Each week, dozens of requests for treatment landed on her desk after preliminary rejections. Her job, with the assistance of a part-time medical director, was to conclusively determine whether the care — from doctor visits to cancer treatment — should be covered under the nation’s health insurance program for low-income Americans.

She was drowning in requests, she said, and felt pressed to uphold most of the denials she saw. “If it was a high-dollar case, they tried to deny it,” Villa said. “I told them you can’t deny it just because it’s going to cost $20,000.”

Villa, 32, did not work for the government. She did not even work for an insurer under contract with the government. She worked for a company now called Agilon Health. Owned by a private equity firm, it’s among the legion of private subcontractors looking to profit from Medicaid patients.

California’s Medicaid program, known as Medi-Cal, has determined that the Long Beach company, which was paid to coordinate care for about 400,000 patients, improperly denied or delayed care for at least 1,400 of them, state officials confirmed. The state Department of Managed Health Care is investigating further.

The state findings, along with internal company documents and a whistleblower complaint obtained by Kaiser Health News, shine a light on the potential dangers of outsourcing care for poor people. Government oversight, not rigorous to begin with, fades as taxpayer money filters down through layers of companies eager to seize on Medicaid’s substantial growth under the Affordable Care Act. Medicaid officials say they have authority only over the health plans, not their subcontractors.

In an interview, Agilon chief executive Ron Kuerbitz acknowledged that some patients experienced modest delays in care but disputed that any suffered unjustified denials. He noted that by the company found no evidence of “systemic” denials and that most of the problems existed before Agilon took over another firm, Primary Provider Management Co., in 2016.

“We did the right thing when it was identified,” Kuerbitz said of the problems. “We disclosed it, we investigated it, and we pursued a remedial path.”

Such concerns are not isolated to one company. Last year, KHN reported on similar irregularities at SynerMed, a Medicaid subcontractor that coordinated care for about 650,000 patients in California.

In response to a whistleblower complaint, the state Medicaid program said it found “widespread deficiencies” at SynerMed that put patients “in imminent danger of not receiving medically necessary healthcare services.” The company’s staffers had falsified documents for years to cover up improper denials of care, according to state officials.

Then SynerMed abruptly shut down, and some of its patients moved to Agilon’s medical groups.

Skimping On Services?

Nearly three-quarters of the 73 million low-income Americans on Medicaid are now in managed care, in which states pay health insurers fixed monthly amounts for each enrollee to cover the range of services they need.

Under this system, keeping patients as healthy as possible is one way to make money. Another is to deny or skimp on services.

Increasingly, Medicaid plans outsource the work of managing patients’ health and medical treatment to subcontractors like Agilon — passing along a share of the government money coupled with the financial risk posed by a fixed budget.

These firms can be powerful gatekeepers. They run physician groups, bear responsibility for forming doctor networks and judge whether a request for care is necessary.

Agilon is a big player in California — doing business with insurers such as Molina Healthcare and Blue Shield of California — and it’s now expanding in other states like Texas and Ohio.

. ran several medical groups, including with more than 5,000 physicians across Southern California. By building off PPMC’s base of Medicaid enrollees in California, the New York private equity firm that owns a majority stake in Agilon — Clayton, Dubilier & Rice — sought to coordinate care in Medicaid and Medicare Advantage plans across the country. (CD&R did not respond to interview requests.)

For several years, the problems at PPMC, and then Agilon, went undetected. Then, in early 2018, Agilon disclosed to the California Department of Managed Health Care its discovery that employees had been altering records prepared for auditors, which it said was not known to top management.

, completed in May and obtained by KHN, staffers had been falsifying documents since at least 2014 to pass audits by health plans. Employees were changing dates, for example, to cover up delays or withholding certain files so they couldn’t be reviewed.

That same month, an anonymous whistleblower sent a letter to health plans and government officials, urging them to investigate “illegal, unethical” conduct at the firm. “Senior management delays treatments for cancer patients without any regard of patient’s well-being, to save their dollars,” the whistleblower wrote in a two-page letter reviewed by KHN. “They brag about how profitable we are.”

In response to the allegations raised by the whistleblower and , Agilon opened another internal investigation. That second report, found inadequate staffing to handle the volume of work, various shortcuts and practices outside industry “norms” and improperly denied claims. Both internal reports were released to the state.

A top official Inland Empire Health Plan, one of the largest Medicaid insurers in the country, said the plan also looked into Agilon’s conduct and found instances in which its patients were harmed.

In an interview, Inland Empire CEO Bradley Gilbert said Agilon denied a patient’s transfusions for anemia, causing the person to be hospitalized. It also improperly denied cardiac rehabilitation to a patient recovering from a heart attack, he said. Inland Empire canceled its contract with Agilon’s Vantage Medical Group in August, he said.

A ‘Manager Told Me To Do It’

Agilon’s June report depicts an operation that was often stretched thin: Nurses were handling 120 to 200 requests for care per day, on average, with no full-time medical director to review the findings.

From 2014 until May, the company relied on a family physician who was working 10 to 12 hours a day running his own medical practice, according to the report.

Dr. Reuel Gaskins was busy seeing his own patients at the Hampton Medical Clinic in Riverside, Calif., where a red neon sign flashes “Open” in the front window. In an interview, Gaskins said he reviewed cases during breaks throughout the day and after normal work hours. He said he left Agilon in April.

Ultimately, Agilon’s internal investigation found that patient care may have been denied 439 times since 2014 without a physician’s review of the medical records — a potential violation of state law. Under California law, only a licensed physician or health care professional who is “competent to evaluate the specific clinical issues involved” can determine medical necessity.

Gaskins said he was not aware of allegations that medical decisions were made without his review until he was interviewed by Agilon’s lawyers.

“That’s inappropriate and unacceptable,” he said. “It really bothered me when I heard about it.”

The June report also found that Villa helped alter 20 files at the request of a supervisor in 2014 so her employer could pass an upcoming audit by an insurer.

A “manager told me to do it,” Villa said in an interview. “They were so adamant that everything look perfect for the auditors.”

A few days after the company’s lawyers made that discovery, Agilon sent Villa home on paid leave, the nurse said. She said that when she returned to work in August, she found she had been replaced as denial nurse, and shortly after that, she was fired.

Meanwhile, in recent months, Agilon has mended its relationships with some insurers and won new Medicaid contracts.

Consumer advocates worry that the concerns surrounding Agilon and SynerMed signal a much larger problem in the burgeoning Medicaid managed-care industry.

“These private entities get very little oversight,” said Linda Nguy, a policy advocate at the Western Center on Law & Poverty in Sacramento, “and there’s real harm being done to patients.”

This story was produced by , which publishes , an editorially independent service of the .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

In one case, the state paid a managed-care plan $383,635 to care for a person in Los Angeles County who had been dead for more than four years, according to California State Auditor Elaine Howle.

She said she found “” in Medicaid enrollment in which state and county records didn’t match up from 2014 to 2017, leading to other errors that persisted for years. The bulk of the questionable payments, or $3 billion, went to health plans that contract with the state to care for 80 percent of enrollees in California’s Medicaid program, known as Medi-Cal.

The program for low-income residents is the nation’s largest and funded by both the federal and state governments. The state findings echo similar problems cited by federal officials and come at a time when the Trump administration has applied extra scrutiny to California’s spending on Medicaid.

In the report, the state auditor said it’s critical for the state to have accurate information on eligibility “because it pays managed care plans a monthly premium for an increasing number of Medi-Cal beneficiaries regardless of whether beneficiaries receive services.”

(Story continues below.)

California’s Medicaid program has 13.2 million enrollees, covering about 1 in 3 residents. It has an annual budget of $107 billion, counting federal and state funds. Nearly 11 million of those enrollees are in , in which insurers are paid a monthly fee per enrollee to coordinate care.

The state’s Medicaid enrollment soared by more than 50 percent since 2013 due to the rollout of the Affordable Care Act and the expansion of Medicaid. Enrollment grew from 8.6 million in December 2013 to more than 13 million in December 2017, according to the audit report.

In the case of the dead patient, a family member had notified the county of the enrollee’s death in April 2014. However, the person’s name remained active in the state system, and California officials assigned the patient to a managed-care plan in November of that year.

From then on, the state kept making monthly payments of about $8,300 to the health plan until August 2018, shortly after the auditor alerted officials of the error. Auditors didn’t identify the health plan.

There also were costly mistakes in cases in which Medi-Cal pays doctors and hospitals directly for patient care – a program known as “fee for service.”

For instance, the state auditor found that Medi-Cal paid roughly $1 million in claims for a female patient in Los Angeles County from June 2016 to December 2017 even though the county office had determined in 2016 that she was ineligible.

In a written response to the auditor, the California Department of Health Care Services said it agreed with the findings and vowed to implement the auditor’s recommendations. However, the agency warned it may not meet the auditor’s timeline, which called for the main problems to be addressed by June 2019.

In a statement to California Healthline, the agency said it is implementing a quality control process and “where appropriate, DHCS will recover erroneous payments.”

Early on in 2014, as the ACA rolled out, the state struggled to clear a massive backlog of Medi-Cal applications, which reached about 900,000 at one point. There were widespread computer glitches and consumer complaints amid the increased workload at the county and state level.

In addition to questionable payments for care of ineligible enrollees, Howle and her audit team also discovered some patients who may have been denied benefits improperly. The state auditor identified more than 54,000 people who were deemed eligible by county officials but were not enrolled at the state level. As a result, those people may have had trouble getting medical care.

In February, a federal watchdog estimated that California had signed up 450,000 people under Medicaid expansion who may not have been eligible for coverage.

The inspector general at the U.S. Department of Health and Human Services said California made $1.15 billion in questionable payments during the six-month period it reviewed, from Oct. 1, 2014, to March 31, 2015.

, Seema Verma, administrator of the U.S. Centers for Medicare and Medicaid Services, told a U.S. Senate committee that she was closely tracking California to ensure the state “returns a significant amount of funding owed to the federal government related to the state’s Medicaid expansion.”

Verma expressed concern that states had overpaid managed-care plans during the initial years of Medicaid expansion, resulting in “significant profits for insurance companies.” By year’s end, she said she expects the federal government to recoup about $9.5 billion from California’s Medicaid program, covering overpayments from 2014 to 2016.

Tony Cava, a spokesman for Medi-Cal, said the state has already returned about $6.9 billion to the federal government and expects more than $2 billion more to be sent back by December.

This story was produced by , which publishes , an editorially independent service of the .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Como la mayoría de las personas en Medicaid, el camionero de Los Ángeles fue asignado a una compañía de seguros privada que coordinaba sus visitas médicas y tratamientos a cambio de recibir una tarifa fija por mes, un acuerdo conocido como atención administrada.

Pero en 2016, cuando la retina de Núñez se dañó por su diabetes, Centene, la mayor aseguradora de Medicaid del país, lo decepcionó. Según una demanda que presentó el hombre de 62 años, después de meses de denegarle tratamiento, retrasos y referencias erróneas, quedó casi ciego de un ojo. Como resultado, perdió su licencia de conducir y el trabajo que le daba de comer a su familia.

“Traicionaron mi confianza”, dijo Núñez, sentado en la mesa de su cocina con sus brazos cruzados.

El debate político actual sobre Medicaid se enfoca en poner a trabajar a los pacientes para que puedan obtener los beneficios del gobierno. Sin embargo, algunos expertos dicen que sería mejor para el país hacerse esta pregunta: las compañías de seguros, que ahora reciben cientos de miles de millones de dinero público, ¿están ganándose sus cheques de Medicaid?

Más de dos tercios de los beneficiarios de Medicaid están inscritos en programas de atención administrada, un tipo de acuerdo público-privado que ha crecido rápidamente desde 2014, impulsado por la afluencia de nuevos beneficiarios luego de la puesta en marcha de la Ley de Cuidado de Salud Asequible (ACA).

Los estados han recurrido con entusiasmo a los servicios de las aseguradoras como una forma de hacer frente a la expansión de Medicaid bajo ACA, que ha sumado 12 millones de personas a la lista de beneficiarios. El 6 de noviembre, los votantes en otros tres estados pueden aprobar medidas que respaldan la expansión. La se ha convertido en el método preferido para ejecutar Medicaid en 38 estados.

Sin embargo, existe de que estos contratistas mejoren la atención al paciente o ahorren dinero al gobierno. Cuando los auditores, los legisladores y los reguladores se molestan en mirar, muchos concluyen que las aseguradoras de Medicaid no toman en cuenta el dinero gastado, brindar la atención necesaria o acceso a una cantidad suficiente de médicos. La supervisión es muy deficiente y los legisladores en varios estados han hecho sonar alarmas a pesar de que continúan pagando dinero.

“No tenemos planes en marcha para el nivel de escrutinio que necesitan”, dijo el doctor Andrew Bindman, ex director de la Agencia federal para la Investigación y Calidad de la Atención Médica y ahora profesor en la Universidad de California-San Francisco. “Este sistema está listo para la obtención de ganancias, y prácticamente no hay penalización por un mal desempeño”.

A cambio de sus tarifas fijas, las aseguradoras privadas distribuyen el tratamiento dentro de una red limitada, lo que en teoría permite una atención más juiciosa y económica. Los estados tienen contratos con los planes de salud como una forma de asegurar cierta previsibilidad en sus presupuestos anuales.

ahora están cubiertos por planes de atención administrada, en comparación con menos de 20 millones de personas en el año 2000. (En Medicaid tradicional, los estados pagan a los médicos y hospitales directamente por cada visita o procedimiento, un enfoque que puede alentar tratamientos excesivos o innecesarios).

Los estados ya canalizan a las aseguradoras de Medicaid. Eso es más de $60 mil millones que hace una década. El gasto de hoy se acerca a lo que el Pentágono otorga anualmente a los contratistas.

Medicaid es bueno para los negocios: el precio de las acciones de la aseguradora de Núñez, Centene, se ha disparado un 400% desde que ACA amplió la elegibilidad para Medicaid. El año pasado, el director ejecutivo de la compañía recibió $25 millones, el salario más alto para cualquier CEO en la industria de seguros de salud. Según un análisis de Kaiser Health News, en California, el mayor mercado de atención administrada de Medicaid con casi 11 millones de afiliados, Centene y otras aseguradoras obtuvieron $5.4 mil millones en ganancias de 2014 a 2016.

Los planes consiguen quedarse con el dinero que no gastan. Eso significa que las ganancias pueden provenir de una mayor eficiencia, o de escatimar en la atención y asumir pagos excesivos del gobierno.

“Los estados solo le están dando a las aseguradoras las llaves del auto y una tarjeta de gasolina”, dijo Dave Mosley, director gerente de Navigant Consulting y ex director de finanzas del programa de Medicaid de Carolina del Norte. “La mayoría de los estados no han presionado a las aseguradoras por la información necesaria para determinar si hay algún retorno de su inversión”.

Según puntajes de calidad y los reclamos registrados por el gobierno, dos de las aseguradoras más rentables de California, Centene y Anthem, administraron algunos de los planes de Medicaid de peor desempeño en el estado. Los funcionarios de California han estado recuperando miles de millones de dólares de los planes de salud.

Durante casi dos décadas, funcionarios federales han intentado construir una base de datos nacional de Medicaid que rastree la atención médica y los gastos en los estados y las aseguradoras. , se ve obstaculizada por los diferentes métodos de presentación de informes estatales y las denegaciones de algunos planes de salud para entregar los datos que consideran secretos comerciales.

En julio, un informe del inspector general federal acusó a las aseguradoras de Medicaid de ignorar deliberadamente el fraude y los sobrepagos a los médicos porque los costos inflados pueden llevar a tasas más altas en el futuro.

En un informe conocido en septiembre, la Oficina de Responsabilidad del Gobierno (GAO) reveló que el programa Medicaid de California no puede enviar electrónicamente registros que justifiquen miles de millones de dólares en gastos, lo que obliga a los funcionarios federales a revisar miles de documentos a mano. California dijo que no puede compartir archivos clave electrónicamente porque utiliza 92 sistemas informáticos separados para ejecutar el programa.

“Simplemente no puede ejecutar un programa tan grande cuando no puede decir adónde ha ido el dinero y en dónde está”, dijo Carolyn Yocom, directora de atención médica de la GAO.

En la actualidad, Medicaid consume la mayor parte de los presupuestos estatales en todo el país en casi el 30%, en comparación con menos del 21% hace una década, desplazando los fondos para educación, carreteras y otras prioridades clave.

“En todo caso, nuestros resultados sugieren que el cambio a la atención médica administrada de Medicaid aumentó el gasto de Medicaid”, concluyeron los investigadores de la Oficina de Presupuesto del Congreso y la Universidad de Pennsylvania en 2013, basándose en .

Los funcionarios de la industria insisten en que la atención médica administrada ahorra dinero y mejora la atención. Medicaid Health Plans of America, un grupo comercial de la industria, apunta a un estudio que muestra que los planes de salud a nivel nacional ahorraron al programa de Medicaid $7.1 mil millones en 2016.

Los planes de salud también dicen que pueden ayudar a modernizar el programa, creado hace más de medio siglo, mediante la actualización de la tecnología y la adopción de nuevos enfoques para el manejo de pacientes complejos.

Hacerlo bien tiene grandes implicaciones tanto para los pacientes como para los contribuyentes, pero los resultados en muchos estados no son tranquilizadores.

Los , tanto republicanos como demócratas, criticaron su programa de Medicaid el año pasado por ignorar el mal desempeño de dos aseguradoras, UnitedHealthcare y Centene, incluso cuando el estado otorgó a las compañías nuevos contratos de mil millones de dólares.

En Illinois, los dijeron que el estado no supervisó adecuadamente los $7 mil millones pagados a los planes de Medicaid en 2016, lo que dejó al programa sin poder determinar qué porcentaje de dinero se destinó a la atención médica en lugar de los costos administrativos o las ganancias.

Mientras tanto, la administración Trump ha enviado señales mixtas sobre la supervisión de Medicaid. Seema Verma, administradora de los Centros de Servicios de Medicare y Medicaid, ha promovido una nueva tarjeta de puntaje nacional y se comprometió a aumentar las auditorías dirigidas a los estados y planes de salud.

Nuñez, el camionero que perdió gran parte de su vista, está demandando a una unidad de Centene por negligencia e incumplimiento de contrato. La compañía negó las acusaciones en los documentos judiciales y se negó a hacer más comentarios, citando el litigio pendiente.

Es difícil para él hablar sobre la necesidad de que los beneficiarios de Medicaid trabajen. “Necesito mi salud para trabajar”, dijo. “Y ellos me la quitaron”.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Like most people on Medicaid, the Los Angeles trucker was assigned to a private insurance company that coordinated his medical visits and treatment in exchange for receiving a set fee per month — an arrangement known as managed care.

But in 2016, when Nuñez’s retina became damaged from diabetes, the country’s largest Medicaid insurer, Centene, let him down, he said. After months of denials, delays and erroneous referrals, he claimed in a , the 62-year-old was left nearly blind in one eye. As a result, he lost his driver’s license and his livelihood.

“They betrayed my trust,” Nuñez said, sitting at his kitchen table with his thick forearms folded across his chest.

The current political debate over Medicaid centers on putting patients to work so they can earn their government benefits. Yet some experts say the country would be better served by asking this question instead: Are insurance companies — now receiving hundreds of billions in public money — earning their Medicaid checks?

More than two-thirds of Medicaid recipients are enrolled in such programs, a type of public-private arrangement that has grown rapidly since 2014, boosted by the influx of new beneficiaries under the Affordable Care Act.

States have eagerly tapped into the services of insurers as one way to cope with the expansion of Medicaid under the ACA, which has added 12 million people to the rolls. This fall, voters in three more states may pass ballot measures backing expansion. this public program to insurers has become the preferred method for running Medicaid in 38 states.

Yet the that these contractors improve patient care or save government money. When auditors, lawmakers and regulators bother to look, many conclude that Medicaid insurers fail to account for the dollars spent, deliver necessary care or provide access to a sufficient number of doctors. Oversight is sorely lacking and lawmakers in a number of states have raised alarms even as they continue to shell out money.

“We haven’t been holding plans to the level of scrutiny they need,” said Dr. Andrew Bindman, former director of the federal Agency for Healthcare Research and Quality and now a professor at the University of California-San Francisco. “This system is ripe for profit taking, and there is virtually no penalty for performing badly.”

In return for their fixed fees, the private insurers dole out treatment within a limited network, in theory allowing for more judicious, cheaper care. States contract with health plans as a way to lock in some predictability in their annual budgets.

More than Medicaid recipients are now covered by managed-care plans, up from fewer than 20 million people in 2000. (In traditional Medicaid, states pay doctors and hospitals directly for each visit or procedure — an approach that can encourage unnecessary or excessive treatment.)

Already, states funnel nearly annually to Medicaid insurers. That’s up from $60 billion a decade ago. Today’s spending is approaching what Pentagon awards annually to contractors.

Medicaid is good for business: The stock price of Nuñez’s insurer, Centene, has soared 400 percent since the ACA expanded Medicaid eligibility. The company’s chief executive took in $25 million last year, the highest pay for any CEO in the health insurance industry. In California, the largest Medicaid managed-care market with nearly 11 million enrollees, Centene and other insurers made $5.4 billion in profits from 2014 to 2016, according to a Kaiser Health News analysis.

Plans get to keep what they don’t spend. That means profits can flow from greater efficiency — or from skimping on care and taking in excess government payments.

“States are just giving insurers the keys to the car and a gas card,” said Dave Mosley, a managing director at Navigant Consulting and former finance director at the North Carolina Medicaid program. “Most states haven’t pressed insurers for the information needed to determine if there’s any return on their investment.”

Two of California’s most profitable insurers, Centene and Anthem, ran some of California’s worst-performing Medicaid plans, state quality scores and complaints in government records show. California officials have been clawing back billions of dollars from health plans after the fact.

For nearly two decades, federal officials have tried building a national Medicaid database that would track medical care and spending across states and insurers. It’s still , hampered by differing state reporting methods and refusals by some health plans to turn over data they deem trade secrets.

In July, a federal inspector general’s report accused Medicaid insurers of purposefully ignoring fraud and overpayments to doctors because inflated costs can lead to higher rates in the future.

In a report last month, the U.S. Government Accountability Office disclosed that California’s Medicaid program is unable to electronically send records justifying billions of dollars in spending, forcing federal officials to sift through thousands of documents by hand. California said it can’t share key files electronically because it uses 92 separate computer systems to run the program.

“You simply cannot run a program this large when you can’t tell where the money is going and where it has been,” said Carolyn Yocom, a health care director at the GAO.

Today, Medicaid consumes the single-largest share of state budgets nationwide at nearly 30 percent — up from less than 21 percent a decade ago — crowding out funding for education, roads and other key priorities.

“If anything, our results suggest that the shift to Medicaid managed care increased Medicaid spending,” researchers at the Congressional Budget Office and the University of Pennsylvania concluded in 2013, based on a .

Industry officials insist that managed care saves money and improves care. Medicaid Health Plans of America, an industry trade group, points to a showing that health plans nationally saved the Medicaid program $7.1 billion in 2016.

Health plans also say they can help modernize the program, created more than a half century ago, by upgrading technology and adopting fresh approaches to managing complex patients.

Getting it right has big implications for patients and taxpayers alike, but the results in many states aren’t reassuring.

State lawmakers in , both Republicans and Democrats, criticized their Medicaid program last year for ignoring the poor performance of two insurers, UnitedHealthcare and Centene, even as the state awarded the companies new billion-dollar contracts.

In Illinois, the state didn’t properly monitor $7 billion paid to Medicaid plans in 2016, leaving the program unable to determine what percentage of money went to medical care as opposed to administrative costs or profit.

In April, Iowa’s state ombudsman said Medicaid insurers there had denied or reduced services to disabled patients in a “” way. In one case, an insurer had cut a quadriplegic’s in-home care by 71 percent. Without the help of an aide to assist him with bathing, dressing and changing out his catheter he had to move to a nursing home, according to the ombudsman, Kristie Hirschman.

“We are not talking about widgets here,” Hirschman said. “In some cases, we are talking about life-or-death situations.”

Meanwhile, the Trump administration has sent mixed signals on Medicaid oversight. Seema Verma, administrator for the Centers for Medicare & Medicaid Services, has promoted a new, nationwide scorecard and vowed to ramp up audits targeting states and health plans.

“We need to do better,” Verma said in a to the Medicaid managed-care industry. “Medicaid has never developed a cohesive system of accountability that allows the public to easily measure and check our results.”

But consumer advocates also are concerned that Verma’s efforts to roll back “” will weaken accountability overall. Many also disagree with her support of Medicaid work requirements.

Nuñez, the truck driver who lost much of his sight, is suing a unit of Centene for negligence and breach of contract. The company has denied the allegations in and declined to comment further, citing the pending .

Talk of requiring Medicaid recipients to work is hard for him to take. “I need my health to work,” he said. “They took that away from me.”

This story was produced by , which publishes , an editorially independent service of the .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Stacks and stacks of it.

Stuck with decades-old technology, the nation’s largest Medicaid program forces federal officials to sift through thousands of documents by hand rather than sending electronic files. That’s one of the critical findings in a from the federal government’s chief watchdog citing inefficient and lax oversight of Medicaid nationwide.

To illustrate, the U.S. Government Accountability Office published a photo showing piles of records submitted for one three-month period. One folder was placed upright to show the height of the heap.

“It’s really amazing when you look at that picture,” said Carolyn Yocom, a health care director at the GAO who focuses on Medicaid, the federal-state health insurance program for low-income people. “For this type of reporting on expenditures, California really should be able to provide that electronically.”

California, with more than 13 million Medicaid enrollees, said it’s hamstrung because it uses 92 separate computer systems to run its Medicaid program — although it has plans underway to modernize its technology.

“Given system limitations and the magnitude of the supporting documentation, providing it electronically is currently not feasible,” the California Department of Health Care Services said in a statement.

The state’s Medicaid program, known as Medi-Cal, has struggled with technology for years. The state thought it had a solution in 2010 when it awarded a $1.7 billion contract to Xerox, which included $168 million for a new system. But after years of delay, the state scrapped the contract in 2016 and started from scratch, leaving the patchwork system in place a few more years.

Nationwide, despite industry buzz about electronic medical records, smartphone apps and artificial intelligence, a lot of paper is still being pushed across the health care system. Consider all those forms patients repeatedly fill out in the waiting room, the screeching sound of fax machines inside doctors’ offices and the bulging binders of patients’ records in file rooms.

Under Medicaid, states submit data quarterly to the federal government on their spending and include supporting documents such as invoices, cost reports and eligibility records. In California, reports on spending are shared electronically, but the copious supporting documentation required for federal review is not, according to the GAO.

When the Xerox venture failed, the company agreed to pay California more than $123 million as part of a settlement agreement, according to state officials.

Meantime, Conduent, the services unit of Xerox that was spun off into a separate company, was left to keep operating the system and process claims.

Last month, the state  to DXC Technology of Tysons, Va., to take over some operations from Conduent. The state said the contract could be worth $698 million over 10 years.

Separately, California’s Medicaid officials are working on plans for a new system that would cost an estimated $500 million. Under the federal-state partnership on Medicaid, the federal government would cover 90 percent of those costs for design and implementation, and the state’s share would be about $50 million.

Pressure has been mounting on California to fix the situation. The Medicaid IT system “needs to be replaced, because it is more than 40 years old, its operations are inefficient, maintaining the system is difficult and there is a high risk of system failure,” state auditor Elaine Howle wrote in to Gov. Jerry Brown and legislative leaders.

In her letter, Howle said the state was paying about $30 million annually to maintain the legacy system.

Overall, Medi-Cal serves 1 in 3 Californians. The annual Medicaid budget in California is about $104 billion, counting federal and state funds.

Beyond California, the GAO criticized the U.S. Centers for Medicare & Medicaid Services (CMS) more broadly. One complaint: Federal officials assign a similar number of staff to states for reviewing case files — even though some states, like California, pose a far bigger risk for enrollment errors and misspent money due to their size and complexity.

For instance, the report’s authors said, CMS reviewed claims for the same number of newly eligible Medicaid enrollees — 30 — in California as it did in Arkansas, even though California had 10 times the number of newly enrolled patients under the Affordable Care Act.

The report also said CMS devoted a similar number of staff to review both California, which represents 15 percent of federal Medicaid spending, and Arkansas, which accounts for 1 percent.

CMS “needs to step back and assess where are the biggest threats and vulnerabilities,” Yocom said. “If you aren’t looking, you don’t know what you aren’t catching.”

Overall, from fiscal years 2014 to 2018, federal Medicaid spending increased by about 31 percent, according to the GAO report. But the full-time staff at CMS dedicated to financial oversight declined by roughly 19 percent over the same period.

In a July 18 letter to the GAO, the U.S. Department of Health and Human Services agreed with the agency’s recommendations for improving oversight efforts.

HHS wrote that it “will complete a comprehensive national review to assess the risk of Medicaid expenditures reported by states and allocate resources based on risk.”

This story was produced by , which publishes , an editorially independent service of the .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Just a quarter of practices were owned by hospitals eight years ago, according to the Tuesday in the journal Health Affairs. That type of rapid industry consolidation was associated with higher prices for primary care visits and treatment from specialists.

In areas with both high levels of consolidation among hospitals and between hospitals and physicians, researchers estimated there was a 12 percent increase in premiums on California’s health insurance exchange from fall 2013 through 2016, beyond the general rise in medical costs.

Acquisitions of physician practices by hospitals tend to be small and typically fly under the radar, said Richard Scheffler, the study’s lead author and professor of health economics and public policy at the University of California-Berkeley.

“But when you add them up, they are having an impact on outpatient prices and Affordable Care Act premiums,” he said. “I call it conglomerate care.”

He said the change in California hospital-physician ownership is more recent compared with the earlier consolidation within the hospital industry and among insurance companies, which also pushed up prices.

The percentage of California primary care physicians in practices owned by hospitals increased from 26 percent in 2010 to 38 percent in 2016, the study found. For the same period, the percentage of specialists in such practices jumped from 20 percent to 54 percent. For all physicians, the statewide figure grew from 24 percent to 39 percent, according to the study’s authors.

The steady decline of inpatient admissions has upended the normal business model for hospitals, and big systems are seeking more control over where patients get care outside their walls. The general trend toward buying doctors’ practices had been known, but the findings in the Health Affairs study make clear how big a change it is. Until recently, however, consolidation among insurers or hospital systems has attracted more attention from regulators and lawmakers.

A similar wave of hospital-physician consolidation has occurred nationally. From 2010 to 2016, the national share of office-based physicians who worked in hospital-owned organizations has increased from 30 percent to 48 percent, according to Scheffler and his co-authors.

Hospital and physician groups defend these mergers as good for patients, saying they help coordinate care that is often fragmented, duplicative and wasteful. The deals enable them to deliver care that’s less expensive and to negotiate more effectively with giant insurance companies, they say.

Carmela Coyle, chief executive of the California Hospital Association, said the study has serious flaws, drawing conclusions about supposed cost increases due to consolidation that aren’t supported by the data.

“These authors start from a place where consolidation and market concentration is bad,” Coyle said. “Our experience in health care suggests that bringing providers together can be a very good thing for communities and the patients they serve. It often preserves access and allows physicians to stay in the community.”

But critics of consolidation say that as large health systems gain market power, they can dictate where patients go for expensive tests and procedures. Some hospitals tack on “facility fees” for outpatient care, which boosts costs even further.

“These mega-enterprises are buying up everything and when you sit down to contract with them it’s ridiculously expensive,” said Glenn Melnick, a health care economist at the University of Southern California.

For instance, Northern California, where a few large health systems dominate the market and own many physician practices, has become the most expensive place in the country to have a baby.

Melnick co-authored a in Health Affairs, also out Tuesday, that described how a steady erosion of competition among hospitals in California has contributed to rising health care costs.

The prices paid by health plans to California hospitals declined by 26 percent from 1995 to 1999, a period when managed care was aggressive at negotiating lower prices. But a consumer backlash against tight controls on care and patient choice ensued, and that trend began to reverse in the early 2000s.

Prices increased by 238 percent from 2001 to 2016 — despite a 10 percent drop in the volume of care for commercially insured patients over that same period.

“Competition was working before, and now that competition has eroded,” Melnick said.

Some health care economists say hospitals and physician groups don’t need to merge in order to collaborate on patient care and that contracting could suffice without diminishing competition through outright acquisitions.

Antitrust enforcers are now giving such consolidation more scrutiny.

In March, California Attorney General Xavier Becerra sued Sutter Health, accusing the health system of overcharging patients for years and illegally driving out competition in Northern California. Part of that case centers on Sutter’s big medical groups, which are a key source for patient referrals and admissions into Sutter facilities. Overall, the nonprofit chain has 24 hospitals, 36 surgery centers and more than 5,500 physicians in its network.

Sutter denies any anticompetitive behavior and touts the benefits of offering patients a broad array of services. “Our integrated network of high-quality doctors and care centers aims to provide better, more efficient care — and has proven to help lower costs,” Sutter said in a recent statement.

Other states have pursued legal action on this front. Last year, for instance, the Washington state attorney general’s office system to unwind its acquisition of two medical groups, saying those deals violated antitrust law and would harm consumers.

Meantime, California lawmakers have tried to ban certain contracting practices used by large health systems, such as “all or nothing” provisions that force health plans to accept all of their facilities and medical groups systemwide. However, for the second consecutive year, failed to advance amid opposition from the hospital industry.

Of course, the doctor’s office — whether it’s owned by a hospital or not — isn’t the only option for many consumers nowadays. Many people visit clinics run by retailers, such as CVS, or talk to a doctor through an app on their smartphone.

Scheffler said his study didn’t examine whether the quality of care had improved under hospital-controlled physician practices. He said, however, that the evidence of any quality improvement is thin so far, and he challenged providers to make their case.

“We want them to integrate care,” Scheffler said. “But if it’s giving them market power and increasing prices, is it worth it?”

This story was produced by , which publishes , an editorially independent service of the .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

La historia de Drew Calver fue reportada por Kaiser Health News y NPR como parte de la serie “Bill of the Month” (Cuenta del Mes), que examina los precios de atención médica en los Estados Unidos y los problemas a los que se enfrentan los pacientes en una industria que genera $3.5 mil millones al año.

Calver, un profesor de historia de 44 años y papá de dos niñas, sufrió un ataque cardíaco en abril de 2017 y un vecino lo llevó rápidamente a la sala de emergencias más cercana, que era un hospital fuera de la red de su plan de salud del distrito escolar de Austin. Su seguro le pagó al hospital casi $56,000 por su hospitalización de cuatro días y un procedimiento para colocar cuatro stents en su arteria afectada.

Pero el hospital, St. David’s Medical Center en Austin, no se conformó con esa cantidad y fue tras el profesor de escuela secundaria, y entrenador de natación, por un adicional de $109,000 en una práctica conocida como “facturación de saldo”.

A las pocas horas de la publicación de la historia, el 27 de agosto, el hospital ofreció renunciar a casi toda la factura y cobrarle, en su lugar, $782.29. Días después, St. David’s bajó la cantidad aún más. Calver dijo que lo pagó por teléfono, ansioso por dejar atrás esta saga estresante.

Agregó que es un alivio que su familia no tenga que enfrentar una factura de seis cifras y amenazas del cobrador de deudas del hospital. Pero dijo que le preocupa que otros pacientes golpeados por cuentas médicas injustas de $10,000 o $20,000 no capten la atención de los medios.

“Es muy bueno que esto haya terminado para mí y para mi familia. Pero no se trata solo de mi factura”, expresó Calver en una entrevista. “No creo que ningún consumidor deba pasar por esto”.

Calver y su esposa, Erin, dijeron que se sintieron alentados por el apoyo y atención efusiva que recibieron. Drew Calver dio entrevistas a la televisión local y su historia apareció en el programa de CBS This Morning. La pareja dijo que tiene la esperanza que el debate nacional dé lugar a cambios que ayuden a otros consumidores en todo el país.

Justo después de pagar su factura del hospital, Calver caminó a la cafetería de la escuela para almorzar. Una de las trabajadoras de la cafetería se le acercó y le dijo que ella también enfrentaba una gran factura médica del mismo hospital de Austin. Calver dijo que planea ayudarla como pueda.

“Esta es la forma en que puedo ayudar a otros”, dijo.

El sistema hospitalario, St. David’s HealthCare, continúa defendiendo cómo manejó la facturación de Calver, diciendo que “hizo todo bien en esta situación particular”. También señaló que informó a la familia en varias ocasiones que podían solicitar un descuento a través de un programa de asistencia financiera, basado en el ingreso de su hogar.

Calver dijo que no completó los trámites de asistencia financiera antes porque no sentía que debía pagar los $108,951, y que estuvo impugnando la validez de los cargos todo el tiempo.

Su plan de salud dijo que los $55.840 que pagó deberían haber sido suficiente para el hospital. Y Calver ya estaba pagando $1,400 de coseguro, que era el monto de gasto de bolsillo calculado por su plan de salud.

HCA Healthcare es la dueña de St. David’s. Es la cadena hospitalaria con fines de lucro más grande del país, y también posee dos fundaciones sin fines de lucro.

El director ejecutivo de St. David’s HealthCare, C. David Huffstutler, escribió un memo dirigido a su junta directiva sobre la historia de Calver. Un empleado de St. David’s compartió la nota con Kaiser Health News, y el hospital no cuestionó su exactitud.

“Me doy cuenta que este no es el tipo de cobertura que cualquiera de nosotros quiere para St. David’s HealthCare”, escribió Huffstutler en su memo del 27 de agosto.

Huffstutler también escribió que los cargos del hospital de $165,000 eran “razonables y habituales”. Dijo que el distrito escolar y su administrador de plan de salud, Aetna, optaron por ofrecer un plan de red estrecho que “potencialmente puede representar una pesada carga financiera para el paciente”.

Defensores de los consumidores dijeron que el hospital debería haber borrado la factura por completo después de someter a la familia a tanto estrés durante meses.

La reducción drástica de la cuenta “muestra que estos números de hospitales simplemente se compensaron”, dijo Bonnie Sheeren, quien dirige Houston Health Advocacy y ayuda a los consumidores con sus facturas médicas. “Debe ser un saldo cero, y el hospital debe pagar las sesiones de terapia para ayudar a esta familia a recuperarse de la terrible experiencia de facturación”.

Varios estados han aprobado leyes o han introducido programas para proteger a los pacientes de facturas médicas inesperadas, en particular las derivadas de emergencias.

Pero esas reglas estatales no se aplican a la mayoría de los trabajadores en el país, porque obtienen su cobertura de salud de empleadores que están auto asegurados, lo que significa que las empresas pagan los reclamos con sus propios fondos. La ley federal gobierna la mayoría de esos planes de salud, y no incluye tales protecciones.

El representante Lloyd Doggett (demócrata de Texas) escuchó la historia de Calver en la radio mientras manejaba el mismo lunes 27 de agosto, e inmediatamente le escribió a la familia una carta ofreciéndole su apoyo. Calver enseña en la escuela secundaria a la que asistió Doggett.

El legislador propuso el año pasado un destinado a limitar la facturación sorpresa para los pacientes, pero dijo que no llegó a tener una audiencia en el Congreso actual.

“Este es un problema a nivel nacional, y necesitamos una solución a nivel nacional”, dijo Doggett en una entrevista. “Tenemos un sistema donde el paciente, la persona más vulnerable de todos los involucrados, queda atrapada entre la aseguradora y el proveedor de atención médica… Estos problemas son solucionables”.

Zack Cooper, profesor asociado de salud pública y economía en la Universidad de Yale, ha estudiado ampliamente las prácticas de facturación del hospital y dijo que la factura de casi $109,000 no fue un accidente.

Señaló que St. David’s, al igual que otros hospitales, promociona cortos tiempos de espera en sus salas de emergencia con el fin de atraer a pacientes fuera de la red, como Calver. Cooper dijo que su caso ilustra la necesidad de una mejor regulación de la facturación fuera de la red a nivel estatal o federal.

“La idea que un hospital envíe una factura que probablemente arruinará a un individuo es simplemente alucinante. Para mí, eso es emblemático de una cultura bastante tóxica”, dijo Cooper.

“Esta fue una historia notable, y le ha hecho un gran bien al paciente”, agregó Cooper. “Pero no deberíamos estar en un mundo donde para evitar la ruina financiera tienes que esperar que tu historia aparezca en la prensa. Podemos actuar mejor”.

Bill of the Month es una investigación de crowdsourcing de Kaiser Health News y NPR que disecciona y explica las facturas médicas.

Ashley López, reportera de la estación miembro de NPR KUT en Austin, contribuyó a la historia de audio en este informe.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

The story of Drew Calver was first reported by Kaiser Health News and NPR on Monday as part of the “Bill of the Month” series, which examines U.S. health care prices and the troubles patients run up against in the $3.5 trillion industry.

In Calver’s case, the 44-year-old father of two had suffered a heart attack in April 2017 and a neighbor rushed him to the nearest emergency room, which was an out-of-network hospital under his school district health plan. His insurance paid the hospital nearly $56,000 for his four-day hospitalization and procedures to clear his blocked “widow-maker” artery.

But the hospital, St. David’s Medical Center in Austin, wasn’t satisfied with that amount and went after the high school history teacher and swim coach for an additional $109,000 in a practice known as “balance billing.”

Within hours of the story publishing, the hospital offered to waive nearly the entire bill and charge him $782.29 instead. By Thursday, St. David’s lowered the amount even further. Calver said he paid it off over the phone, eager to put this stressful saga behind him.

Calver said it’s a relief that his family doesn’t face a six-figure bill and threatening letters from the hospital’s debt collector. But he said he worries about other patients hit with unjust medical bills of $10,000 or $20,000 who don’t catch the media’s attention.

“It feels great that this is over for me and my family. But this isn’t just about my bill,” Calver said in an interview. “I don’t feel any consumer should have to go through this.”

Calver and his wife, Erin, said they were encouraged by the outpouring of support and attention they received. Drew Calver gave local TV interviews after teaching class and his story was featured on CBS This Morning. The couple said they’re hopeful the national conversation that ensued will lead to changes that help other consumers across the country.

Just after paying off his hospital bill, Calver walked to the school cafeteria Thursday to grab lunch. One of the cafeteria workers approached him and shared that she, too, was facing a huge medical bill from the same Austin hospital. Calver said he plans to follow up with the woman and assist in any way he can.

“This is the next way I can be of help to others,” he said.

The hospital system, St. David’s HealthCare, continues to defend its handling of Calver’s bill, saying it “did everything right in this particular situation.” It also pointed out that it informed the family on several occasions that they could apply for a discount through a financial assistance program, based on their household income.

Calver said he didn’t fill out the financial assistance paperwork earlier because he didn’t feel he owed the $108,951 — and had been contesting the validity of the charges all along.

His health plan said the $55,840 it paid the hospital should have satisfied the hospital’s claim. And Calver was already paying $1,400 as coinsurance, which was the out-of-pocket amount calculated by his health plan.

HCA Healthcare, the largest for-profit hospital chain in the country, and two nonprofit foundations own St. David’s.

The chief executive of St. David’s HealthCare, C. David Huffstutler, wrote a memo Monday addressed to his board of governors about Calver’s story. A St. David’s employee shared the memo with Kaiser Health News, and the hospital didn’t dispute its accuracy.

“I realize this is not the type of coverage any of us want for St. David’s HealthCare,” Huffstutler wrote in his Aug. 27 memo. “With this story, we had a number of circumstances that made it difficult to neutralize the coverage — a monthly news segment that seeks to empower patients to challenge their medical bills; a gap in the system that is affecting patients … and, a compelling patient story.”

Huffstutler also wrote that the hospital’s charges of $165,000 were “reasonable and customary.” He said that the school district and its health plan administrator, Aetna, chose to offer a narrow network plan that “can potentially place a heavy financial burden on the patient.”

Consumer advocates said the hospital should have erased the bill completely after putting the family through so much stress for months.

The drastic reduction in the bill “shows that these hospital numbers are just made up,” said Bonnie Sheeren, who runs Houston Health Advocacy and assists consumers with their medical bills. “It should be a zero balance, and the hospital should pay for therapy sessions to help this family recover from the billing ordeal.”

Several states have passed laws or introduced programs to help shield patients from surprise medical bills, particularly those stemming from emergencies.

But those state rules don’t apply to most U.S. workers because they get their health coverage from employers that are self-insured, meaning the companies pay claims out of their own funds. Federal law governs most of those health plans, and it does not include such protections.

Rep. Lloyd Doggett (D-Texas) heard Calver’s story on the radio while driving Monday and immediately wrote the family a letter offering his support. Calver teaches at the high school that Doggett attended.

The lawmaker proposed last year aimed at limiting surprise billing for patients, but he said it hasn’t received a hearing in the current Congress.

“This is a nationwide problem, and we need a nationwide solution,” Doggett said in an interview. “We have a system where the patient, the most vulnerable person of all those involved, is caught between the insurer and the health care provider. … These problems are solvable.”

Zack Cooper, an associate professor of public health and economics at Yale University, has studied hospital billing practices extensively and said the nearly $109,000 bill was no accident.

He noted that St. David’s, like other hospitals, advertises short wait times for its emergency rooms in order to attract out-of-network patients like Calver. Cooper said his case illustrates the need for better regulation of out-of-network billing at the state or federal level.

“The idea that a hospital would send a bill that will probably bankrupt an individual boggles the mind. For me, that is emblematic of a fairly toxic culture,” Cooper said.

“This was a remarkable story, and it has done remarkable good for him,” Cooper added. “But we shouldn’t be in a world where to avoid financial ruin you have to hope your story is featured in the popular press. We can do better than this.”

Bill of the Month is a crowdsourced investigation by Kaiser Health NewsÌý²¹²Ô»åÌýthat dissects and explains medical bills.

Ashley Lopez of member station KUT in Austin contributed . “CBS This Morning” featured it on Wednesday.

Do you have a bill you would like us to examine? Submit it here.

This story was produced by , which publishes , an editorially independent service of the .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Minutos más tarde, el popular profesor de historia de escuela secundaria y entrenador de natación en Austin, Texas, colapsó en su habitación por un ataque al corazón. Calver golpeó con el puño el marco de la cama, mientras violentos dolores en el pecho lo inmovilizaban en el suelo.

“Pensé que me estaba muriendo”, recordó este padre de 44 años. Calver llamó a la única persona que había en la casa, su hija mayor, Eleanor, quien ahora tiene 7 años. Utilizando la voz, le envió un mensaje de texto a su esposa, quien estaba con su hija menor, Emory, ahora de 6 años. Un vecino lo llevó a la sala de emergencias más cercana en el St. David’s Medical Center, el 2 de abril de 2017

Los médicos confirmaron el trauma en el corazón de Calver y lo internaron en la unidad cardíaca del hospital. Al día siguiente, le implantaron stents en la arteria obstruida.

El ataque al corazón fue un shock para Calver, un nadador experimentado que había competido en un triatlón “Ironman” solo cinco meses antes.

En medio de la crisis, en su cama en el hospital, Calver preguntó si su seguro de salud cubriría todo esto, una preocupación financiera que acompaña a casi todas las estadías hospitalarias en los Estados Unidos. Estaba preocupado porque St. David’s estaba fuera de la red de su plan de salud del distrito escolar. El hospital le dijo que no se preocupara y que aceptarían su seguro, contó Calver.

El hospital cobró $164,941 por su cirugía y cuatro días en el hospital. Aetna, que administra beneficios de salud para el Distrito Escolar Independiente de Austin, pagó al hospital $55,840, según los registros. A pesar de la diferencia de más de $100,000, con la garantía previa del hospital, Calver creía que no pagaría mucho, o nada, de su propio bolsillo por aquella emergencia potencialmente mortal y la cirugía que lo salvó.

Pero luego comenzaron a llegaron las facturas.

Paciente: Drew Calver, de 44 años, profesor de historia de secundaria y padre de dos niñas en Austin, Texas.

Factura total: $164,941 por una estadía en el hospital de cuatro días, incluyendo $42,944 por cuatro stents y $10,920 por la habitación. La aseguradora de Calver pagó $55,840. El hospital facturó a Calver por el saldo remanente de $108,951.31.

Proveedor de servicios: St. David’s HealthCare, un sistema de hospitales en el centro de Texas. Pertenece a HCA Healthcare, una de las mayores cadenas de hospitales privados del país, con dos fundaciones sin fines de lucro.

Tratamiento médico: tratamiento en la sala de emergencia seguido de cuatro días en el hospital, la mayor parte en la unidad cardíaca. Durante la cirugía, se implantaron cuatro stents para despejar una obstrucción en su arteria descendente anterior izquierda, que provoca los llamados ataques cardíacos “de viuda”, porque con frecuencia son mortales.

Resultado: el Centro Médico St. David’s factura a Calver el saldo de $109,000, una cantidad que es casi el doble de su salario anual como maestro.

La compañía de facturación del hospital envió un aviso el 26 de junio instándolo a aprovechar esta

“Me van a provocar otro ataque al corazón, estresándome con esta factura”, expresó Calver. “No puedo pagarla con mi salario de maestro, y no quiero que esto vaya a una agencia de recolección de deudas”.

A raíz de su ataque al corazón, Calver fue víctima de dos prácticas de facturación médica que acosan cada vez más a muchos estadounidenses, incluso cuando los legisladores han tratado de protegerlos: facturas sorpresa y facturación de saldos.

Las facturas sorpresa ocurren cuando un paciente ingresa en un hospital de su red de seguros, pero recibe tratamiento de un médico que no participa en la red, lo que genera una factura directa al paciente. También pueden ocurrir en casos como el de Calver, donde las aseguradoras pagarán la atención de emergencia necesaria en el hospital más cercano, incluso si está fuera de la red, pero es posible que el hospital y la aseguradora no acuerden un precio razonable. El hospital luego exige que los pacientes paguen la diferencia, en una práctica llamada facturación de saldos.

Varios estados, incluyendo Texas (así como también Nueva York, California y Nueva Jersey), han aprobado leyes para ayudar a proteger a los consumidores de las facturas sorpresa y la facturación de saldo, particularmente para la atención de emergencia.

Pero existe una : las protecciones impuestas por el estado generalmente no se aplican a las personas, como la familia Calver, que obtienen su cobertura de salud de los empleadores que están auto asegurados, lo que significa que las compañías o los empleadores pagan reclamos con sus propios fondos. La ley federal rige la mayoría de esos planes de salud, y no incluye tales protecciones.

 de las personas con beneficios de salud del empleador están cubiertos por planes auto asegurados, pero muchos ni siquiera lo saben, ya que los empleadores suelen contratar a una aseguradora para administrar el plan y los empleados llevan una tarjeta con el nombre de Blue Cross Blue Shield u otra gran aseguradora.

Este caso “ilustra los peligros que enfrentan incluso las personas aseguradas”, señaló Carol Lucas, abogada de Los Ángeles con experiencia en disputas de pagos de atención médica. “La injusticia resulta más dramática cuando hay una emergencia y el paciente, que normalmente cumpliría con las normas, no tiene voz sobre el lugar en el que termina recibiendo atención médica”.

En un comunicado, St. David’s HealthCare defendió la forma en que se facturó a Calver y culpó al distrito escolar y a Aetna por ofrecer una red tan reducida.

“Si bien actuamos de manera correcta en esta situación particular, la estructura del plan de seguro del paciente con una red reducida colocó una gran parte de la responsabilidad financiera directamente sobre el paciente porque nuestro hospital no estaba dentro de esa red”, comunicó el hospital.

Los pacientes que experimentan una emergencia corren un riesgo mayor de terminar en un hospital fuera de la red. St. David’s dijo que, una vez que los pacientes de la sala de emergencias se consideran estables, tratan de transferirlos a una instalación dentro de su red. “Sin embargo, esto no siempre es posible porque la salud del paciente debe ser lo primero”, indicó el hospital.

Este caso también genera dudas sobre la validez de la factura del hospital.

Analistas de la industria y defensores de los consumidores dicen que St. David’s tiene una reputación de facturación exorbitante y de tratar de cobrar grandes cantidades como proveedor fuera de la red. “Es un proveedor bien conocido por ser problemático. Hemos visto varias facturas de ellos y siempre están muy infladas “, dijo el doctor Merrit Quarum, director ejecutivo de WellRithms, que analiza las facturas médicas de los empleadores autofinanciados y otros clientes en todo el país.

A pedido de Kaiser Health News, WellRithms revisó la factura de Calver en detalle, y determinó que un reembolso razonable hubiera sido de $26,985. Eso es menos de la mitad de

Healthcare Bluebook, que ofrece estimaciones de costos para pruebas y tratamientos médicos, llegó a una conclusión similar. Para ellos, un precio justo por una hospitalización en Austin con cuatro stents cardíacos sería de aproximadamente $36,800. El Centro Médico St. David’s cobró cuatro veces esa cantidad.

Quarum y otros analistas que revisaron la factura dijeron que llamaba la atención varios cargos, especialmente en los cuatro stents, que fueron facturados a $42,944. Los stents coronarios son típicamente tubos de malla metálica implantados en arterias para mejorar el flujo sanguíneo. La mayoría están cubiertos con drogas para ayudar a la curación.

St. David’s cobró $19,708 por cada uno de los dos stents Synergy fabricados por Boston Scientific. Otros dos stents utilizados fueron mucho más baratos.

El precio de $20,000 representa un recargo importante en comparación con lo que los hospitales a nivel nacional suelen pagar por stents. El precio promedio pagado por los hospitales por el stent Synergy fue de $1,153 el año pasado, según la firma de investigación sin fines de lucro ECRI Institute.

“El cobro del [Hospital] St. David’s de más de $19,000 por esos stents es absolutamente escandaloso”, expresó Quarum.

St. David’s se negó a comentar sobre el precio de los stents o sobre lo que realmente le pagó al fabricante.

Resolución: por ahora, Calver aún enfrenta una factura de $108,951.31, sin que ninguna de las partes involucradas en su tratamiento o cobertura proporcione alivio alguno.

De hecho, la compañía cobradora de deudas del hospital envió en la que se exigía el pago completo.

Después que un periodista hizo averiguaciones, St. David’s explicó que por el momento se habían suspendido las acciones para cobrar la deuda, y un representante del hospital llamó a Calver ofreciéndole ayuda para solicitar un descuento basado en sus ingresos.

En un comunicado, St. David’s dijo que “trabajamos con todos los pacientes que necesitan asistencia financiera para ayudar a determinar su elegibilidad para este descuento”.

Calver dijo que el enfoque no aborda la facturación del saldo o si los cargos eran apropiados.

Una portavoz de Aetna indicó que “estamos trabajando activamente para rectificar la situación en nombre del paciente”. Pero el plan de salud no ha compartido más detalles. El distrito escolar de Austin se negó a discutir este caso específico.

Calver dijo que toda la experiencia ha sido increíblemente estresante para él y su esposa.

“Estoy atrapado en medio de este sistema intrincado y defectuoso”, dijo. “Nunca he debido una cantidad tan grande como ésta ni siquiera una deuda de tarjeta de crédito. ¿Qué pasaría si esto se refleja a mi reporte de crédito?”

La Lección: ante una factura sorpresa o una situación de facturación de saldos, no se apresure a pagar las facturas médicas que reciba. En primer lugar, deje que el proceso del seguro se cumpla por completo para asegurarse de lo que el plan de salud paga al hospital y a los médicos, y de lo que en última instancia podría ser responsable, en términos de coseguro o copagos.

Solicita una factura detallada. Revisae los cargos cuidadosamente y habla con su aseguradora, su empleador y el hospital si los precios parecen excesivos. Documéntate sobre las estimaciones que puede encontrar en internet de los precios promedio cobrados en su área a medida que negocia con las partes implicadas.

Si las facturas siguen llegando, habla con el departamento de beneficios de su empleador o el departamento de seguros del estado sobre sus protecciones legales. La situación variará según el tipo de seguro de salud que tenga y el estado en el que viva. Díle a cualquier agencia de cobro de deudas que lo contacte que está impugnando la factura.

Con cualquiera de estas entidades, siempre puedes recurrir a la razón argumentando lo siguiente: no tuviste más remedio que ir a un hospital fuera de la red al sufrir una emergencia que puso en peligro su vida, por lo que la aseguradora y el hospital deberían llegar a un acuerdo sobre el pago y mantenerte a salvo de facturas que te incapacitarían financieramente.

ACTUALIZACIÓN: poco después de la publicación y transmisión de esta historia por Kaiser Health News y NPR, St. David’s dijo que ahora estaba dispuesto a aceptar $782.29 para resolver el saldo de $108,951 porque Drew Calver califica para su “descuento de asistencia financiera”. En un comunicado, el hospital dijo que esta oferta dependía de que Calver presentara su solicitud de descuento en función de las finanzas de su hogar. Calver negó que deba dinero adicional a St. David’s y dijo que esta situación debería haberse resuelto hace mucho tiempo.

Bill of the Month es una investigación de crowdsourcing de Kaiser Health News y NPR que disecciona y explica las facturas médicas.

Ashley López, reportera de la estación miembro de NPR KUT en Austin, contribuyó a la historia de audio en este informe.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Minutes later, the popular high school history teacher and swim coach in Austin, Texas, collapsed in his bedroom from a heart attack. He pounded his fist on the bed frame, violent chest pains pinning him to the floor.

“I thought I was dying,” the 44-year-old father recalled. He called out to the only other person in the house, his oldest daughter, Eleanor, now 7. Using his voice, he texted his wife, who was at the store with their youngest, Emory, now 6. A neighbor rushed him to the nearby emergency room at St. David’s Medical Center on April 2, 2017.

The ER doctors confirmed the trauma to Calver’s heart and admitted him to the hospital’s cardiac unit. The next day, doctors implanted stents in his clogged “widow-maker” artery.

The heart attack was a shock for Calver, an avid swimmer who had competed in an Ironman triathlon just five months before.

Despite the surprise, even from his hospital bed, Calver asked whether his health insurance would cover all of this, a financial worry that accompanies nearly every American hospital stay. He was concerned because St. David’s is out-of-network on his school district health plan. The hospital told him not to worry and that they would accept his insurance, Calver said.

The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, . Despite the difference of more than $100,000, with the hospital’s prior assurance, Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him.

And then the bills came.

Patient: Drew Calver, 44, a high school history teacher and father of two in Austin, Texas.

Total Bill: $164,941 for a four-day hospital stay, including $42,944 for four stents and $10,920 for room charges. Calver’s insurer paid $55,840. The hospital billed Calver for the unpaid balance of $108,951.31.

Service Provider: St. David’s HealthCare, a large hospital system in central Texas. It’s run by HCA Healthcare, the nation’s largest for-profit hospital chain, and two nonprofit foundations.

Medical Treatment: Emergency room treatment followed by four days in the hospital, most of it spent in the cardiac unit. During surgery, four stents were implanted to clear a blockage in his left anterior descending artery, the source of so-called widow-maker heart attacks, because they are so frequently deadly.

What Gives: St. David’s Medical Center is billing Calver for the $109,000 balance — an amount nearly twice his annual pay as a teacher.

The hospital’s billing company sent a notice June 26, urging him to take advantage of this “”

“They’re going to give me another heart attack stressing over this bill,” Calver said. “I can’t pay this bill on my teacher salary, and I don’t want this to go to a debt collector.”

In the wake of his heart attack, Calver fell victim to twin medical billing practices that increasingly bedevil many Americans, even as legislators have tried to protect them: surprise bills and balance billing.

Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor that does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver’s, where insurers will pay for needed emergency care at the closest hospital — even if it is out-of-network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.

Several states, including Texas (as well as New York, California and New Jersey) have passed laws to help shield consumers from surprise bills and balance billing, particularly for emergency care.

But there’s : Those state-mandated protections typically don’t apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or employers pay claims out of their own funds.  Federal law governs most of those health plans — and it does not include such protections.

About of people with employer health benefits are covered by self-insured plans, but many don’t even know it, since employers typically hire an insurer to administer the plan and employees carry a card bearing the name of Blue Cross Blue Shield or another major insurer.

This case “illustrates the dangers that even insured people face,” said Carol Lucas, an attorney in Los Angeles with experience in health care payment disputes. “The unfairness is especially acute when there is an emergency and the patient, who might ordinarily be completely compliant, has no say about the facility he winds up in.”

In a statement, St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network.

“While we did everything right in this particular situation, the structure of the patient’s insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network,” the hospital said.

Patients experiencing an emergency are particularly at risk of landing at an out-of-network hospital. St. David’s said once ER patients are deemed stable, it tries to transfer them to an in-network facility. “However, this is not always possible because the patient’s health must come first,” the hospital said.

This case also raises questions about the validity of the hospital’s charges.

Industry analysts and consumer advocates say St. David’s has a reputation for exorbitant billing and for trying to collect big payouts as an out-of-network provider. “This is a well-known, problematic provider. We’ve seen multiple bills from them and they are always highly inflated,” said Dr. Merrit Quarum, chief executive of WellRithms, which scrutinizes medical bills for self-funded employers and other clients nationwide.

WellRithms reviewed Calver’s bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That’s less than half .

Healthcare Bluebook, which offers cost estimates for medical tests and treatments, arrived at a similar conclusion. It said a fair price for a hospitalization in Austin involving four heart stents would be about $36,800. St. David’s Medical Center charged four times that amount.

Quarum and other analysts who reviewed the bill said several charges stood out, especially on the four stents, which were billed at $42,944. Coronary stents are typically metal mesh tubes implanted in arteries to improve blood flow. Most are coated with drugs to assist in healing.

St. David’s charged $19,708 apiece for two Synergy stents made by device giant Boston Scientific. Two other stents used were far cheaper.

The $20,000 price tag represents a significant markup of what U.S. hospitals typically pay themselves for stents. The median price paid by hospitals for the Synergy stent was $1,153 over the past year, according to the nonprofit research firm ECRI Institute.

“St. David’s charge of over $19,000 for those stents is absolutely outrageous,” Quarum said.

St. David’s declined to comment on its markup for the stents or what it actually paid the manufacturer.

Resolution: For now, Calver still faces a bill for $108,951.31, with none of the parties involved in his treatment or coverage providing significant redress.

In fact, the hospital’s debt collector demanding payment in full.

After a reporter made inquiries, St. David’s said collection efforts were put on hold, and a hospital representative called Calver, offering to help him apply for a discount based on his income.

In a statement, St. David’s said “we work with all patients needing financial assistance to help determine their eligibility for this discount.”

Calver said that approach doesn’t address the balance billing or whether the charges were appropriate.

A spokeswoman for Aetna said “we are actively working to rectify the situation on behalf of the member.” But the health plan hasn’t shared any further details. The Austin school district declined to discuss this specific case.

Calver said the whole ordeal has been incredibly stressful for him and his wife.

“I am stuck in the middle of this convoluted, flawed system,” he said. “I’ve never owed a large amount like this or had credit card debt. What does it mean if this goes on my credit report?”

The Takeaway: Faced with a surprise bill or a balance-billing situation, don’t rush to pay any medical bills you receive. First, let the insurance process play out completely so you’re sure what the health plan is paying the hospital and doctors — and what you ultimately might be responsible for, in terms of coinsurance or copayments.

Ask for an itemized bill. Review the charges carefully and talk to your insurer, your employer and the hospital if the prices seem out of line. Arm yourself with estimates you can find online of the average prices charged in your area as you negotiate with all the players.

If the bills keep coming, talk to your employer’s benefits department or the state insurance department about your legal protections. The situation will vary depending on the type of health insurance you have and the state you live in. Tell any debt collection agencies that may contact you that you are contesting the bill.

With any of these entities, you can always appeal to reason, with this argument: You had no choice but to go to an out-of-network hospital in the case of a life-threatening emergency, so the insurer and the hospital should work out payment and hold you harmless from financially crippling bills.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and that dissects and explains medical bills.

Ashley Lopez, a reporter with NPR member station KUT in Austin, contributed to the audio story in this report.

This story was produced by , which publishes , an editorially independent service of the .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).