus the cost of the test—$500 for the X-ray or perhaps $1,400 for an MRI, on top of blood/laboratory work—that could put the total cost at almost $2,000. In network, you are responsible for the cost up to the deductible, say $800, plus the co-pay amount of perhaps $20. If you are out of network, the plan may only cover 10%, leaving you with $1,800 to pay out of pocket.
And with some plans, the out-of-network costs are not considered part of the deductible. So check out that physician or specialist before heading to the appointment.
(Note: In the above example, the dollar amounts are simply examples and will not represent actual costs to you or any other patient.)
These second opinions are not wellness visits. They are not automatically covered by the ACA. Expect to pay all co-pays at the time of the visit and for costs to be billed to you until you reach your annual deductible. If you have decided to go with a less-expensive plan with a lower monthly rate, you will not be faced with a high deductible out of pocket.
This is the insurance gamble. No plan is immune from these charges.
As for that emergency visit? Since it was an emergency, and you did not have the choice in who you saw, almost all plans will treat the visit as if it was an in-network visit. If you were admitted into the hospital, most plans will also wave the ambulance visit. If you were not admitted as an inpatient, then you will have a preset amount you need to pay (usually $40 to $250 per ride, but it does vary based on plan type).
This too will be billed as part of your overall deductible since it’s almost always in-network.
Beyond the HMO and PPO plans, some people may opt to have an exclusive provider organization, or EPO, plan. The monthly rates for these plans are closer to those of an HMO, but are like a PPO in that a patient doesn’t need a referral to see a specialist. However, the network of doctors is very narrow, and nothing is covered outside the healthcare plan unless it’s viewed as an emergency in the eyes of the payer. There is more coverage in a catastrophic insurance plan, but only if patients stay in the network.
Getting the Insight on Physicians
Choosing a primary physician is sometimes complex, but locating one for a second opinion can be daunting, as one is usually looking for a specialist. Many payers will provide a list of in-plan physicians on their websites—just look for a link such as Physician Locator, or perhaps Find a Doctor. Almost all websites have the ability to choose a physician specialty along with an area code to help you locate the nearest ones, although the FCC’s new rules allowing everyone to keep their phone numbers—including area code wherever they go—mitigate against the effectiveness of area codes as geographic predictors.
For those who wish to broaden their option—knowing full well this could mean complete out-of-pocket expenses—many professional associations have physician lists on their websites. Use the search engine of choice (Google, Bing, DuckDuckGo, for example) to locate these professional associations.
For example, searching Association of Orthopedic Surgeon will locate the American Association of Orthopedic Surgeons (AAOS). In the upper-right corner of the website is the link Find an Orthopaedist. The Patient section provides search methods such as ZIP code, name, or specialty, such as arm, hip, or knee.
These association sites will not give you any insight into whether their services are covered by your health plan. Only your individual insurance provider has that information. Be sure to call your provider and check if the physician is in-network.
Having a physician’s name is the next step, but is the physician any good? Does he or she make errors? Is the doctor being sued for malpractice? Are the office wait times impossible? Is the staff nice or rude? Everyone weighs factors differently, so there are many different resources one may use for investigation.
The U.S. government has provided a single source called Physician Compare. Launched in late 2010 as part of the ACA requirements, the site is designed to provide insight into the quality of a physician based on certain metrics set forth by the Centers for Medicare and Medicaid Services (CMS; cms.gov). These include group reporting measures, certification maintenance, and even electronic health records incentives. Details about each measure as well as what is being included in the future can be found on the About Physician Compare website from CMS: cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/physician-compare-initiative/About-Physician-Compare-An-Overview.html.
The website with the data is located here: medicare.gov/physiciancompare. Users will find a simple search box. Fill out the city or ZIP code, then choose from the drop-down list. Enter the last name of the provider or the physician specialty. The website will guide you through the rest. Results will cover when the physician graduated, where residency was done, affiliations, and insights into participation in the quality indicators.
The government, however, does not “rate” a physician. That would imply endorsement of a person, organization, or company, which is something the government does not do. There are other websites that have different levels of insight.
Users who would like some information on a medical condition while locating a physician may like WebMD (doctor.webmd.com). Searches are by specialty, location, or procedure. Standard information is the number of years in practice, office locations, and accepted insurance (always check with your provider directly to be sure!). Ratings are very basic: Does the doctor explain things, take time, provide follow-up? Based on this, doctors receive a rating of 1 to 5 stars. Users may also rank the cleanliness of the office and indicate the average wait time. There are no comments permitted, but the ratings come from anyone who wishes to submit insights. There is no vetting of the contributors, so beware.
Healthgrades (healthgrades.com) is another service which assists in locating physicians based on specialties. There is a general search, or users may opt to use the walk-through specialty guide. Unlike most websites, Healthgrades has many photographs of physicians. Users may filter by selecting from the options on the left side. Clicking on Patient Reviews will provide ratings of 1 to 5 stars based on actual feedback from patients, which will help remove those with lower ratings.
Clicking on a physician’s name brings up the individual profile. Scroll down the page to locate information such as conditions treated, procedures performed, and information regarding malpractice lawsuits (under Background Check). Users will also find information about the languages spoken by the physician. And, while there is information on the insurance carriers the physician accepts, always check with your individual provider and plan, as there may be specific restrictions not clearly noted on the website.
Reviews are by patients and are not screened for anything except inappropriate (vulgar) terminology. Many times, reviews are written by either extremely pleased or very disgruntled people, so please be sure to read all reviews with care.
One of the original doctor rating sites is RateMDs (ratemds.com), launched in 2007. Ratings are by real patients and, as with other sites, are not edited for content except for inappropriate language. Comments can be fairly lengthy; readers may give a review a thumbs up or flag it as “libelous or erroneous.” Editors will individually read the comments and determine if they should indeed be removed. Information on a physician’s credentials that appears on other sites is not always included here, and the insurance list is often incomplete.
These are just a few of the websites providing a range of information. Everyone has a personal preference for data needed, and there are many websites available. A few others worth noting include Zocdoc (zocdoc.com), which has a smart phone app to download, and a newcomer, CareDash (caredash.com), which is still building the number of reviews per physician. Paid members to sources such as Angie’s List (angieslist.com) will find feedback based on paid members, so it’s not the “anonymous person” submitting insight, nor can doctors log in and pay to have insights changed.
Some users may find friends on Facebook have used certain physicians. This is helpful if you don’t mind the world knowing your medical condition. Just in keep in mind how far-reaching social media can be.
Getting the Insight on Hospitals
The second opinion confirms the first; surgery is needed. Now comes the next hard decision—which hospital? In smaller, more rural areas, there may only be one option. In larger suburbs, however, the network allows you to choose the surgeon and perhaps the hospital. Or, if your surgeon only works at one facility, maybe you just want to know more about where your surgery and recovery will be taking place. How do you glean the dirt and insights?
With a resource similar to Physician Compare, the U.S. government—specifically the abovementioned CMS—provides a website called Hospital Compare (medicare.gov/hos
pitalcompare/Data/About.html). It does not recommend one facility over another. Instead, it provides data on each so a patient may make an educated decision about the quality of the facility. There are up to 64 different measures. Many facilities do not submit all of them, so the average number is actually 39 measures.
These measures are aggregated into seven key groups: Mortality, Safety of Care, Readmissions, Patient Experience, Effectiveness of Care, Timeliness of Care, and Efficient Use of Medical Imaging. The data is pulled together, analyzed, and results in a series of ratings using weights. Only facilities contributing at least three measures in at least three of the seven groups are eligible for a hospital summary score.
What does the score mean? The better the score, the better the patient outcome. This could mean fewer deaths in a facility, no wasted spending on useless medical imaging exams (which cost lots of money), or perhaps a more careful treatment plan, surgery, and outcomes which lower the number of readmissions. That means less may go wrong with a patient’s surgery and recovery.
Since October 2016, the CMS website has included data from the Veteran’s Administration facilities. For more information, and the data itself, users will need to visit another website: medicare.gov/hospitalcompare/VAData/main.html. Again, this government site does not provide patient feedback. It doesn’t provide much insight into patient wait times, or how friendly the staff may be, or how good the food tastes. There are other websites and sources of data, just as with physicians.
Many websites take the back-end datasets, available for free, and create their own dashboards. These include sites such as WhyNotTheBest and HealthInsight. It does not mean the data is not reliable. It just means the user will be getting the same information and indicators from these sites. Anyone wishing to check should look for the About Us section, an FAQ page on the site, or the description on the main sites such as “rankings for hospitals are calculated using publicly reported data downloaded from the Centers for Medicare & Medicaid Services.” Some of these sites may be easier for a user to navigate—it’s personal preference at this point, not data content.
Quality Check (qualitycheck.org) is a listing of those facilities which have received accreditation from the Joint Commission (JC); there are 21,000 in the U.S. at this time. The JC is an independent, not-for-profit organization whose certification is recognized as a standard of quality, but does not have any legal impact on how a facility may operate. This source, therefore, notes which facilities meet the criteria set forth by the JC itself, not by the federal government. Not having JC accreditation does not in any way limit the ability of a facility to operate. It’s essentially a voluntary “stamp of approval.”
Reports from Quality Check include lists of available services by each affiliated site as well as comparisons to similar facilities in terms of safety goals. As with the government, the JC does not rank a facility or endorse one over another. The JC also does not cite which services are performed “better” by one facility than another.
The Leapfrog Group (leapfroggroup.org) has been tracking information on facilities in its own way for more than 16 years. This not-for-profit organization was founded by large employers and other purchasers with the goal of tracking patient safety, rating hospitals, and thereby improving patient care. While it does not track all 6,300-plus hospitals across the U.S., it does have detailed insights on more than 1,800 of them, including a voluntary survey on safety and quality. Leapfrog also does not rely on the CMS resources.
Researchers and patients will need to look for the small font at the very top of the page for the Compare Hospitals link. Then, simply enter the hospital name or the ZIP code. Facilities are returned in alphabetical order, not based on distance. Users can compare up to three hospitals at one time in a grid or click on More Details to see feedback on inpatient care management and medication safety. Some hospitals will not have data on items such as high risk surgeries, meaning that, in general, such procedures aren’t performed and instead recommend patients go to a more specialized facility. As with the government site, Leapfrog does not provide individual patient feedback.
The Becker’s Hospital Review site (beckershospitalreview.com/lists.html) tracks hospital business happenings, but also releases a list of the 100 great hospitals each year. It uses a variety of sources such as the U.S. News & World Report lists, Quality Check, CMS, and Leapfrog to come up with a single list. Individual articles do have comments, but they are not usually direct feedback on a specific facility. Users may find the smaller lists useful as well—top rural hospitals, top facilities with orthopedic programs, and even those with spine programs.
If the user just wants a ranking of facilities, U.S. News & World Report has been releasing its annual data for years (health.usnews.com/best-hospitals). The final scores are based on a variety of criteria, including staffing, patient survival, and safety. Exact methodology is not provided, however—it’s just general: “In four specialties, ranking is determined entirely by reputation, based on a survey of physician specialists.” In recent years, there are rankings not just by specialty, but by procedure type as well. Individual profiles include number of beds, ranking of other specialty areas, photos of the facility, and often a list of the doctors themselves—with profiles.
One source of data is the Hospital Consumer Assessment of Healthcare Providers and Systems Survey, or HCAHPS (hcahpsonline.org/home.aspx). This is a 32-question survey of patients, not a website based on data submitted by a hospital. However, it’s also a ranked set of criteria that does not allow great flexibility in comments. There is a select group of about 35 organizations made up of market research firms, institutions, and consulting firms which have been trained and certified in the collection of data. The name of each organizations is listed on the HCAHPS website with an address and a named contact person.
Once a patient leaves a short-term hospital—this survey is not for outpatient visits or physician offices—they may receive a message from one of these organizations. It may be by mail, telephone, or both. There is no obligation for the patient to respond—there is no penalty for not responding—but there is also no payment for completing the survey. What patients need to know is that the data collected with be shared with the hospital, but in an aggregated format, which protects the identity of the individual.
So how does this help the patient? Hospitals are given stars based on the feedback. The more stars, the better the hospital is at addressing patient concerns. How does a patient learn about the scores? On the Hospital Compare website, discussed earlier in this article.
As with all the other previously noted sources, there are still no individual patient comments. For these, the websites are surprisingly difficult to locate. It turns out one is a more typical review site—Yelp. Yes, you read right. Yelp tracks feedback about hospitals and allows users to provide feedback. In 2016, researchers at the Perelman School of Medicine at the University of Pennsylvania compared approximately 17,000 Yelp reviews of 1,352 hospitals to the HCAHPS reviews for the same facilities. The Yelp reviews added the context of interpersonal relationships to the government’s data-based ranking. For more on the study, go to pennmedicine.org/news/news-releases/2016/april/penn-medicine-study-suggests-y.
Users can search the Yelp website (yelp.com) directly and look for the hospital in a given area or use a variety of criteria to narrow down to a given list of facilities. An alternative option would be to use a search engine of choice (Google, Bing, DuckDuckGo, etc.) with terms such as ™Yelp review of Massachusetts General Hospital∫ to locate the review of that particular hospital.
There are fewer places for feedback on facilities than individual physicians, as most patients make decisions based on the treating doctor. Hospitals are still worth investigating, however—especially when it comes to costs.
Places to Check Out Costs
In recent years, more and more resources are becoming available to check out how much the average physician and/or facility charges for a procedure or operation. What is the difference between a cost and a charge? The perspective: that is, on which side of the amount someone is looking.
Take a manufacturing firm. It sells a product—it’s what the company charges for it. This same amount is the cost to the facility/hospital purchasing it. So, what a hospital charges a patient is what it cost the patient to have a procedure or surgery done. This is a rather large generalization, but a key point when investigating the impact on a patient.
For those researchers, the Hospital Cost Report Information System (HCRIS) by CMS is helpful for tracking overall costs by service area such as the operating room. Data is available for individual hospitals, skilled nursing homes, and a few other facility types. These annual reports are required by law to be submitted to CMS and are available for free each year. Visit the HCRIS page at cms.gov/research-statistics-data-and-systems/downloadable-public-use-files/cost-reports.
Unfortunately, these are obscenely huge files for the average person to use, requiring special software programs. The files also do not track individual procedure data, but are only aggregated to the top-level facility and are therefore not useful to most patients. Someone researching Medicare costs may find these datasets helpful, however, so it’s critical to understand when to use them. Looking for individual procedures costs and charges is not that time.
Many states also release general cost reports provided by hospitals. As with HCRIS reports, these are almost always aggregated and not by individual procedures. Not only does this make it easier to generate top-level insights, it also keeps the states HIPAA-compliant, as they do not need to track if a facility has conducted 10 or less of a given procedure.
HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. To summarize it in one sentence, this legislation sets mandates in place to ensure all patients have access to care and that their privacy is protected. The government has created a detailed website for anyone wanting to know specifics about the law: hhs.gov/hipaa. There are many fine points to the law, of course, with one major implication for researchers.
For those interested in data and facts, this law generally means that if an individual physician or an individual facility performed, billed for, saw, processed, and/or recorded 10 or less of any one diagnosis or procedure or other expense, the data is not publically available. If someone with a rare disease is diagnosed in a small rural hospital, this diagnosis won’t be tracked except at a state or nationwide level.
If someone wants to know the number of coronary artery bypass grafts (CABG) procedures conducted in an inpatient setting, that information can be found using a source such as the Healthcare Cost and Utilization Project (HCUPnet; hcupnet.ahrq.gov), a database that “provides health care statistics and information for hospital inpatient, emergency department, and ambulatory settings.” HCUPnet is the online portal created by the organization behind HCUP, the Agency for Healthcare Research and Quality (ARHQ; ahrq.gov). However, this information is not available at the individual facility level. It can, however, give you a sense of how many people have a given procedure done each year nationwide.
Individual facility level data is not easy to find. One source for this information is AHD.com. There is some data available for free, while other parts of the site require payment. Simply search for the named facility and then choose from the drop-down list.
Because of HIPAA, there is only information available on any procedure performed 11 or more times at a given facility. That is in the pay section of the site. The free section has information on general utilization. This would include the number of patients, average length of stay, and average charges based on broad clinical area—such as burns, oncology, or orthopedic surgery. To get a detailed report on an individual facility, users must either pay the annual $395 fee or reach out to a support team directly.
Why is this data useful? Because for each facility, patients can see the average charges (the total gross charges by the facility by procedure) plus the average cost (basically what it costs the hospital to perform that procedure). Too low a cost and the facility may be streamlining too much (does it skimp on providing quality pain drugs?); too high and the facility may be very inefficient. Higher costs almost always mean higher charges to the patient.
The data for AHD directly comes from CMS’s Medicare files. As with the HCRIS reports, however, the data files are really massive and impractical for the average user and require an application process, approval, and a fee. This is very impractical for the average patient.
Another source, when available, is called a hospital chargemaster (or charge master). Depending on the state, this data may be required to be released; it may cover all payers or it may cover just those who make cash payments. Many facilities deem these to be the average prices, and, in fact, charge different amounts to Medicare, Medicaid, commercial payers, and those without insurance.
California was a leader in ensuring these chargemasters were made public as far back as 2005 based on a 2003 law. The target is the 25 most common procedures per hospital, but many facilities (not all) include far more. The Office of Statewide Health Planning and Development (OSHPD; oshpd.ca.gov) oversees the publicly available, easily searchable website: oshpd.ca.gov/chargemaster. Most are not listed by a medical code but by a name or abbreviation; the format varies based on the hospital. Sometimes the information is easy to understand “PTA and Stent Replacement.” Sometimes it looks like a foreign language: “GRFT BIF ENDO-PROS” (that’s a type of vascular graft).
In the fall of 2016, the British Medical Journal (BMJ) published an article whose title says it all: “US Hospitals Mark Up Prices More Than 20-Fold to Maximize Revenue, Study Suggests” (bmj.com/content/354/bmj.i5015). In short, many hospitals had higher chargemaster mark-ups than actually billed to Medicare, thus allowing them to charge more for cash-paying patients.
So, if someone has a high deductible (meaning more cash out of pocket before insurance will start paying), or has no or very limited healthcare insurance, it is very important to compare physicians but also to compare hospitals. If there are two really good physicians at two different hospitals, perhaps it would be more financially feasible to choose the less-expensive hospital.
Those with insurance would be wise also to check with their insurance provider to make sure the facility is indeed in-network and the procedure will be covered.
How do you tell if it’s a reasonable price? Some people use the Healthcare Bluebook (healthcarebluebook.com), a website run by CAREOperative whose entire mission is to provide “fair pricing to consumers, employers, and providers.” For the patient and consumer, there is a free fair price search by procedure. Just enter the city/state, and the procedures—or use the menus to find what you want.
The resulting price is based on a proprietary system which takes into account claims data, fee schedules, and some other data elements. The amounts are designed to be specific to the city selected for the search. The FAQ page indicates there is facility level data, but it’s not part of the basic search page.
How can CAREOperative afford to offer this site for free, beyond including minimal advertisements? By offering a premium access to employers, a specialized software system which connects into actual claims data. This data then feeds into the core dataset, making it more robust and providing even more accurate insight to the consumer.
Users may also wish to search the internet using their preferred search engine. Sites will appear with articles sourcing a wide variety of data. Sometimes the recent articles use data and prices from more than 6–10 years ago. Healthcare has changed, prices have changed, and the patient may find this data misleading. Articles usually only cover the most common procedures because those are the ones being researched the most.
The critical takeaway from all this information is simple: Be aware of what the fair price is for a given surgery. Find out if your local hospital is charging along the same lines. Most importantly, check with your insurance provider to ascertain if the hospital and physician are indeed in-network.
The physician has been chosen, the appointment has been made at the hospital, and your payer has assured you of coverage. Now it’s just a matter of time before the procedure/surgery happens. Instead of twiddling your thumbs, you decide to get informed about what is about to happen. With the entire internet splashed with dire warnings of everything that could go wrong for anything in life, knowing the sources to trust for reliable healthcare information is a must. There are many out there; here are a few core ones which have proven reliable across time.
The National Library of Medicine (NLM)’s MedlinePlus (medlineplus.gov) is a great place to start. Information is laid out in an easily navigable website, separating health topics not only by body location but by common disorders and even by general patient age, e.g., children and teenagers.
The target audience for many of the MedlinePlus disease briefings is the average patient, not the physician. Each topic has a simple overview of the condition and links on the right for additional terms, as well as “What to ask your doctor” sections. Much of the material is also available in Spanish—look for the notes or use the Español link in the upper-right side for the website in Spanish. For other languages, look on the homepage near the bottom for the link Health Information in Multiple Languages; there are more than 45 different languages from which to choose.
The Patient Care and Health Information section (mayoclinic.org/patient-care-and-health-information) of the Mayo Clinic’s website is detailed without being overly technical, friendly without being patronizing. There is information on several hundred conditions ranging from the clinical such as Blastocystis hominis infection to the seemingly benign bags under the eyes. If it is something people inquire about, the team at the Mayo Clinic has worked to develop insightful guides.
There is information about specific tests and procedures, such as what to expect from a pulmonary vein isolation. The site lists why it’s done, risks to consider, how a patient may prepare for the procedure, the clinic’s experience (with patient stories), and general insights about costs and insurance. Some of this information is for the clinic specifically, but the general information uses layman’s terms and is understandable. Some sites have multimedia presentations as well, interviewing the physicians or showing general artist renditions of the procedure to occur.
Medscape’s eMedicine portal (emedicine.medscape.com) is more clinical in nature. Patients who want more technical details will find this source helpful. Users may browse either by medical specialty or by surgery, or by using the search button in the upper-right-hand corner.
Being as specific as possible with a disease/procedure works best with this site. Are you interested in hypercalcemia, hyperkalemia, hypermagnesemia, hypernatremia, hyperphosphatemia, or hyperuricemia? All are types of acid-base, fluid, and electrolyte disorders, but eMedicine has insight into each one. Each disease report walks users through the pathophysiology (sign, symptoms), the DDX (diagnostic tests to diagnose the condition), overall treatment protocols, and medications that may be available. When possible, dosage forms and strengths for both adults and pediatrics are listed on a per-drug basis along with interactions that may occur.
The site may require a free registration to access its more detailed sections, and yes, there are advertisements in the right-hand frames. The site is available in English, German, Spanish, French, and Portuguese.
No website, however, can ever replace the help which the local medical librarian is able to provide. That’s right—a medical librarian. These are professional librarians with degrees who work inside the local hospitals to provide information and insights to physicians, nurses, and, yes, the general public regarding health issues. They may not be able to provide you with the latest thriller from your favorite crime author, but they can help you find the information you need on your medical condition.
They are easier to find than you may realize. The NLM’s MedlinePlus portal (noted above) has an entire directory: medlineplus.gov/libraries.html. Just choose the U.S. state or Canadian province from the drop-down list. Look for the nearest listed facility, each with a link to the library’s website.
Many of the libraries will assist the general public, meaning it’s OK to ask someone for assistance even if you are going to another location for a procedure. Phone numbers are often posted on the website in addition to hours the reference desk is open to help someone in person. These libraries will often have access to detailed information sources such as UpToDate, Harrison’s Online, or ClinicalKey. Many have journal subscriptions as well via Ovid or SpringerLink for full-text clinical materials. These libraries have paid subscriptions to such services and will know the best ones to use in order to help you.
Librarians are just awesome about sharing information.
Help at Home, Post-Hospital Stay
In a quick jump ahead, the surgery is over and you have survived your stay without complications. You are home … now what?
Based on the insurance plan and type of surgery/procedure—and thanks to any calls you made in advance—chances are, there is help available. This may include the services of a home health aide, a physical therapist, an occupational therapist, or perhaps a speech language pathologist who can also assist with eating skills.
A physical therapist (PT) concentrates on helping someone become active. Sometimes this means home visits; other times, the patient may go to the PT’s office. Movement is at the core of this profession. It may mean helping someone learn to walk again, to feed themselves, or to work on exercises which improve muscle tone for injured backs or torn rotator cuffs. These degreed and trained professionals know just how far a person may be pushed—and where the limits are—to help a patient become active faster but in a safe manner. Many insurance providers will have a list of in-network PTs to help, and they will be able to tell you just how many visits are covered under your specific insurance plan.
Want to know more? Prefer to see if there are more PTs near you? The American Physical Therapy Association (APTA) website (moveforwardpt.com/Default.aspx) has a Find the PT in the For the Public section. Visitors may also learn more about living healthy, including tips on running correctly to stay fit.
An occupational therapist (OT) is a trained healthcare professional who, essentially, teaches a person how to live again. OT includes focusing on the physical, sensory, and cognitive skills to help someone become socially integrated and fully engaged in daily life. An OT works with patients with mental illness in addition to helping families cope with dementia. An OT can provide guidance regarding ergonomics in the workplace and often visit patients at home to help them focus on daily activities. Learn more about OTs, and find one near you, by visiting the website of the American Occupational Therapy Association (AOTA) at aota.org/About-Occupational-Therapy/
Speech pathologists handle more than just helping someone talk again. They learn how a person swallows, thus understanding if food needs to be softened for eating or if liquids need to be thickened (and by how much) for safe consumption. They perform tests to assess a person’s hearing and understand how this may impact a person’s balance. They may be able to diagnose neurological conditions such as aphasia (a form of language impairment). Some, like an OT or PT, will specialize in either adult or pediatric care. All qualified individuals should be members of the American Speech and Hearing Association (ASHA), which maintains a public information website at asha.org/public.
Speech paths, OTs, and PTs work together to ensure a patient recovers safely. All these professionals also have advanced degrees to help them help the patient. If the visits covered by an insurance provider end before a patient is well, please call the insurance provider! In some cases, additional visits may be added based on the recommendations of the healthcare team. Be sure to have the recommendations of the healthcare team at hand so the insurance provider understands all issues.
Based on your level of confinement and support at home, your insurance provider may offer access to home health aides. They assist patients with bathing, dressing, and meals around the house. Some provide general clean-up of the home as well as patient care. The National Association for Home Care and Hospice (NAHC) provides a variety of resources for patients, including a by-state directory of home care (and hospice) providers: agencylocator.nahc.org. The local agencies will be able to assist patients with understanding available services as well as what the local laws require for help provided to each patient.
Hospice is end-of-life care. The patient is terminal, the future is not long. Treatment is usually canceled, and the emphasis is on patient comfort. There are different regulations and costs associated with hospice, none of which are covered in this article due to nuances. For questions, please visit the consumer section of the NAHC, or contact the site directly: nahc.org/consumer-information/home-care-hospice-basics.
In many cases, facilities discharging a patient will provide a drug supply designed to last 2–5 days. This allows the patient to get settled in a new location (home, rehabilitation facility, long-term care setting) and arrange for access to medications.
Many local pharmacies will offer a home-delivery service within a limited distance to one’s house for a small fee. Others will ship to your house; it depends on the location and the store. There is no federal requirement for this option.
Ordering a prescription online is easy—after the initial account set-up. This may take 15 or more minutes based on one’s comfort with a computer system. You will need a credit card, your insurance information, and primary doctor name. If your provider submits a prescription electronically, this is easiest. For those receiving a paper prescription (also known as a “script”), many times the pharmacy will require that it is mailed/received before the prescription is shipped.
Shipping costs are not included in the co-pay amount, which covers only the cost of the medication (not the access to the medication). A $4 co-pay on a drug may cost an additional $3 to ship to a house. That means the patient would pay $7, not the $4 co-pay.
Family members may be able to pick up a prescription for you—this varies by store policy and by drug. This is often possible with drugs classified as Schedule III, IV, or V, meaning there is a low potential for abuse. Lists of drugs in this class may be found on the Drugs.com website: drugs.com/csa-schedule.html.
(Note: Researchers looking for the Food and Drug Administration (FDA) official Code of Regulations documentation with legalese and generic names will find it here: www.ac
Those drugs in Schedule I and II often have restrictions on who may pick them up. Stores may have additional requirements, such as a person being a healthcare proxy, before permission is given. These are the opiates, the opium derivatives, the hallucinogenic substances most often used as pain killers. Check with your local pharmacy to see what can be done for access. In some situations, arrangements may be made for a visiting registered nurse (RN) to pick up the prescriptions and bring it to the patient.
Visiting nurses used to be more common in decades past, but according to the Visiting Nurses Association of America (VNAA; vnaa.org), there are more than 150 agencies in more than 40 states. Many insurance plans will cover a limited number of visits, especially when a medication needs to be infused. In the Connect tab, there is a Find a Provider site that lists the most local organization along with contact information.
Again, check your insurance plan to be sure this is covered in-network to reduce the amount you would need to pay out of pocket for this assistance.
When the Bill Arrives
Insurance and hospital bills may appear overwhelming at first glance. There are all sort of medical codes listed, and it’s hard to tell what is what—DRGs for inpatients, CPT codes for outpatient and sometimes inpatient, and laboratory tests. For an older article as basic reference, see my Searcher article from July/August 2010 (“What’s in the Patient’s Medical Bill?”; infotoday.com/searcher/jul10/Breton.shtml). The core information remains the same with the exception of using the updated ICD-10 coding system, not the ICD-9 system.
Invoices will arrive at separate times, but not everything is actually a bill to be paid. Some are “estimated charge invoices,” meaning if you actually paid 100% of the charges being billed to your provider, this is what you would pay. It’s not actually a bill to you. It’s just designed to let you know the total costs for that event.
There may be invoices for inpatient stays—and you may receive two or three depending on what services were used. Not all internal departments within a hospital use the same billing system, and therefore invoices are generated separately. Outpatient, home care invoices are all run through different departments, and again, a patient may receive several of these invoices.
Check each invoice for statements such as, “This is not an invoice,” “This is not a bill,” or even, “Do not pay until further notice.” If you see this, do not send any money. The facility is just letting you know the costs. Save this paperwork.
Painful as this may be, wait for the statement from your insurance provider. If you have both Medicare and Medicare Supplemental, wait for it to be determined which provider will pay for which service. You should receive a statement from the insurance provider(s)—depending on your coverage—which explains what will be covered and at what amount.
If the insurance plan gives you a percentage, compare it to the saved paperwork of estimated costs to get a sense of how much you may owe to the facility. Wait for the facility to send an actual bill to you—this may be 30–60 days after you are released because it is working out payments with the insurance companies.
If you don’t know if it’s the correct bill, call the facility. Talk to someone in the billing department. Ask them if this is the final payment and what the balance is at that time. Ask for the due date of payment. Most facilities post the contact information on their website, and it should also be on the bill itself.
What if you can’t pay the final amount? What if it will drain your savings, and there is nothing left? Do not despair. Do not panic. There are resources to help, more than you may realize.
If you understand how a bill works and you know exactly what to look for, check it for errors. The longer and more complex the treatment, the more services were u sed, the higher the cost—and the higher the possibility of errors on the claims. In 2014, a NerdWallet analysis found that 49% of Medicare claims had errors (nerdwallet.com/blog/health/managing-medical-bills/medical-bills-debt-crisis).
If you have a large bill, contacting a claims assistance professional (sometimes referred to as a medical billing advocate) may be worthwhile. The charge is often $100 per hour, but it may help if the claims assistant can cut your overall bill in half. There are many companies (all for-profit) to be found via your favorite search engine, but try ones recommended by the Alliance of Claims Assistance Professionals (ACAP) first. Visit its website for a directory, but also for a better understanding of what services are offered: claims.org/capservices.php.
Don’t want to shell out the money? Prefer to work on a reduction yourself? Try contacting your insurance provider or the hospital/facility itself. Ask to talk to the medical billing manager—don’t necessarily settle for the first person to answer the phone. You need to have the correct person on the phone who can talk to you. If necessary, ask to set up an appointment and go to the facility to talk in person. By using the resources listed earlier in this article, see if you can find a fair price online. If your bill has a higher price, you may be able to negotiate the amount down, and every little bit helps.
There are also state and federal programs that may be able to help. You need to do the work to contact them, but it may be worth it. A list of suggestions is available on the USA.gov website: usa.gov/help-with-bills#item-36707.
You are never alone. There is always someone to contact, someone to call, someone who can help out. This may be local or state officials, an insurance provider, or a not-for-profit institution who can help you get started.
Medical librarians can help provide information on a disease/condition/procedure.
There are sources to get insight into how good (or poor) a physician or facility may be. Use them; be educated. The more you know, the less scary it will be for you and your family.
And never, ever hesitate to contact your local librarians. They can use the resources in this article if you have access issues. They may direct you to certain city organizations. They may know someone to contact for local, regional information. Call, email, or walk up to the reference desk for help. Tell them your friendly healthcare librarian suggested it.