Thinking About Health columns (Rural Health News Service)

Hospitals Are
Penalized for Harming Patients
By Trudy Lieberman, Rural Health News Service
Anyone facing a hospital stay
for themselves or a family member should look at new data the government
released right before Christmas showing that it
penalized 769 of the nation’s hospitals for having high rates of patient
injuries. The monetary penalties – a reduction for the year in their
reimbursement for treating Medicare patients – do bite. Larger teaching
hospitals could lose as much as $1 million or more.
This is the third year the
government has penalized hospitals in an effort to prevent avoidable patient
deaths in hospitals, which emerged as a big issue about 18 years ago. This year
the government added injuries caused by MRSA and C diff infections to their
list of other harmful conditions patients contract in a hospital such as
urinary tract and surgical site infections resulting from hysterectomies and
colon procedures. MRSA – a staphylococcus bacterium – can cause pneumonia and
bloodstream infections. C diff is a germ that can multiply in the gut when patients
are taking other antibiotics to kill other germs.
While some facilities like
those serving children and psychiatric patients and critical care hospitals are
exempt from penalties, this year’s data show that more than 200 facilities,
including some of the nation’s most well-known hospitals, have the dubious
distinction of being on the government’s penalty list for all three years. They
include the Cleveland Clinic, Ronald Reagan UCLA Medical Center in Los Angeles,
Northwestern Memorial Hospital in Chicago and Boston’s Brigham and Women’s
Hospital. The message for patients:  A
hospital’s TV advertising campaign for its great cancer care may obscure
significant safety issues.
Have penalties and other harm
reduction initiatives made hospital care safer?
This time 347 hospitals
penalized last year are not on the bad-guy list, which shows that some are
paying attention. But hospital injuries have not vanished. The federal Agency
for Healthcare Research and Quality says there were 3.8 million hospital injuries
last year. That translates to 115 injuries per 1,000 patient stays.
Antibiotic-resistant bacteria
infect some two million people annually. One quarter of a million cases occur
in hospitals.
I wanted to know why more
progress hasn’t been made. While the new government data reflect improvements
at many hospitals, why is there still such a long way to go? I rang up Lisa
McGiffert, the head of Consumers Union’s Safe Patient Project who has been a
leading voice since 2004 to bring attention to infections and medical errors.
She told me there’s been a significant shift in the way hospitals view
infections. Twelve years ago they used to say they were not preventable. “Now,
most people in healthcare believe most infections are.”
In the early days of her
campaign, government agencies like the Centers for Disease Control and
Prevention were reluctant to back public reporting of hospital mistakes and
other data to help patients. Now they support it. Still, she says, “what I am
most frustrated about is the lack of urgency in the country and at the agencies
for eliminating these infections. They are aware of them, but there’s not a
sense of urgency to stop them.”
The financial penalties levied
by the Medicare agency have made a significant difference because they get the
hospital CEO’s attention. Unless the CEO is involved, change is not going to
But the penalties along with
the entire program to eliminate hospital-acquired conditions were authorized
under the Affordable Care Act. They could be in jeopardy if the law is
repealed. Some hospitals probably would be happy if they disappeared.
Patients need to make use of
the data that is available and study it to inform their decisions about where
to go for care when they have a choice. 
McGiffert advises looking at how your hospital compares to similar
facilities. Look for improvement. If a hospital was penalized the first or
second year of the program but not this year, that indicates it could be
serious about safety. Also look to see if a facility’s scores are moving in the
right direction. If the numbers show they are not performing as well on some
dimension as they previously were, patients need to ask why.
Some states and some hospitals
are using other strategies. Illinois and California, for example, have passed
legislation that requires hospitals to screen for MRSA when patients are
admitted. Some hospitals have stewardship programs to address the overuse of
antibiotics, which contributes to drug resistance.
To start learning about your
hospital, consult the government’s Hospital Compare website
Follow the prompts to find the hospital you are looking for and then search the
tabs for “complications.” This will let you look at actual numbers to help you
see how your hospital is doing.
experience have you had with patient harm in a hospital?  Write to Trudy at 

Non-network ER docs may charge big bucks

By Trudy Lieberman, Rural Health News Service
Surprise medical bills spell
big trouble for consumers, especially those who find themselves in an emergency
room. Such “surprises” have surfaced as a major patient problem, but because of
entrenched healthcare interests, a solution is not likely any time soon.
Here’s what happens. Patients
arrive at the emergency room of a hospital that is in their insurer’s provider
network. However, the physician who treats them is out of network.
Because ER docs are usually
assured a steady stream of patients, many believe they don’t need to accept
potentially lower fees from insurers in exchange for any new patients they
might attract by belonging to a network. That’s not the case for other
specialists who may rely on insurer networks for more business.
Whatever the reason, emergency
room patients may be stuck with huge bills their insurance company may not
cover, or it will pay less than if patients had used in-network doctors. 
If you think this is unfair, it
A study by Yale researchers of
more than 2 million emergency room visits across the country was just published
in the New England Journal of Medicine. It found that out-of-network doctors
treated 22 percent of the patients who visited emergency departments; the
departments themselves were part of their insurers’ networks.
The average bill patients
incurred was $623. The highest bill was more than $19,000. To put that number
in perspective, this year the Federal Reserve reported that 46 percent of
Americans were unable to pay a $400 expense without running up credit card debt
or selling assets.
Not surprisingly, researchers
found out-of-network ER doctors ended up getting paid a lot more than those who
were part of a network. “The fact this type of price gouging has become routine
operating procedure in so many emergency departments is shameful and
appalling,” says Chuck Bell, programs director for Consumers Union.
A recent study in Texas by the
Center for Public Policy Priorities shows how prevalent out-of-network ER
doctors are. Using a 2013 report from the Texas Department of Insurance, the
Center found that 45 percent of in-network hospitals in the state used by
United Healthcare had no in-network ER doctors. Fifty-six percent of Humana’s
hospitals had none. “Consumers would be astonished to see how poor the odds are
of getting an in-network doctor in the emergency room.” Bell added.
odds of getting redress are also low. Too many consumers don’t contest their
bills. Only about 25 percent of those getting surprise bills do, Bell told me.
Of those who do protest to their insurer, only half get their bill forgiven or
Surprise bills are a variation
of what’s called balance billing, the gap between what insurance, including
Medicare, pays and what a doctor charges. It’s been around for decades, but in
the late 1980s, the outcry from Medicare beneficiaries became so loud that
Congress did something about it.
For doctors who accept
Medicare’s payment in full, there is no balance billing – called “excess
charges” in Medicare speak.  Doctors,
including ER physicians who don’t accept that payment, can sock beneficiaries
with excess charges. But Medicare limits what they can charge.
Beneficiaries can protect
themselves from these excess charges should they use a doctor who doesn’t
accept Medicare’s fee schedule by buying Medigap policies Plan F and Plan G.
For those with Medicare Advantage plans, there’s no protection until the
beneficiary reaches the plan’s out-of-pocket spending limit. After that, the
doctor can’t balance bill separately.
There’s no similar help for
those not on Medicare.
Many consumers are unaware that
an out-of-network doctor is treating them.
The standard advice – to ask if
your doctor is in the network – is silly when it comes to care in the ER.  What patient having a heart attack is going
to look up and say, “Hey doc, are you with Aetna?”
A few states – New York,
California, Illinois, Connecticut, and Florida – hold patients harmless if they
find themselves with a surprise bill or require outside arbitration to decide a
case. But Bell says it will take an act of Congress to solve this problem.
Public outrage will have to get much louder if that’s to happen.
Because chances are high you’ll
find yourself with such a bill, think twice before you choose to go to the ER
for a problem that can wait until you see your regular doctor. 
Although Obamacare was supposed
to cut down on emergency room use, that hasn’t happened. People are still going
to ERs for less serious conditions, many being enticed by hospitals themselves
that advertise their ER wait times on billboards.
Our healthcare system is all
about making money. And balance billing, its causes and consequences, is
another sorry example.
is your experience with surprise billing? 
Write to Trudy at


What you need to know about choosing health insurance

By Trudy
Rural Health News Service
Even though the election is
over and Republicans are in a position to repeal and replace Obamacare as
they’ve been vowing to do for several years, that doesn’t mean you should avoid
signing up for 2017 insurance coverage.
If you’re eligible and need
insurance, the state shopping exchanges are open for business even if options
this year are limited in many counties, particularly in rural areas. More than
40 percent of the counties where residents can buy an Obamacare policy have
just one insurer selling them. That’s not a lot of choice, and policies that
are offered are likely to have high premiums and limited options for doctors
and hospitals.
Still, some careful shopping is
in order to minimize any surprise bills. After the election, White House Press Secretary
Josh Earnest urged Americans to sign up and announced “the vast majority” of
eligible consumers would be able to buy insurance for a monthly premium of $75
or less, which has been the administration’s sales pitch.
Assuming the White House math
is correct, that doesn’t mean the vast majority should automatically buy a
policy with a $75 premium. That strategy can mean expensive trouble later on.
Reviewing the basics before wading into the Obamacare marketplace this year is
For starters, recall that
platinum policies, generally the most costly, cover 90 percent of someone’s
medical costs; gold plans cover 80 percent; silver plans pay 70 percent; and
the bronze variety pays the least – only 60 percent of a patient’s healthcare
expenses.  Silver plans have been the
most popular, largely because those who buy them and have family incomes below
$60,750 get extra government subsidies to help pay their deductibles, copays
and coinsurance.
Bronze policies are popular,
too, because they have low premiums, but people buying those policies won’t get
the extra subsidies, a point that’s worth remembering. Those subsidies can be a
big help if you need a lot of medical services. Both bronze and silver policies
generally come with lower monthly premiums, but that doesn’t mean they are
cheaper in the long run.
Here’s where
comparison-shopping gets tricky. It’s possible a bronze policy and maybe a
silver one could end up costing more than a gold one with a higher premium if
you get sick. That’s because of the relationship between the premium, copays,
coinsurance and deductibles. Insurers mix and match these features to fit their
marketing strategy.
In general, a lower premium
means higher deductibles and higher other out-of-pocket expenses.  A policy with a higher premium often means
lower out-of-pocket costs.
For 2017 the maximum amount a
family would have to pay out-of-pocket for copays, coinsurance and deductibles
is $14,300. That’s a lot of money and enough to deter some people from signing
up. Many people say paying that much before insurance pays isn’t really
insurance. It’s also high enough to keep people from seeking medical care even
when they need it. If people go to the doctor less, the country’s national
health expenditures will drop – at least that’s the rationale for the high
out-of-pocket limit.
An Indiana couple I’ve written
about before in this column recently sent an email updating me on the family’s
insurance options for next year. Their carrier had increased their $836 monthly
premium to about $1,300; their cost even after an Obamacare tax subsidy was
applied. What’s more, the reader said, the insurer had raised the amount of coinsurance
for hospitalizations from 20 percent to 50 percent.
Given how much a hospital stay
costs, they worried they’d be on the hook for a lot of money until they reached
the $14,300 out-of-pocket maximum. It was a risk they weren’t willing to take,
and they shopped until they found new coverage for only $700 a month with their
Choosing an Obamacare policy or
any other insurance coverage comes down to how much risk you want to assume. If
you are reasonably certain you won’t need many medical services, you may want
to take a chance and buy less expensive insurance that comes with high
deductibles, copays, and coinsurance.
But if you’re like the Indiana
couple, and afraid of high expenses for unexpected medical care, buy the best
policy you can afford that reduces that risk.
Another thing to keep in mind!
Beware of policies with really low premiums, prices that seem too good to be
true. Consumers who bought insurance from the Obamacare co-ops learned that.
Almost all of the 23 co-ops
authorized to compete with the big carriers have gone out of business. They
priced their policies too low, and too many sick people signed up. Government
regulators closed them down, sending thousands of people scrambling for new
coverage – an unwelcome chore for anyone.  
have your experiences been shopping for insurance?  Write to Trudy at   

Obesity Rates
Fall in a Few States but Are Still 
Far Higher Than
in 1990

By Trudy Lieberman, Rural Health News Service

Is the message that the nation is getting too fat beginning to sink in?

The answer is “yes but,” says the Trust for America’s Health, a nonprofit, non-partisan group that aims to protect the health of communities and make disease prevention a national priority. And a study of healthcare quality and quantity across the nation suggests some reasons why things are not improving uniformly.

Trudy Lieberman

Obesity is a disease, and for the last 13 years the Trust and the Robert Wood Johnson Foundation have monitored obesity rates in the country, focusing on the proportion of a state’s population that is obese. The study designates someone as obese whose body mass index (a measure based on height and weight) is 30 or higher.

This year’s results show that after a decade in which every state’s obese population rose, a few states have finally experienced a decrease.

“We’re seeing the rates plateau albeit at a very high level,” says Richard Hamburg, the interim president of the Trust.

Although rates have dropped in Montana, Minnesota, New York, and Ohio, even those decreased rates are still high. Twenty-six percent of adults in Minnesota were still considered obese, and nearly 30 percent were in Ohio. Even in the states with the lowest rates – Colorado, California, Utah, Montana, Hawaii and Massachusetts – rates remain between 20 and 25 percent.

Twenty-two of the 25 states with the highest adult obesity rates are in the South and Midwest, including Kansas and Kentucky, both of which experienced an increase.

To put this in perspective, Hamburg told me that in 1980 no state had a rate above 15 percent; in 1990 no rate was above 20 percent. “Colorado is the healthiest state but exceeded the 20 percent rate years ago,” he said.

What happened? Hamburg explained that many societal changes have conspired to increase obesity rates. Children have less opportunity for physical activities; parents are no longer comfortable sending their kids out to play and telling them to come home by dark.

Other reasons?

  • Sedentary activities like computer games have replaced physical activity. 
  • Many schools no longer offer physical education, and are not always open for physical activity after the school day ends. 
  • More kids arrive at school via car or bus. In 1969, 89 percent of kids walked or rode their bikes to school. By 2009, the number had dropped to 35 percent. 

Eating habits are different, too, with families eating more often in restaurants, including fast food establishments, and consuming more added sugars and fats. Many families eat at McDonalds or Burger King a few times a week, but even if they cooked at home, they might not be eating “healthy” because they don’t have access to fresh fruits and vegetables.

Hamburg told me 30 million people don’t have easy access to a supermarket; many residents in dense urban areas have to walk or take public transportation more than a mile to get more than a “convenience store” selection. Many in rural areas must drive 10 miles or more.

Powerful marketing from the food industry is also a culprit, beckoning consumers to eat pizza, overstuffed tacos, and sodas without regard for the effect on their weight or health.

I usually don’t pay much attention to state rankings from various groups. Most people aren’t going to move to another state just because it ranks better on whatever is being measured. But this time I did because as the obesity report came out, a personal finance website, WalletHub, announced its latest report “2016’s States with the Best & Worst Health Care.” And I was struck by a possible connection.

What did WalletHub have to say about those states in the South and Midwest with high numbers of people who are obese? Were they getting routine examinations, and dental care? Were physicians accepting Medicare? Were there adequate hospital beds particularly, in rural areas where many hospitals have closed?

Now I didn’t attempt to do a scientific correlation, and there may be many reasons why a state’s healthcare system ranks high or low on the WalletHub site. But for me, the take-away from these studies is that communities must offer not only treatment for health problems relating to obesity but also ways to prevent the underlying cause in the first place.

Communities must have not just enough and appropriate medical facilities and personnel but also programs to encourage better eating habits and more physical activity.

The Trust report offers suggestions that point in that direction. To learn more about how your state ranks on both these studies, go to and

New Hospital Safety
Ratings Available to the Public
By Trudy Lieberman,
Rural Health News Service
Aug. 8, 2016
The Centers for Medicare and
Medicaid Services (CMS) recently signaled to the nation’s hospitals that it was
getting serious-and tough-about patient safety and the quality of care
hospitals provide. The government’s rating system-five stars for the best
hospitals and one star for the worst-sends a message that patients have a right
to know what’s going on inside the hospitals they entrust with their lives or
those of their family members.
The overall star ratings, the
first for CMS, are a composite of 64 measures the government has used the past
few years to rate hospital performance. They include factors such as
complication rates for patients who’ve had knee and hip replacement surgery,
urinary tract infections associated with catheter use, death rates among
patients with serious but treatable complications after surgery, and patients’
reported experience with their care.
Only 102 hospitals out of the
3,600 rated received five stars, and they included less well-known specialty
facilities such as Lincoln Surgical Hospital in Lincoln, Nebraska, and the
Orthopaedic Hospital of Lutheran Health Network in Ft. Wayne, Indiana. Medicare
gave 129 hospitals one star. They included two prominent hospitals in
Washington D.C. – MedStar Georgetown University Hospital and George Washington
University Hospital – as well as several hospitals in New York City. Geisinger
Medical Center in Danville, Pennsylvania, that health policy experts and
politicians cite for exemplary quality involving new ways of delivering and
coordinating care, received a below-average two-star rating. 
The ratings reveal a
contradiction between scientifically measured evidence and the advertising
hospitals use to build their brand. Hospitals like to tell their communities
about new cancer treatments or new children’s wings, not mediocre ratings. In
my neighborhood New York City’s Mt Sinai Hospital has used banner ads on the
street to create an awareness of the hospital, which received only a mediocre
three-star rating.
Those of us who have written
about hospitals know that smart patients need to look way beyond the nightly
advertising on TV.
Medicare often caves in to
healthcare industry demands and has backed off many proposed rules that
powerful doctors, hospitals, and drug companies opposed. But it isn’t pulling
any punches on this one despite attempted roadblocks.  Last April some 200 members of the House of
Representatives and 60 U.S. senators sent letters to CMS urging delay in
releasing the star ratings.
They argued that the ratings may
not take into account that many hospitals treat low-income patients with
complex conditions and, thus, may not be fair to providers.  “The star system is an irresponsible slap in
the face to America’s most essential hospitals, those that take in the sickest
patients,” Dr. Eric Dickson, the chief executive of UMass Memorial Health Care,
told the Boston Globe. His flagship teaching hospital in Worcester,
Massachusetts, received one star. 
But as Leah Binder who heads The
Leapfrog Group, which advocates for patient safety, has noted on,
the letter sent by the senators did not mention responsibility to patients who
may suffer harm in a hospital. The British Medical Journal reported in May that
researchers who examined the scientific evidence concluded that in 2013 medical
errors were the third-leading cause of death in the U.S. behind heart disease
and cancer.
That’s cause for alarm and may be
a reason why CMS didn’t bow to political pressure this time.
Jordan Rau, a staffer at Kaiser
Health News who has written about the evolution of hospital ratings, told me
the stars may influence low-rated hospitals to improve their scores.
Hospitals may also fear that
consumers will see the stars, which are easy to understand, dig into the
numbers behind them, ask questions, and perhaps choose other facilities if they
can. If that happens, CEOs may feel mighty uncomfortable going before their
boards and explaining why they received only one or two stars.
Medicare has also just released
the names of hospitals required to pay monetary penalties for having more
patients than expected return to the hospital. 
About one-third of readmissions, considered a marker of quality, are
preventable.  The government looks at
readmissions for such conditions as heart attacks, pneumonia, and hip and knee
Clearly, if you’re planning a
hospital stay for major surgery or any reason, check both CMS sites for the
star ratings
and the readmissions penalties
Examining the ratings for facilities you are considering should either give you
peace of mind-although nothing is guaranteed in the patient safety business-or
cause for concern.
My advice: see how the “stars”
align before you’re a patient at any hospital.

been your experience finding a good hospital or with hospitals where you or a
family member have experienced a medical error? Write to Trudy at