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'There's got to be a better system': The problem with posting health care prices

Jill Jank tries to be a wise consumer, whether it’s her money or someone else’s she’s spending.

The Lincoln woman compares prices on groceries and clothes, and on bigger items she consults Consumer Reports.

She’s even done her best to shop for health care — she’s called around for prices on stress tests and found the least expensive lab in town. When she needed an X-ray some years ago, she went to a less expensive location after being sent to a more costly one.

But Jank, 66, a registered dietitian, says tallying costs really only works when patients know what they need ahead of time. Even now that she’s on Medicare, it’s difficult to pull together all the pieces needed to get a full picture on costs.

“There’s got to be a better system,” she said. “You just can’t be a responsible citizen with this.”

Plenty of folks agree, particularly at a time when health care costs continue to rise, and a growing number of Americans have high-deductible plans that require them to pay a greater share of the first dollars toward their care.

As part of an ongoing push for greater price transparency, the federal government on Jan. 1 began requiring hospitals to post price lists on their websites.

It’s not clear whether all of the state’s hospitals have posted prices — there are no penalties for those that don’t — but the Omaha metropolitan area’s large health systems have met the mark. CHI Health and Methodist Health System, in fact, began offering online price tools in 2007.

Whether posting prices, at least as it’s currently done, will encourage people to shop and drive significant savings, however, appears questionable.

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Dr. Ateev Mehrotra, an associate professor at Harvard Medical School who studies how consumers use price information, said he and his colleagues haven’t seen any substantive effect from making price information available . That’s consistent with what others have found.

What’s been more effective, he said, and where interest is growing, are changes in benefits that reward people for moving to lower-cost providers — such as tiering providers by cost, the way drugs are tiered, or paying people cash rewards for choosing the lower-cost option.

Jana Danielson, Nebraska Medicine’s executive director of revenue cycle, said the intent behind publicizing pricing is good in the long run. “Just right now, for patients, it can be confusing,” she said.

Problem 1: The listed price isn’t straightforward

For starters, the lists include medical jargon and abbreviations not easily translated by most patients.

Nebraska Medicine’s spreadsheet, for instance, lists a “Closed TX post hip arthro disloc w/o anes,” for $1,257, which essentially involves putting a dislocated hip back in place. Could patients guess that? Would they know whether they’d also need imaging or other care?

Mike Feagler, vice president of finance for the Nebraska Hospital Association, said patients can get a good idea of prices for simple procedures — say, a chest X-ray — from the information hospitals post, if they know what their physician wants.

But figuring out all of the pieces that go into a more complex procedure, such as a surgery, would prove too much for most, said Feagler, who worked in a hospital finance department for 21 years.

Many variables can come into play. One patient may require more time in the operating room than another, even for the same surgery. Same goes for recovery time in the hospital. Two patients getting knee replacements may need different implants. And hospital price lists typically don’t include professional fees for the surgeon or the anesthesiologist.

And of course, for most patients, any thought of shopping typically goes out the window in an emergency.

Problem No. 2: The listed price isn’t what you actually pay

Health system officials also caution that the prices listed aren’t what patients actually will pay.

For patients with insurance, the actual price will be a discounted one, negotiated by their insurance company, said Dr. Debra Esser, chief medical officer for Blue Cross Blue Shield of Nebraska. Negotiated rates can vary by insurer and health system, even for the same procedure.

In an effort to get past that issue, President Donald Trump in late June signed an executive order that would require hospitals to publish the prices they negotiate with insurers, which traditionally have been confidential. Bipartisan legislation in the U.S. Senate would ban “gag clauses” that prevent parties to negotiations from disclosing that information.

Lee Handke, chief executive officer of the Nebraska Health Network, said posting negotiated prices might encourage health systems to be more competitive. But it also could have unintended consequences — a system with lower prices might decide it’s time to negotiate higher rates.

But Feagler, with the Nebraska Hospital Association, said making negotiated prices available still wouldn’t get to what patients really want to know.

“As a patient, what I want to know is what I’m paying out of pocket,” Feagler said. “I’m not worried about what the insurance company is paying the hospital.”

But, Handke said, the prices as currently posted help raise awareness about the true costs of health care services, including the impact on health care spending as a whole. Many people, particularly those with insurance, never see the full tally.

“I think that information starts to be empowering,” he said.

Problem No. 3: Historically, people don’t use price tools, although that may be changing

Historically, use of various price tools hasn’t been particularly high. But there are some indications that that may be changing.

A 2018 study by UnitedHealthcare indicated that more than one-third of Americans had used the Internet or mobile apps during the preceding year to comparison-shop for health care, up from 14% in 2012.

Katherine Bisek, the insurer’s vice president for strategic initiatives, said people who used their tools paid 36% less than nonusers, according to the insurer’s analysis of claims data from 2016.

Insurance companies recommend that members contact them or use their tools, which take into account the specifics of their insurance plans, to figure costs. Even nonmembers typically can get basic information. Users of UnitedHealthcare’s public website — uhc.com/transparency — can see average costs for various treatments and procedures, for instance; they have to log in to get out-of-pocket expenses.

Blue Cross’ Esser said millennials are more in tune with apps and tools. While they’re younger and healthier now, she said, she anticipates that they’ll use them more as they get older.

“They’re willing to go where they can get a good deal,” she said.

The hospital association’s Care Compare tool — nhacarecompare.com — allows prospective patients to select and compare prices among several hospitals. It now includes inpatient data. A pending upgrade will add outpatient information and improve ease of use.

How a hospital system’s financial counselors can help

Because of the complexity of the posted information, hospital finance officials advise patients to contact a financial counselor within their institutions to get an estimate. CHI Health, Methodist and Nebraska Medicine automatically provide estimates for many prescheduled services.

“We do everything we can to make the process for our patients as seamless as possible,” said Jeff Francis, Methodist’s chief financial officer. “Because it can be unsettling for people talking about finances when they’re also worried about their physical well-being. The more we can make it easier for them, the more they can focus on getting well after the procedure.”

Counselors typically provide a range and a mid-point, based on the patient’s insurance. They also factor in how much of a patient’s insurance deductible has been met, if it’s available from the insurer.

“We may not know all of their out-of-pocket expenses at the time,” said Nebraska Medicine’s Danielson. “So there’s always a disclaimer. But generally, we’re pretty close, which is nice.”

Danielson said Nebraska Medicine has counselors in many locations, including most clinics. In those that don’t, patients can reach a counselor by video link. Since an upgrade this spring, patients also can get estimates by logging in to the health system’s patient portal.

“We’re going to meet them where they’re at, as much as possible,” she said.

Jank, the Lincoln resident, said she has no answers. She just wants the process to be easier.

“I’d love to have prices posted if they were practical to use them,” she said.

17 rare and unusual health stories out of Omaha

Politics
Donors wait to jump in as uncertainty clouds the 2nd District Democratic primary

U.S. Rep. Don Bacon has raised far more money than all of his potential Democratic challengers combined — a gap that can be attributed to the power of incumbency, the early campaign announcements from top Democrats and uncertainty among donors.

According to the latest Federal Election Commission filings, Bacon, of the Omaha area’s 2nd District, is sitting on more than half a million dollars, compared with $36,000 for Democrat Ann Ashford and $120,000 for Democrat Kara Eastman.

In the first half of this year, each has raised the following: Bacon, $800,000; Eastman, $150,000; and Ashford, $100,000, including a $10,000 loan from the candidate herself.

In a district that’s often seen as one of the closest in the country, these figures show that either Democrat has a large gap to make up in order to compete with Bacon in a general election.

Money buys more access to voters — through TV and newspaper ads, mailers and other means — and is key in getting a lesser-known candidate’s name out there.

Incumbents are generally able to raise more money than challengers. So the partisan fundraising gap in part can be attributed to the fact that it’s still early for the challengers to be ramping up.

But it’s also a sign that Democratic donors are feeling uncertainty — about whether another candidate will jump in the race, about the political climate in 2020, and about who would be the best candidate to take on Bacon.

“Major donors are sitting on the sidelines,” said Nebraska Democratic Party Chairwoman Jane Kleeb, who said she’s not sure if another candidate will jump in.

But Kleeb said she thinks Democrats will come through for the eventual nominee.

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“The fundraising numbers right now are not an indicator of the desire to get rid of both Dons (Bacon and Trump),” she said.

The Eastman and Ashford campaigns pointed to the 20-plus-candidate Democratic presidential field, saying that race is taking both attention and money that could otherwise go to the 2nd District.

“We’ve only really just gotten started with our fundraising,” said Eric Aspengren, Ashford’s campaign manager. “Campaigns get expensive so every single one of those dollars counts, even this early. It’s going to be a long race.”

Eastman’s finance director, Dave Pantos, said that she met her goal for the quarter and that the team was happy with what it has taken in.

“Kara’s the by far leading Democrat, and I think we’re competitive with Bacon,” he said.

One key fundraising difference is that Eastman has long refused to receive contributions from political action committees associated with businesses. Ashford’s campaign said she will not refuse such money unless it’s affiliated with an industry or organization that she disagrees with, such as a gun manufacturer.

Pantos said donors are looking to not just give to a candidate who matches their values — but also to the candidate who can unseat Bacon.

This is a major area where Eastman and Ashford differ. Eastman has long said that the way to win the 2nd District is to embrace progressive issues such as “Medicare for All” and to court Democratic voters.

Ashford strikes a more moderate tone, arguing that messages about bipartisanship will persuade independent voters to turn the tide in Democrats’ favor. She has gained the support of party establishment such as former Sens. Bob Kerrey and Ben Nelson.

This difference played out in last year’s primary, when Eastman challenged Brad Ashford — husband of Ann and former congressman — for the party’s nomination.

Eastman started as an underdog. But she went on to beat Ashford in the primary — though the Democratic Congressional Campaign Committee supported the former congressman over her — but lost to Bacon on Election Day by about 2 percentage points.

Kleeb noted that 2020 will be the first time that independent voters can vote in a primary election in which presidential candidates are also on the ballot.

(In previous years they could vote in primaries but Nebraska Democrats held caucuses to select the Democratic presidential candidate. Before caucuses, independents could not vote in the primary.)

Bacon’s political director, Kyle Clark, struck a confident tone about the latest figures: “Nebraskans are showing incredible support for Don, and he couldn’t be more grateful. Based on great feedback from independents and swing voters, it is abundantly clear where people stand: they want civility, they want common sense, and they want Gen. Bacon to stay in Congress.”

The teams of both Eastman and Ann Ashford’s say they’ll have the resources to compete in the general election.

At this point, one major question is whether the 2nd District will draw outside groups such as the Democratic Congressional Campaign Committee and others not directly affiliated with the Democratic Party.

Such groups will come in to a district if they think the race will be close to buy ads on behalf of their favored candidate. If that kind of money flows into Omaha, it could make up for any gap in candidate fundraising.

John Ewing, a Democrat and the Douglas County treasurer, said outside groups were key when he ran for the office against incumbent Rep. Lee Terry in 2012. He struggled to convince donors that his candidacy was viable, and he ended up facing a Catch-22.

“The problem I saw when I ran in 2012 was that I had the DCCC wanting me to show better fundraising numbers in the district, and I had the people in the district wanting me to have some commitment from the DCCC,” he said.

Donations started coming in toward the end of the campaign — but the lack of early support put Ewing at a disadvantage in getting his message out, especially to those who voted early. In the end, he lost to Terry by less than 2 percentage points.

The DCCC — which aims to get Democrats elected to the House across the country — was criticized by Eastman’s camp for not investing enough in Nebraska’s 2nd District in 2018. But, the group has noted that it did spend “six figures” in the district to help Eastman.

When asked about the latest fundraising numbers and how the group decides to invest in a particular candidate, DCCC spokesman Mike Gwin said the group is “closely targeting” the district.

“Don Bacon is vulnerable,” he said in a statement. “The DCCC is closely targeting this district because we know that Nebraskans are ready for a leader who will look out for working families.”

Ewing said he thinks that Nebraska’s 2nd District remains purple and that the Democratic nominee, with sufficient resources, could overtake Bacon.

“It’s always winnable,” he said. “I just think it’s tougher if you don’t have the money to actually be able to be in front of the voters as much as possible.”

Meet the Nebraska state senators

Articles
Programs to detect weapons of mass destruction have been gutted

WASHINGTON — The Trump administration has quietly dismantled or cut back multiple programs that were created after the Sept. 11, 2001, attacks to help detect and prevent terrorism involving weapons of mass destruction, a Los Angeles Times investigation has found.

The retreat has taken place over the last two years at the Department of Homeland Security. That agency has primary domestic responsibility for helping authorities identify and block potential chemical, biological, radiological and nuclear threats.

The changes, not previously reported, were made without rigorous review of potential security vulnerabilities, the Times found, undermining government-wide efforts aimed at countering terrorist attacks involving unconventional weapons, known as WMD.

More than 30 current and former Homeland Security employees and contractors voiced concern that the changes — including the cancellation of dozens of training exercises and the departure of scores of scientists and policy experts — have put Americans at greater risk.

"What we had done in the past was analytically based: Where are the threats? Where can we get the most return on the taxpayers' investment for security?" said Paul Ryan, who until mid-2017 helped lead Homeland Security's Domestic Nuclear Detection Office, which was merged with another office last year.

"We're not as secure as we were 18 months ago," said Ryan, a retired Navy rear admiral.

The cutbacks and shifts have been directed by James McDonnell, who has been appointed by President Donald Trump to successive posts at Homeland Security, a long-troubled department that has seen waves of leadership changes and policy upheaval since 2017.

McDonnell declined through a Homeland Security spokeswoman to be interviewed for this report, and the department did not answer written questions submitted June 27.

On July 15, the spokeswoman, Ruth Clemens, emailed a three-sentence statement, saying that the Countering Weapons of Mass Destruction Office, which McDonnell heads, "is focused on preventing WMD terrorism by working with federal, state, and local partners across the nation."

It also said, "some programs were realigned or restructured to better address threats, remove bureaucratic redundancy, and fully align with (Trump's) National Security Strategy."

Trump pledged in that 2017 document to "augment measures to secure, eliminate, and prevent the spread of WMD and related materials ... to reduce the chance that they might fall into the hands of hostile actors."

Among the programs gutted since 2017, however, was an elite Homeland Security "red team," whose specialists conducted dozens of drills and assessments around the country each year to help federal, state and local officials detect potential threats such as an improvised nuclear device concealed in a suitcase, or a cargo ship carrying a radiation-spewing "dirty bomb."

Another Homeland Security unit, the Operations Support Directorate, had helped lead up to 20 WMD-related training exercises each year with state and local authorities. The directorate participated in less than 10 such exercises last year and even fewer so far this year, according to internal Homeland Security documents.

Experts at Homeland Security's National Technical Nuclear Forensics Center had worked with counterparts throughout the federal government to strengthen detection and tracing capabilities that might deter a hostile foreign state from slipping radiological or nuclear material to terrorists.

The center has been reduced to a shell: Its leadership is out and its staff has shrunk to three positions from about 14.

A separate Homeland Security component, the International Cooperation Division, which worked closely with foreign counterparts and the United Nations nuclear watchdog agency to track and stop the smuggling of dangerous nuclear materials overseas, has been disbanded.

Also cut back was the use of specialized mobile detection units to help protect large public events from nuclear and radiological threats. The deployments have helped train local and state responders for a potential emergency.

For the first time in years, Homeland Security did not send a unit to protect the NCAA Final Four college basketball championship in April in Minneapolis or to an annual hot air balloon festival last fall in Albuquerque.

Homeland Security also has halted work to update a formal "strategic, integrated" assessment of chemical, biological and nuclear-related risks.

The assessment had previously analyzed millions of potential WMD threat scenarios. Under a directive President George W. Bush signed in 2007, the assessment is supposed to be updated at least every other year.

Overall, more than 100 scientists and policy experts specializing in radiological and nuclear threats have been reassigned or left to take jobs unrelated to their expertise, the Times found, undermining the department's ability to protect the nation from devastating attacks.


Articles
Ancient life awakens amid thawing ice caps and permafrost

From about 1550 to 1850, a global cold snap called the Little Ice Age supersized glaciers throughout the Arctic.

On Canada's Ellesmere Island, Teardrop Glacier extended its frozen tongue across the landscape and swallowed a small tuft of moss. Since 1850, the plant lay frozen under a 100-foot-thick slab of ice as humans discovered antibiotics, visited the moon and burned 2 trillion tons of fossil fuels.

Evolutionary biologist Catherine La Farge arrived a decade ago at Teardrop's melting edge to find the tuft of the species Aulacomnium turgidum finally free from its icy entombment. The moss was faded and torn but sported a verdant hue — a possible sign of life.

Climate change stories often highlight the teetering fragility of Earth's ecological system. The picture grew even more dire when a United Nations report said that 1 million of our planet's plant and animal species face the specter of extinction. But for a few exceptional species, thawing ice caps and permafrost are starting to reveal another narrative — one of astonishing biological resilience.

Researchers in a warming Arctic are discovering organisms, frozen and presumed dead for millennia, that can bear life anew. These ice age zombies range from simple bacteria to multicellular animals, and their endurance is prompting scientists to revise their understanding of what it means to survive.

"You wouldn't assume that anything buried for hundreds of years would be viable," said La Farge, who researches mosses at the University of Alberta. In 2009, her team was scouring Teardrop's margin to collect blackened plant matter spit out by the shrinking glacier. Their goal was to document the vegetation that long ago formed the base of the island's ecosystem.

"The material had always been considered dead. But by seeing green tissue, I thought, 'Well, that's pretty unusual,' " La Farge said about the centuries-old moss tufts she found.

She brought dozens of these curious samples back to Edmonton, lavishing them with nutrient-rich soils in a bright, warm laboratory. Almost a third of the samples burst forth with new shoots and leaves. "We were pretty blown away," La Farge said. The moss showed few ill effects of its multi-centennial deep-freeze.

It's not easy to survive being frozen solid. Jagged ice crystals can shred cell membranes and other vital biological machinery. Many plants and animals simply succumb to the cold at winter's onset, willing their seeds or eggs to spawn a new generation come spring.

Mosses have forged a tougher path. They desiccate when temperatures plummet, sidestepping the potential hazard of ice forming in their tissues. And if parts of the plant do sustain damage, certain cells can divide and differentiate into all the various tissue types that make up a complete moss, similar to stem cells in human embryos.

Thanks to these adaptations, mosses are more likely than other plants to survive long-term freezing, said Peter Convey, an ecologist with the British Antarctic Survey.

On the heels of La Farge's Canadian moss revival, Convey's team announced that it had awakened a 1,500-year-old moss buried more than 3 feet underground in the Antarctic permafrost.

"The permafrost environment is very stable," said Convey, noting that the perennially frozen soil can insulate the moss from surface-level stresses, such as annual freeze-thaw cycles or DNA-damaging radiation.

The regrowth of centuries-old mosses suggests that glaciers and permafrost are not merely graveyards for multicellular life, but they could instead help organisms withstand ice ages. And as human-caused warming peels away ice cover in the Arctic and Antarctic, whoever makes it out of the ice alive is poised to dominate the budding polar ecosystems.

Convey explained that as melting ice exposes land surfaces, plants generally colonize the new terrain from "somewhere else" via spores carried long distances by the wind. Such far-flung dispersal is slow, often taking decades.

But "when something can survive in situ," said Convey of the moss his team discovered, "that really accelerates the recolonization process." These mosses can paint a lifeless landscape green almost overnight, paving the way for other organisms to arrive and establish.

While the elderly mosses discovered by La Farge and Convey are remarkable, the clique of ice age survivors extends well beyond this one group of plants.

Tatiana Vishnivetskaya, microbiologist at the University of Tennessee, drills deep into the Siberian permafrost to map the web of single-celled organisms that flourished ice ages ago. She has coaxed million-year-old bacteria back to life on a petri dish.

But last year, Vishnivetskaya's team announced an "accidental finding" — one with a brain and nervous system — that shattered scientists' understanding of extreme endurance.

As usual, the researchers were seeking singled-celled organisms, the only life-forms thought to be viable after millennia locked in the permafrost. But hulking among the puny bacteria and amoebae were long, segmented worms complete with a head at one end and anus at the other — nematodes.

"Of course we were surprised and very excited," Vishnivetskaya said. Clocking in at a half-millimeter long, the nematodes that wriggled back to life were the most complex creatures Vishnivetskaya — or anyone else — had ever revived after a lengthy deep freeze.

She estimated one nematode to be 41,000 years old — by far the oldest living animal ever discovered.

Experts suggested that nematodes are well-equipped to endure millennia locked in permafrost. "These buggers survive just about everything," said Gaetan Borgonie, a nematode researcher at Extreme Life Isyensya in Gentbrugge, Belgium, who was not involved in Vishnivetskaya's study.

When environmental conditions deteriorate, some nematode species can hunker down in a state of suspended animation called the dauer stage — dauer means duration in German — in which they forestall feeding and grow a protective coating that shields them from extreme conditions.

Vishnivetskaya is not sure whether the nematodes her team pulled from the permafrost passed the epochs in dauer stage. But she speculated that nematodes could theoretically survive indefinitely if frozen stably.

Borgonie agrees. While he conceded that the finding of Pleistocene-aged nematodes was "a huge surprise," he said "if they survived 41,000 years, I have no idea what the upper limit is."

He views nematodes' virtuosic endurance in a cosmic context. "It's very good news for the solar system," said Borgonie, who believes these feats of survival may portend life on other planets.

Here on Earth, many species are spiraling toward extinction as humans jumble the global climate. But near the thawing poles, a hardy few organisms are revealing incredible stamina. It is ecological gospel that some creatures — from birds to butterflies to wildebeest — survive by migrating vast and hazardous distances to find favorable habitat. More recent discoveries hint at a different migratorymode: through time.

After protracted slumber in Earth's icy fringes, bacteria, moss and nematodes are awakening in a new geologic epoch. And for these paragons of endurance, the weather is just right.