Jan 11, 2020 11:34 AM

Odds may be worse in Kan. for surprise medical bill

Posted Jan 11, 2020 11:34 AM
A student practices surgery techniques at Washburn Tech in Topeka. Chris Neal / For the Kansas News Service
A student practices surgery techniques at Washburn Tech in Topeka. Chris Neal / For the Kansas News Service

By CELIA LLOPIS-JEPSEN, Kansas News Service

KANSAS CITY, Mo. — Chris Costantini lay in a cold sweat, his shoulder dislocated after slipping on a porch in Kansas City, Kansas.

He’d been out alone, knocking on doors and rustling up voters for the upcoming midterms in October 2018. Now he waited for an ambulance, full of anxiety about how the injury could hinder his next performance at the Kansas City Ballet.

“‘I’m not afraid to admit it was the most pain I’ve ever been in,” Costantini recalled. “The shoulder was probably out of the socket for about 45 minutes.”

A different anxiety only began later, when the bills rolled in. That ambulance, it turned out, didn’t fall in his insurance network. So Costantini found himself on the hook for a $900 bill.

Americans frequently get slapped with costs for out-of-network services in situations where they never had the chance to shop for an in-network option. But research suggests Kansans may be especially vulnerable.

A Kaiser Family Foundation study put Kansas in the five worst states for how often patients ran into out-of-network providers in 2017 during emergencies or during inpatient care at their in-network hospitals.

The extra bills that land in their mailboxes often come as a surprise, and pile onto in-network medical costs that already have patients’ heads spinning.

Costantini’s emergency led to more than $6,000 in in-network charges alone, for the hospital and doctor. His insurance company’s pre-negotiated rates knocked those charges down to less than $2,000.

He tackled that and the ambulance in more manageable monthly increments, counting his blessings that he could afford it.

“Perversely, I feel lucky,” Costantini said. “You would think that we wouldn’t have to feel lucky.”

The ‘black box’

Kaiser tapped a database with claims for 19 million people nationwide who got their health insurance through large-employer plans.

Nearly one in five emergency care visits meant running into a doctor or someone else outside a patient’s network. The situation was only slightly better for inpatient care at in-network hospitals.

But those figures mask a more complex picture: The situation varies widely by state. While Kansas fell at the bottom of the pack, neighboring Nebraska rose to the top.

What explains higher out-of-network rates in Kansas? Experts aren’t sure.

Hospitals and billing are “very much a black box,” said Karen Pollitz, the study’s co-author.

That complicates research. And patients wonder whether they’ll make it out the hospital door without bumping into an out-of-network assistant surgeon or radiologist.

“It just feels like a minefield, you know,” Pollitz said.

Nationally, experts know some hospitals are far worse than others, though it’s difficult to pinpoint the culprits behind wide regional and even local disparities. And situations can vary year by year, as insurance networks change, as hospitals buy up physician groups, or as new staffing companies land on the scene with business models built around aggressive billing.

The Kansas Insurance Department doesn’t oversee the nitty-gritty details of insurer-provider contracts that might shed light on Kaiser’s analysis of Kansas claims. The kind of private insurance studied by Kaiser overwhelmingly falls under federal, not state, law.

Where logic fails

Patients often don’t realize they’ve received out-of-network services until an extra bill arrives from a provider they never chose.

“The anesthesiologist is who’s on call when you show up,” Pollitz said. “If you’re having cancer surgery, you’ll never meet the pathologist who looks at your slides.”

Laura Burton made the common assumption that the doctors walking the halls of her in-network hospital in Topeka work for that hospital and fall in the same network.

“Absolutely,” she said. “One hundred percent, that’s what I believed.”

Then came a letter from a Michigan mailing address demanding $400 for a pediatrician employed by an external staffing firm who checked on baby Amelia soon after her 2014 birth.

“It was not something we could pay off off-hand,” Burton recalled. “Who would ever anticipate that a random physician would come in who wouldn’t be covered?”

After a pregnancy full of complications, her bills surpassed her deductible and out-of-pocket maximum well before labor. She and her husband went into the final stretch thinking delivery wouldn’t cost more. They paid off the unpleasant surprise gradually.

A Federal Reserve survey found an unexpected $400 bill would cause problems for 40% of U.S. adults, making them borrow money, sell property or fall behind on credit card debt. And surprise bills are, by definition, impossible to plan for.

“It’s a really frustrating, powerless feeling for patients,” said Chris Garmon, an economist at the University of Missouri-Kansas City who previously worked on antitrust investigations at the Federal Trade Commission. “The more things that are done to you in the hospital, the more likely you are to encounter an out-of-network provider.”

Credit Chris Neal / For the Kansas News Service
Credit Chris Neal / For the Kansas News Service

Even a brief drop-in to someone’s room can lead to a hefty surprise bill.

“That’s called drive-by doctoring,” he said. “That’s a real source of this.”

In search of a solution

People like Burton in Topeka have done things right, said Jack Hoadley, a health policy researcher and professor emeritus at Georgetown University. They got insurance and went to an in-network hospital.

Yet none of that helps if the pediatrician who pops by has no deal with your insurer.

“You run into a situation that — how do you control?” he said.

Experts warn that some providers — such as hospital staffing companies backed by private equity funds — avoid joining networks to cash in on the lucrative world of surprise billing. That lets them charge more than the rates negotiated by insurance companies.

A Stanford University analysis of millions of insurance claims found more than 80% of ambulance rides fell outside patients’ insurance networks. New research from Yale University, meanwhile, estimates that reining in out-of-network billing by anesthetists and others could cut health care spending by tens of billions of dollars annually.

“It’s (a problem) that jumps up and bites people for a significant amount of money that they can’t afford,” Hoadley said, “And it’s one that that is fixable.”

A recent push in Congress has advocates hopeful that 2020 could finally bring a federal solution, though details remain up in the air. Surprise billers have pressed Congress not to curb charges too much.

Meanwhile, half of states — red and blue alike — didn’t wait for a federal fix. They’ve passed some level of consumer protections against surprise bills.

Kansas hasn’t. And though it might be especially useful in a state where the ACA health exchange offers only plans that are particularly unhelpful for out-of-network care, advocates say action in Washington, D.C., is the ideal.

State laws can’t help most people with private insurance through work, for example. Only changes to federal law can.

Celia Llopis-Jepsen reports on consumer health and education for the Kansas News Service. You can follow her on Twitter @Celia_LJ or email her at [email protected] The Kansas News Service is a collaboration of KCUR, Kansas Public Radio, KMUW and High Plains Public Radio focused on the health and well-being of Kansans, their communities and civic life.

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Jan 11, 2020 11:34 AM
Kan. sees shortage of psychiatrists, other mental health providers
Kansas community mental health centers say job vacancies for doctors and therapists sometimes stay open for years.  Celia Llopis-Jepsen / Kansas News Service

Kansas News Service

TOPEKA — It typically took Walt Hill more than a year to recruit a psychiatrist to northwest Kansas. Now he doesn’t even bother.

Instead, the executive director of the High Plains Mental Health Center relies on out-of-state doctors willing to work remotely, treating patients through video conference.

For years, the center has used remote appointments with local psychiatrists to reach patients in far-flung corners of its coverage area, which spans 20 largely rural counties.

But recently, Hill said, it’s been almost impossible to find psychiatrists and psychiatric nurses to do even that. He’s had to turn to providers who conference in from Kansas City, Texas and Tennessee.

Like the rest of the United States, Kansas is seeing an increase in patients seeking mental health treatment. But the state can’t find enough doctors, nurses and therapists to treat them. Providers say the problem is worse in the state’s least-populated rural areas, where clinic jobs can stay open for years at a time. 

“Fewer and fewer individuals are going into these professions,” Hill said. “We’re seeing a demographic challenge, a crisis coming.”

One measure from the federal government suggests only nine of the counties in Kansas have enough psychiatrists, and they’re mostly in urban areas: Johnson, Wyandotte, Shawnee, Douglas, Harvey, Sedgwick, Marion, McPherson and Miami counties.

There are 431 psychiatrists actively licensed to practice in Kansas, according to the state’s Board of Healing Arts. One calculation by the Kaiser Family Foundation estimates the state needs 53 more to meet its needs.

The state’s community mental health centers, like the one Hill manages, face a particular challenge. The centers treat people regardless of their ability to pay. Some say they’ve had to absorb more patients since the state-run mental health hospital in Osawatomie reduced its admissions drastically.

Hill said High Plains Mental Health Center hasn’t experienced that so much. But as reimbursement rates from insurance companies have stagnated, the center has had to raise its base fees to cover costs.

The center sees 6,000 patients a year, about half of whom need medication. Some have to wait as long as six weeks for an initial appointment with a provider.

“It’s stretched. Some people do have to take on a lot more cases,” he said. “That is just way too long for people to have to wait.”

Hiring issues

In some ways, telemedicine has helped, said Greg Hennen, executive director of the Four County Mental Health Center in Independence. But it’s also made it worse.

“It’s a very nice resource, but it’s also hampered our capacity to recruit because people can work from their living room instead,” he said. “People don’t have to relocate to deliver services.”

Hennen’s center has been trying to recruit a psychiatrist to serve as medical director for two years. Only two people have applied for the job. One couldn’t get his license and the other decided he didn’t want to live in southeast Kansas.

The location is a hard sell for many candidates.

“We do have some people that are not interested because it’s an hour and a half to drive to Tulsa or Joplin or two hours to Kansas City,” he said. “They just want to be a little closer to the cultural offerings of a big city.”

Pay is an issue, too. Neighboring states like Nebraska and Colorado can afford to pay medical staff and therapists partly because they expanded Medicaid coverage. That can mean more of their patients have health insurance. Oklahoma and Missouri have federal funding from another source: the Excellence in Mental Health Act, a program Kansas never applied for.

The result is that other states have hired providers away from Kansas. Hennen said one experienced therapist left his center to work across the border in Oklahoma for a $20,000 raise.

Meanwhile, he has three openings for therapists. And he hears regularly from schools and other community organizations that they’re hiring, too.

“If I was actually going to answer the demand,” Hennen said, “ I could hire another five on top of those three.”

For Lisa Southern, executive director of Compass Behavioral Health in Garden City, hiring nurses is the challenge.

She has hired nurse practitioners on a temporary basis through the National Health Service Corps, which repays student loans in exchange for a few years of work. But it’s hard to get people to stay in southwestern Kansas. Many qualified nurses just end up going back home, she said.

The center paid a recruiter $20,000 to find a qualified nurse. But in 18 months, they only had two applicants. Even those nurses decided not to take the job because they didn’t want to move.

“It’s not about the agency. It’s not about the population we serve,” Southern said. “It is simply about people wanting to live in a different area than where we are.”


The Garden City center hasn’t had any trouble recruiting therapists. That’s because aspiring social workers in the area can earn a master’s degree at the University of Kansas or Washburn University.

“That is our saving grace for therapy staff,” Southern said. Her center has also offered scholarships for staff to get their master’s degrees.

The centers that Hennen and Hill run have also paid for master’s degrees for nurses who agree to come back and work at their centers.

In an effort to recruit and retain more staff, Gov. Laura Kelly raised salaries for employees at Larned State Hospital, a state-run mental health facility, in early December. The vacancy rate at the hospital is 57% for RNs and 73% for LPNs, said a spokeswoman for the Kansas Department for Aging and Disability Services. The hospital does not track vacancies for psychiatrists or therapists. The state’s other mental health hospital in Osawatomie has 14 vacancies for RNs and none for psychiatrists or therapists.

In 2017, to attract more psychiatrists to rural areas, Kansas passed a law that added psychiatry to the state’s medical student loan program. The program helps pay for tuition and other expenses in exchange for the student practicing primary medicine in the state’s less populated counties after graduation.

It’s too early to tell whether that’s encouraged more medical students to choose psychiatry and practice in Kansas, said Dr. William Gabrielli, head of psychiatry at the University of Kansas School of Medicine, the only medical school in the state.

But as attitudes toward mental health treatment change, Gabrielli is optimistic more students will feel encouraged to do psychiatry residencies in rural areas.

“It’s really where they do their residency training that helps them put down roots and that keeps them in those locations,” Gabrielli said.

Typically, doctors are reluctant to go to rural areas because they prefer not to practice alone, Gabrielli said.

“If you go out and be a lone practitioner in a rural part of the state, you have no partner,” he said. “You have nobody to help cover for you. You have nobody to bounce cases off of.”

Plus, psychiatry is one of the lower-paying medical specialties, which means it’s a hard draw for medical students, who can rack up hundreds of thousands of dollars in loans. The problem is exacerbated by an aging population of psychiatrists who are retiring, Gabrielli said.

Ultimately, he said, doctors go into the field because of intrinsic motivations.

“Most of the people that pursue psychiatry as their medical specialty are not focused on maximizing their incomes,” he said. “They’re focused on taking care of the people.”

Nomin Ujiyediin reports on criminal justice and social welfare for the Kansas News Service.  Follow her on Twitter @NominUJ or email [email protected]