May 21, 2019

The Culture of Entitlement in Medicine II: Your Invoice is Rejected

billI previously wrote about the culture of entitlement in medicine back in 2017. This is to be expected in an industry in which half of all gross revenue is tax revenue. That’s not to say doctors, nurses, etc. are bad people. Quite the contrary. But it’s human nature to overestimate the value of one’s own services – who doesn’t think he or she is underpaid?

The market provides discipline for this childish impulse. In a vibrant free market, we find out precisely what the goods or services we offer are worth to other people, because each customer decides precisely how much money they are willing to pay for our products, not to mention whether to buy them at all. Government regulations and subsidies have largely removed these market forces from the medical industry.

In addition to skyrocketing prices, this has fostered a culture of entitlement among medical providers. They feel entitled to an arbitrary amount of compensation for their goods or services, regardless of whether their customers are willing or able to pay.

This is reflected in their invoices. Rather than bill you for the amount both parties previously agreed to for a given service, as is customary in every other industry, they send you a bill for what they believe they “should” be paid and then represent the difference between that arbitrary amount and their contracted reimbursement (usually established via your health insurance provider) as an “adjustment.”

This passive-aggressive tactic attempts to portray  medical providers both as victims of “greedy” insurance companies (and moochers like you) and as altruists who have foregone most of what they believe owed to them out of the goodness of their hearts. It is important we disabuse them of these delusions.

I suggest we consumers, who not only pay for our own medical care but for the care of millions of strangers, process medical bills the way invoices are processed in any other industry. If you receive a bill priced any way other than what you and your provider have previously agreed to, simply reject the invoice with an explanation and invite the provider to resubmit. Repeat the process until you are billed accurately. Feel free to use the example below as a template:

Dear Accounts Receivable Manager,

Your invoice #XXXXX (copy enclosed) has been rejected for the following reasons:

*Pricing Errors

Your invoice contains five procedure codes for which you have a contracted rate with us through our health insurance provider. It is clear you are aware of this contract as you would not even agree to an appointment until eligibility with our health insurance provider was confirmed.

However, the billed charges on your invoice exceed the amount you agreed to in that contract. For example, your contract stipulates a charge of $38.14 for CPT code 99214. You have billed $175.00 for this service and then represented the difference as an “Adjustment” down to our contracted rate.

It is standard business practice for any going concern to bill its customers at the price(s) the customer agreed to pay via purchase order or contract, not the price the vendor wishes it could get paid.

In no other industry do vendors enter a contract to provide goods or services at one price and then bill for a higher one, representing the difference as an adjustment, as if the vendor were doing the client a favor. Rather, they bill for the agreed upon price and thank the customer for the business.

Please resubmit your invoice within 30 days with billed amounts matching our contracted rate for each service. We will waive the invoice rejection fee on this occasion as a courtesy. If you have any questions, please do not hesitate to contact me. Thank you.

Best regards,

Tom Mullen

Tom Mullen is the author of Where Do Conservatives and Liberals Come From? And What Ever Happened to Life, Liberty and the Pursuit of Happiness? Part One and A Return to Common Sense: Reawakening Liberty in the Inhabitants of America.

Should Social Security Be Means Tested?

383px-Ponzi1920Ken Langone told CNBC on Wednesday Congress “has to have the courage” to make Social Security means tested, arguing a billionaire like him shouldn’t be getting $4,000 a month (he and his wife) from the government when entitlements are 71% of spending.

In a way, means testing would be a good thing, as it would finally cure the delusion that Social Security is anything other than a welfare program, although I’m not sure the public wouldn’t make peace with that rather quickly, rather than consider turning off the spigot.

What it wouldn’t do, unless the benefit cutoff threshold were very low, is make a difference in the program’s basic insolvency. The problem with Social Security isn’t just that it’s welfare, but that it’s welfare for everyone – “Everybody plunders everybody,” as Frederic Bastiat would say. There are currently 62 million currently receiving checks. For 60% of them, Social Security makes up half or more of all their income. Millions more have come to depend upon the benefits, even if they make up a smaller percentage.

It might make people feel good to know millionaires and billionaires will no longer receive Social Security checks, but it won’t make much of a fiscal difference. There aren’t enough of them to significantly lower the payouts. To affect Social Security’s bottom line, people who would miss the money are going to have to take a hit.

There are only two ways out: default or bankruptcy. Either way, it’s going to be ugly. Social Security really is an evil mess that can’t but end badly. Ditto for Medicare, times ten.

Tom Mullen is the author of Where Do Conservatives and Liberals Come From? And What Ever Happened to Life, Liberty and the Pursuit of Happiness? Part One and A Return to Common Sense: Reawakening Liberty in the Inhabitants of America.

The Culture of Entitlement in Medicine

medicare-logoSenator Rand Paul has introduced an alternative bill to what he calls, “Obamacare Lite,” a.k.a. the American Health Care Act, introduced by House Speaker Paul Ryan. Paul’s criticism of Ryan’s bill was mild compared to Rep. Thomas Massie’s. Massie called Ryan’s bill a “stinking pile of garbage.”

While Paul’s plan is more free-market oriented than Ryan’s, no plan is addressing the one elephant in the room that must be slain before anything resembling a free market in health care can emerge: entitlements.

While Medicare and Medicaid’s effect on the federal budget is generally acknowledged, seldom mentioned is the percentage of overall health care spending that is tax-subsidized and the effect that has on prices. A study by the Georgia Institute of Technology found that of over $2.5 trillion in total U.S. health care spending in 2014, Medicare, Medicaid and “Other Public Insurance” accounted for 44% of it. By comparison, spending by private insurance companies accounted for only 33%, with out-of-pocket spending a mere 13%. Most of the remaining 10% was attributed to “other payers.”

In other words, almost half of all health care purchases in the United States occur free from the two strongest price-limiting market forces: the freedom not to purchase and finite demand.

Yes, the patients have a choice of which medical services they utilize. But they don’t buy them; taxpayers do. And the taxpayers don’t have a choice. And “demand” means not only the desire, but the ability to purchase a product at a given price. I may want to purchase a Rolls Royce. But if I don’t have enough money, I don’t represent demand for a Rolls Royce.

Price is determined by the intersection of supply and demand. By adding over $1 trillion to total funds available for health care spending, government health care programs significantly increase demand. When demand significantly increases, supply and other factors being equal, prices go up. It’s Economics 101.

If half of all automobiles were purchased by government programs, the price of automobiles would behave just as health care prices do now. And politicians and other “experts” would be wringing their hands over how to solve the automobile crisis and ensure everyone has the opportunity to exercise their fundamental right to drive to work.

Anyone who points out these rather uncontroversial economic realities can expect to be answered with, “What? You want to let my grandmother just die because she can’t afford health care? Do you believe only rich people should be treated for sickness and injuries and everyone else should just be left to suffer?”

Invariably, opponents of these programs take the bait and respond as if government health care programs were solely entitlements for consumers. They’re not. They’re much more entitlements for providers, who believe they are entitled to fees their markets won’t bear.

Having worked in a past life with physicians, hospitals and other providers for over a decade, I had a unique opportunity to understand their thinking (Disclosure: much of this time was spent in management positions at two of those “evil” HMOs). And while there are many exceptions to what I’m about to say, there are two things I found to be true about most physicians. One, they are among the most generous and compassionate people in society. Two, they share academia’s absolute contempt for the free market.

This results in a kind of Jekyll/Hyde aspect to their approach to reimbursement. On one hand, a physician who encounters a patient with no verifiable ability to pay will nevertheless care for that patient, if the need is serious, without hesitation. Physicians and hospitals provide a considerable amount of care every year for which they are not paid, without complaint.

Yet the moment there is a payment avenue, that same physician suddenly loses not only his compassion, but all connection with reality. Many were the times when a physician would say to me words to the effect of, “I’m entitled to higher compensation in return for the years of training I completed and the money I spent acquiring it.”

No, doc, you’re not. It is true that your skills are scarce and will fetch a higher price on the market than skills less scarce. But you’re only entitled to what others have agreed to pay you, like everybody else.

This culture of entitlement extends throughout the health care industry. How many times have you spoken with the billing manager for a hospital or medical practice who makes some form of this passive-aggressive complaint: “Our billed charges for this procedure are $835.00, but your insurance only pays $520.”

I’ve taken to responding, “Yes, I know how you feel. My billed charges to my employer are $1,000.00 per hour, but my paycheck is only for what he agreed to pay me.”

I’m not suggesting physicians’ salaries necessarily must be cut to restore price reality to medicine. A free market may give them a haircut; it may not. But there are many costs other than the physician’s salary in delivering health care  and there is no real pressure on improving efficiency in any of them.

As just one example, think about how many times you provide your health insurance information to your doctor’s office. They get it from you on the phone before even agreeing to make an appointment. Then, you have to write it on a paper form when you get to the office, sometimes more than once, on more than one form. Why? They’ve already captured that info on the phone. It’s in their billing system. Who’s reading, filing and otherwise processing the paper form(s) and why?

Many medical practices run the way they did in the 1950s for one reason: they don’t have to change. Half their revenues are guaranteed, at any price, by a customer base that can’t say no. Grocery stores, which provide products far more vital to human survival than medical care, operate on razor thin margins. Their prices behave normally, when adjusted for inflation. No one seems curious about why that is.

From time to time, proposals are made to try to phase out Medicare and Medicaid, the assumption being that there can be no major market disruption. That’s just another manifestation of the strange notion that medical care is in some sacred and holy category that more important goods and services don’t occupy.

While there are plenty of government interventions on the supply side that artificially inflate health care prices, the most effective way to normalize pricing would be to abolish Medicare and Medicaid tomorrow. That would cut demand for those services immediately by over $1 trillion per year. With a significant decrease in demand comes a significant decrease in prices.

And guess what? There would still be doctors, hospitals, pharmaceutical companies and other providers who want and need to deliver care and make profits. Only they’d have to adjust their business models to deliver their products at prices their customers could afford. This may sound scary, but industries have demonstrated their resilience to disruption over and over throughout history. And we’re talking about one composed of people at the far right of the bell curve. All experience says the turmoil would be far briefer and less harmful than the hysterical predictions we can expect from those benefiting from the current system.

Abolishing these programs won’t cut off granny. It will cut off McKesson, Merck and a lot of very wealthy physicians (who’d still be wealthy afterwards) from the government till. We’d all be treated much more like customers by the people whose medical services we purchase and health insurance premiums would plummet.

Proposals like Senator Paul’s will produce positive results on the margin, but until the entitlements are abolished, they won’t succeed in restoring normalcy to the health care market.

Tom Mullen is the author of Where Do Conservatives and Liberals Come From? And What Ever Happened to Life, Liberty and the Pursuit of Happiness? Part One and A Return to Common Sense: Reawakening Liberty in the Inhabitants of America.