June 28, 2021: Never Pay the First Bill: A Virtual Conversation with Marshall Allen of Propublica

David.

I'm David Levine, Swiney co chair. My guest tonight is Marshall Allen. He's a reporter for ProPublica, where he covers the healthcare industry. He is one of the creators of ProPublica's Surgeon Scorecard, which is published. The complication rates for about 17,000 surgeons perform eight common electrical procedures. Alan's work has been honored with several awards, including the Harvard Kennedy School's 2011 Goldsmith Prize for investigating, reporting, and coming as a finalist for the Pulitzer Prize for local reporting to work at the Las Vegas sun, where he worked before he came to ProPublica in 2011.

One of the reasons we're speaking to Marshall Lee is his new book out. And this is the book called Never Pay the First Bail and Other Ways to Fight the Healthcare System and Win. It's a really good book. I read it. Gives me good idea, gave everyone good ideas, very practical.

And you can get it. And we'll discuss later where you can get it. So I wanted to ask you.

Marshall.

You talk about the health care system wastes a lot of money in the United States. How much money and why are we wasting it?

I mean, it's obviously hard to measure how much money is wasted. But I spent 2017 that entire year investigating squandered health care spending. And that series of stories was based on a 2012 report by the Institute of Medicine where they estimated that the system was wasting $865 billion a year. That's billion with a B. At the time, that was about 25% to 33%, maybe 25% to a third of all healthcare spending they said was being wasted. And there have been other studies more recently that have found the same thing again and again. So I think if you estimate that we're getting upwards of $4 trillion in spending, you could estimate that we might be wasting as much as $1 trillion.

Of spending a year.

And that's being wasted on things like administrative complexity. They estimate if they simplified our billing system alone, it could save hundreds of billions of dollars. High prices are obviously a huge source of waste. The whole system is kind of built on getting some patients to pay way more than others pay for the exact same services. And we also have problems like over treatment. You know, unnecessary care is a huge problem. So all of these things combine to squander a ton of our money. And so I think if you just said, what if we took 25% of the healthcare cost and just lopped it off the top, we would have enough money to insure every American to make sure people have the care that they need. But unfortunately, there's no incentive for the healthcare system to stop wasting our money because our wasted spending is actually their revenue, it's their profits, it's their returns for their investors. And so it's difficult to get the health care system to rein in the spending and make things more efficient because it's really not in their best interest to do so.

So I was in the hospital, I had my gallbladder taken out and I looked at my bill and there were four, four doctors who billed me for visits whom I never saw. And a friend of mine said, what do you care? I said, what do you mean what do I care? I said, are they billing? He said, you're not paying anything. He said, I know I'm not paying anything, but I don't think it's right. And I think that's the nature of the system is that the people get large hospital bills, they bill for all kinds of procedures. You had a case of a woman who had her earrings pierced.

Her daughter.

Yeah, her daughter Pearson cost thousands of dollars.

Yes. So one of the fundamental misconceptions, I think, is that just because our health plan covers something does not mean that we aren't the ones paying for it.

And so I think one of the.

Fundamental reasons why we need to fight back against this system as it currently stands is that every dollar of our health care system is funded by the public through our taxes, through our premiums, through our out of pocket payments. All of this combines to fund Medicare, Medicaid, and every single hospital and insurance plan and drug company out there. There's no magic money tree where like, oh, my employer is paying it, or oh, the health insurance company is paying it, or oh, the government's paying it. All of this money starts with us. And so even if you've met your deductible, so you're not going to have any additional out of pocket costs.

When we keep, we don't challenge these.

Bills, these phantom doctor visits that result in massive bills in the hospital, we need to challenge those because if we don't, those costs are going to get added to our health plan. And so those of us who are in employer sponsored health plans, we're going.

To end up paying a lot more.

In premiums the next year. This is something that we've seen a trend now happening for 20 years or more.

Every year.

Our premiums keep going up, our deductibles continue to rise while our coverage is being reduced. Especially for people in employer sponsored health plans, that cost is added and added and added. And probably the sneakiest way that it's added to us is it's tamping down how much money our employers have to compensate us. All the money that's funding our healthcare benefits comes out of our employee compensation. And so, yes, the employers are generously funding our compensation, but just like my employer funds my wages and my paid time off and maybe my retirement benefit.

You know, if I'm lucky, well, they're.

Also funding my health care benefits. So I think it's inaccurate to even say that employers are paying for health care. Employers are funding employee compensation, and then employee compensation is paying for healthcare. And when that employee compensation gets squandered on things like phantom doctor visits in the hospital or overpriced ridiculous prices or those kinds of things, well, then there's less money left over for our employer to pay us. And so wages are being suppressed for workers all over the country because their compensation is being squandered by these high health care costs.

So one thing I'll talk about is that you can go to one hospital and surgery, heart surgery can be $100,000 and go to another hospital, it's $500,000. They can be in the same zip code. Yes, but the insurance company pays for it. Pays for it. Why do they do that?

Because the prices are not negotiated with insurance companies and hospitals based on actual value. Right. They're not actually saying, oh, this heart surgery is better than that one.

Or a more common example would be.

Say, a knee replacement.

You're using the same components, the same.

Type of operating room, the same type of procedure, same type of doctor. There's not something special that you get for a knee replacement at one hospital versus another. In most cases, it doesn't get you more to go to the high priced, academic, ivory tower medical center than it does to go to a community medical center, especially if it's something common and elective like a knee replacement.

And so the prices are set by market forces.

Right? By power, by monopolies. So if there's a marquee medical center that's really dominating a market, or they have the brand name that everybody wants.

Well, then they know that they can.

Extract a larger payment out of that insurance company than say, a small independent community hospital that doesn't have the same market power to fight against the insurance company.

So it's a bunch of behind the.

Scenes horse trading that sets these prices. It's not prices that are actually set on value. I think one of the most powerful things that has happened in recent years to me is this hospital price transparency rule. It went into effect at the beginning of this year. This is something that actually came about by a Trump executive order where hospitals are required starting on January 1st of this year to post all of their prices. And when I say all their prices, they have to post a cash price, they have to post their Medicare prices, they have to post every insurance company's negotiated price for the different MRIs, CT, scans, tests, procedures. It's supposed to be in a spreadsheet on their websites. And so far, what I've heard from people who are studying this is that about half of the hospitals in America seem to be complying.

Think about that. That means half the hospitals in America are not complying with the government's federal rule to follow and post the prices. It's not because they can't do it. It's because they've resisted it. The American Hospital association tried to sue to get out of this.

They lost.

And so for the first time, we're seeing this price variation posted right on the hospital websites where you can look and see, okay, so if I have United Healthcare or Aetna or Cigna, I can see how much I'm being forced to pay compared to the Medicare price or the cash price or the other insurance companies prices. In a lot of cases, patients are seeing, wait a minute, why am I being required to pay more just because my health plan negotiated this price with my hospital? It does not make a lot of sense. And that's something that I'm urging patients and showing them how to push back. I mean, this is a fundamental inequity in our system that somehow you could be discriminated against just because you have a particular insurance plan. Those two parties set the prices and then they say that I have to pay it even if it's twice as much or five times more than a different rate. That doesn't make a lot of sense. And that's something that as insurer, excuse me, as patients and employers get more wise to the way this pricing has worked, I think they're going to feel more motivated and equipped to push back and just ask for fair prices and demand them.

I used to work at the New York City Health and Hospitals Corporation, which is the largest public health system, Bellevue, Harlem Hospital, Jacoby, all these. And we were the first people to.

Post.

Outcomes.

Such as, you know, were antibiotics prescribed in time, how many had catheter infections? So if you have an elective surgery, you can actually look up and see which hospitals do better with this. But I don't Think most people do.

Most people don't. That's right, most people don't. I think now with price transparency, it hasn't ever really been tried where we explain to people just how out of whack the system is and showed them what to do about it. So I think with price transparency there's more motivation because people do understand dollars and sense and especially when more employees have been put on these high deductible health plans or they have to pay the first 3,000 or 5,000 or even $10,000 before their insurance plan pays anything, people have a lot more motivation now to find out the prices up front wherever they can. So I think that, you know, maybe not everybody is going to use this, maybe not even the majority of people, but I think a lot of people are going to start using these tools and you're going to see third party vendors start scraping all this data, analyzing it and exposing it in a really understandable way. I mean, this is something that is possible to do and I think it's coming down the pipeline very quickly where we're going to see tools that consumers can use to highlight these prices and then the goal, I think, because studies have shown there's no relationship in health care between quality and cost. It's not like you went and bought a giant mansion or a penthouse down by Central park where you got a much, much nicer penthouse for your money than you would if you had a little tiny apartment in some bad part of town. Right? You're getting the equivalent thing in most cases, but you're just paying way more for it. And so once people realize that, I think that they will begin to push back because frankly, they can't afford those prices. They're being bankrupted by the prices.

Sarah.

What about the concept of.

Procedure is denied and you get this bill for $100,000 and somehow you know you did something wrong. It's very hard to, it's very hard to correct that. Then you sent to collection agencies at some point. And what do you do?

Well, if a procedure is denied by your insurance plan and you're sitting on $100,000 bill, you definitely need to fight that thing tooth and nail, right, to get that corrected. And the first thing to do when you're fighting for an insurance company to, you know, you're appealing their rejection of.

Your claim, whether you've had the care or not, you first need to understand what type of a health plan are you in. If you're in a fully insured plan. And a lot of people don't realize there's a difference here.

So.

So let me explain something really important. There are fully insured health plans. That's where you pay the premium and your employer pays a premium to the insurance company. And then the insurance company bears the risk and the responsibility of paying those bills. That's what we traditionally think of as health insurance. But actually most employees around the country, about 60% of people in the employer sponsored health plans are, are in what's called self funded plans. That means their employer has actually allocated the compensation of the employees to fund those healthcare bills. So they might hire an insurance company to process and administer the plan. But ultimately it's the employer's kind of bank account that's funding the care. And self funded plans are actually great. I think they're better for bigger employers and we're seeing even more smaller employers use them because they give the employer more control over how those health care dollars are spent. And they can actually save money if they use those plans wisely. However, if you get care denied by your insurance plan, if you're in a fully insured plan, well then your battle is with the insurance company. If you're in a self funded plan and you've just had $100,000 procedure denied, well then your battle is also with your insurance. You have to take on the insurance company that's administering the plan, but you also have to take on your employer. And so it's really important to know the difference because you need to know who are you really doing battle with. The second thing I just want to point out about appeals with denied coverage, it's really tempting to make an emotional argument. So let's just say you've been denied something and you're now on the hook for $100,000 and you're literally about to be bankrupted because of this. Or let's say you're. Your child needs care, they're telling you it's too experimental and so they're denying you that claim. It's really tempting and I've seen this a lot with patients where they want to make an emotional appeal to the insurance company. You don't understand. I'm going to be bankrupted or my child is going to die if this care isn't delivered. Those are legitimate arguments, but unfortunately for the insurance companies, they look at this as a contractual relationship. They're not really swayed by emotional arguments. What they're swayed by is their need to comply with the contract. They have to provide care to you as their member. You have to understand your health plan and you have to argue it as a contractual violation by them. And so they're in breach of contract and they need to correct it. I go through this in a chapter in my book. Some various state laws people can turn to and some strategies they can use, frankly, to pressure their employer or their insurance company to approve the care that they need.

So I know people go to the media where they have like all these reporters who will.

Confront the person not paying and just say, you're not paying, why aren't you paying? And then go.

I mean, that's one strategy. But there's also, you said you can take people to small claims court.

What can you do if you get denied?

Well, this isn't just about denial, but let's say you get over billed, right? So when you get a bill from say, a hospital, I called the book, never pay the first bill. That doesn't mean that you should never pay your bills. I mean, what I'm saying is never pay the first bill until you have analyzed that bill to make sure that it's accurate and that it's priced fairly. Then if it's accurate and fairly priced, pay the bill. Right? The way you analyze your bill, you start off by getting an itemized medical bill. So when we go to the grocery store or when we go to a car mechanic or a fast food joint for a burger and fries, we get a receipt. The receipt is itemized. It has each item that you were billed for. It adds up to a total cost. Hospitals somehow aren't in the habit of giving out itemized bills. They just give people a lump sum payment that they need to pay. Or maybe they break it down by pharmacy services and medical services. Start by having your hospital give you an itemized bill that includes the billing codes that breaks out each individual charge. Then once you have those billing codes and those descriptions of each charge, and by the way, if your hospital won't give you the breakdown and the billing codes, you can get those from your insurance company. Call your insurance company's customer service and say, hey, can you tell me the billing codes that were used for this particular visit? Can you give me a breakdown of each of the individual charges? I'm just not sure how that total came to be. So then once you have those billing codes, you can look those things up. Like I said, you can look up prices now on hospital websites. And if your hospital isn't complying, you can at least go to other nearby hospitals and see if that price was fair. You can also go to a website called FairHealthConsumer.org FairHealth is a nonprofit that gathers all of the insurance company payments in each zip code. And then they produce, they publish, like a fair price estimate. It's basically an average of what insurance companies in your community are paying. And so that way you can kind of see, okay, I got a negotiated price of this amount for this billing code. Is that fair or not? Am I being overcharged or not? The second thing you want to look for is are you being billed for services that you did not receive? So, David, you mentioned on your visit you had these bills from doctors who you say didn't even see you. In that case, you'd want to pull your medical records, right? Every patient has a right to get their medical records. And you'd want to see do the medical records document, Dr. So and so, and Dr. So and so coming in and doing some type of an examination or providing some treatment. If they don't document it. You know, there's a saying about medical records. If it's not documented, it didn't happen. They should not be billing you for anything that's not in the medical record. So that's one starting point. And if it's in the record and you think the record is falsified, well, then you have a whole nother ball of wax going on right there.

Right?

So if you see things in your itemized bill that didn't happen or that are overpriced, that's when you want to contest those charges. You need to go to the billing department, you need to go to the cfo, you need to go to the board members of the hospital. You need to appeal as high up as you can to get them to correct or change their overcharges. And if they ignore you and they refuse to be fair with you, that's when I recommend suing in small claims court. Suing in small claims court is much, much easier logistically than people think it is. In fact, I actually did it myself when I was a 16 year old kid and my employer ended up closing down his company without paying all of us teenagers who had been working for him. I was able to use small claims court to sue him and get him to pay me the money that I was owed. In the same way, patients can do this when they're being overcharged or billed unfairly or inaccurately, they can file a claim in small claims court. That is our constitutional right as Americans. And it requires the hospital to then justify and explain their charges in a court of law, or at least they're threatened to have to do that, because what they're really going to want to do is settle that case with you. It will give them the motivation they need to come to the table and treat you fairly as a consumer and not overcharge you or to correct a bill that's inaccurate. In fact, when you think about it, when they get sued in small claims court, now they have to hire an attorney at a cost of hundreds of dollars an hour to defend themselves against your medical bill. Your medical bill might be a few hundred dollars or a few thousand dollars. It's really not worth their while to mess with that battle, especially when it costs you so little to file the claim. So I think small claims court, I have a whole chapter on it in the book. I think it's a real great opportunity. I will say this about small claims court. I've helped some patients do it, and I also talked to a lot of patients who did.

Takes courage, right? You're going to be stepping out into an unchartered territory where you're not sure what's going to go on. You're going to get some squealing from the attorneys for the hospitals. They're going to accuse you of doing something you're not supposed to do. And so you have to be prepared for some anxiety, some stress. It's easy to do logistically, but it takes some courage to do. But I'm telling you, most people don't have more than a few hundred dollars at a time in their bank account. Or I should say, many Americans don't. And so when you're hit with a bill that's inaccurate or unfair and it's in the thousands of dollars, it's worth our time, it's worth our stress to fight these bills and overcome these injustices.

So I'm interested people listening in. If you have questions, please put them in the Q and A box and we will answer them. So final questions. How can you save money on healthcare?

I mean.

Okay, let's talk about pharmacy costs. You go get a pharmacy and you see all these commercials for Goodrx or Blink Health and it shows it's a hundred dollars. And it's like, oh, my gosh. Then you look at Goodrx and says it's $5 and it's like, okay, so is that something people should be always checking before they fill a prescription?

Yes, I definitely think so. I think the price variation is so rampant in prescription drugs and also in all types of healthcare that you should always be exploring again if you're able to. Right. Because a Lot of people, you're in a physical state where you're fighting some kind of a problem.

You might not be able to.

But if you're able to realize that there is massive price variation in our healthcare system, and that price variation is designed to get you to pay more than you should for the same service, you could get for a lot less elsewhere.

Let me give you an example.

Lots of research has shown that if you need a CT scan or an MRI or an X ray, the hospital.

Imaging center is the most expensive place you can get that type of an imaging test. Whereas if you go to an independent imaging center, you can save a lot of money. So recently I talked to a guy named Kevin Vincent. He lives in Amarillo, Texas. And Kevin needed two MRIs before he underwent a back operation. He had a $10,000 deductible. So he was going to be paying a lot of money out of pocket for these tests. And he knew that. But he went to first he went to the hospital imaging center where his doctor had referred him to get the MRIs. He called them and said, what's this.

Going to cost me?

They said, it's going to be $11,000 for the two MRIs. If you run it through insurance, and if you pay cash, it'll be $9,000. Well, Kevin had a friend who worked in healthcare. He thought those prices sounded really high. And so Kevin decided his friend referred him to a company called Green Imaging. And if you go to greenimaging.net, you can see what Green Imaging does. What they do is they contract for direct payments to independent imaging centers. Kevin got referred very quickly. He sent his order to Green Imaging. They routed him to an imaging center near him. It was about a half a mile away from that hospital imaging center. He got both those MRIs, including the reading of the MRIs and copies of the scans for $950. For both, he saved by going a different alternative route. He saved $8,000 on those two MRIs. It was hundreds of dollars per MRI instead of thousands of dollars per mri. So it is possible to save a lot of money in health care. And we're seeing now that more progressive employers are starting to work with independent advisors to help them redesign their benefit plans to take advantage of this price variation and avoid the high price places and give their business to the places that have more value and better prices. I think this is something that we're going to see more and more because employers are desperate for solutions. Employers are really funding all of this largesse by the health care System. And employees, I think, are more and more willing to do something different, too, because they can't take these costs anymore. They say now that one in six Americans has medical debt in collections, and bankruptcies are often caused by healthcare expenses. So I think everybody is ready to try some other routes to getting the care that they need. And when they do, they can save big money on their healthcare.

I feel like you're on an airplane and the person next to you spent $150 for the ticket, and you spend $500 because you pulled the day before. It's the exact same seat, exact same plane.

That's an awesome comparison.

Yeah. So, okay, so we have some questions. What's the cleverest bill hack you've ever seen?

Okay, the cleverest bill hack I've ever seen is utilizing financial assistance policies.

People are not really looking into these.

The way they should be. And I have to say that I've been guilty, too. I didn't realize just how generous many hospital financial assistance policies are. In fact, there's a charity that I want to refer people to called $4$d o l l a r4f o r. I think their website is Dollarfor.org if.

You email me the websites, I'll put them on our website.

Yeah, so this, this charity helps people.

They really say that they help enforce.

Hospital financial assistance policies. The IRS requires nonprofit hospitals to provide financial assistance, and it's up to 300% of the federal poverty level. Those bills for those patients can get forgiven in a lot of cases, entirely 100%. And even people who make six figures can qualify for discounts under many hospital financial assistance policies. You do have to prove your income.

So let's say you're under that 300%.

Of the federal poverty level guidelines.

You may have to turn in pay.

Stubs, you may have to provide tax records, but you can get your bills forgiven with hospital financial assistance. And maybe the most clever thing I've ever heard, and this was from Jared Walker, the founder of $4. He has actually helped people retroactively apply for financial assistance from hospitals where they have received checks, repaying them for the money that they already had paid to the hospital. So if that's not extremely clever in terms of using financial assistance policies, I don't know what is. I mean, you just don't hear many times of a hospital paying a patient because they used financial assistance.

So here's on Medicare, drug prices and drug plans are very expensive. Is a Medicare Advantage plan better than a Medicare Part D plan for drug costs? So Medicare Advantage is like an hmo. It's all in one. It covers your health care, covers the hospitals, covers the doctor's bills, and it covers your. So you don't have to buy. You don't have to buy Medicare Part A, part B and Part D. So that's what Medicare Advantage.

Yeah.

So I can't really speak to Medicare drug prices. That's not something that I've researched in depth. But what I can say is that in many cases it may save you money to pay cash rather than run things through your Medicare or your other health plan. And it's something you should always explore. Like we mentioned earlier, Goodrx, when David and I were talking, GoodRx is a coupon program that often has the lowest prices for a particular drug of any pharmacy in your particular community. So check out Goodrx and see if that will get you the price of the discount. There are also some pharmacies around the country that have membership plans where you can be a member and get particular drugs for like $5 a month or something like that. So check out like one of them I know of is called Good Shepherd Pharmacy in Memphis, Tennessee. Check out Good Shepherd's membership program and then also check out. This is a really crazy thing about drug pricing. There are companies now that are importing drugs especially. This works with specialty drugs from Canada.

New Zealand, Australia, the English speaking countries.

Around the country, England. They will import the specialty drugs to the United States and you can get those drugs for a much lower price than you would pay if you paid them through your insurance. So I don't know if that's true for Medicare pricing because I just don't know enough about Medicare drug pricing. I also think it's going to vary depending on the drug. So check those options out and see if those might be better for you.

One advice I will give people is that with Medicare, when you choose your plan, choose to see what the formulary is because certain drugs may be on the formulator and they're covered. There'll be two, tier one which is zero, or tier two which is $10 or it could be. Or tier four which could be $1,000. Yeah, but check and make sure that the drugs you want would change every year are on your formulary.

That's smart.

And unfortunately, sometimes the health plans will game the formularies to cherry pick or lemon drop. You know, find patients who are healthier and avoid patients who are less healthier.

By making the drugs not as available on the formulary.

So you do want to check that formulary if there's a drug that you really need, make sure that it's on the formulary for the health plan that you choose.

Okay, here's another question. Thanks for investigating our broken system. I'm a cancer patient, carries about end of life care and the expenses associated with it. Mainly I want to know if end of life medical expenses will be taken from the life insurance, meager retirement fund will pass to my children.

I have no idea the answer to that question. I'm sorry, I can't answer that one. There are so many complexities to our healthcare system that sometimes I think, wow, I've spent 15 years investigating these things and in some ways I feel like I've just scratched the surface. I don't know if you ever feel that way, David, but.

It is a really, really.

I learned about phantom networks. I was looking for a doctor for my son and they listed 20 doctors. 18 of them only saw adults.

Wow.

Yeah.

And the other, there were two more left. One of them had retired.

Wow. So.

And the other one other one was not accepting new patients. So I called the insurance company and said you have an obligation to provide some doctors. So that was not. It's not fun though.

Okay, here's a question. Is it helpful to file a complaint with the state insurance company if your health insurance company is refusing to pay your medical care?

Yes, it is. But realize that if you're in a self funded plan where your employer is the one bearing the risk, those are not regulated by state insurance commissioners. So that's also why it's reasonable important to know are you in a fully insured plan? If you are, those are regulated by the state. If you're in a self funded plan, those are regulated by the federal Department of Labor. So again, it's really important to know what type of health plan you're in and then who you should complain to if you have a problem.

How do you know?

You ask. You can ask your HR department. Your HR department, they might not know.

But you can also have them ask.

Your health benefits broker. And if you don't know that, you can also call your insurance company. But go through your HR department, they should be able to find that out for you.

I have a whole chapter in the book, by the way, about how to appeal again when you have had that care denied. So it's really important. It's a long conversation that has lots of nuance to it. Depending on someone's case. Some states have.

Supposedly they say they're independent medical reviewers. And so you see like a state like California, they have a process set up where you can have an independent medical review and they will often overturn what the decision was of the insurance company.

Okay, so there's a question. Any advice on how to deal with a recalcitrant crime victims unit that is supposed to be paying my bills? I was the victim of a hit and run car accident. They paid the hospital bills and for some initial treatment, but forced me to jump through hoops to get follow up paid care despite the fact that it didn't come close to maximum amount. They requested 15 years of medical records and then just ghosted out.

Well, I can tell you I was in a car accident and they wrote to every doctor I had ever seen in wanting records, including my gastroenterologist. I didn't hit my stomach, you know, I mean every, every doctor. And then they say, well, you can't do anything until we hear from these doctors. And I don't really have any. Do you have any advice?

I don't. In fact, you know, all I can.

Say is that our healthcare system, we.

See this over and over again, where the healthcare system is not designed for the benefit of the patients. It's more designed for the benefit of the stakeholders who are making money off the system. And when patients get in these accidents or suffer the victims of a crime, unfortunately they get victimized again by a health care system that doesn't really have the incentive to care for them in the way they need to be cared for. And I wish, I feel like our elected officials, like on both sides, have let down the American people. I look at this book I wrote, Never Pay the First Bill. I wish that I had never had to write this book because unfortunately I don't feel like anyone is coming to our rescue. And so now we are forced. Even this poor person who was the victim of a crime and suffered physical harm is now required to navigate this twisted health care system. I think the one piece of advice I would have is if you can hire a patient advocate.

I put some links to different patient advocate organizations in the book and there are excellent patient advocates who navigate these things for a living. They know how the system works, they know the tricks, they know how the incentives might work for or against you. And so they can kind of pull the levers that need to be pulled. And while you may have to pay them or if I was in that victim's case, I would see if they could make part of the recovery, if there is any, for the victimization that they've suffered, make some of that to fund a patient advocate to help that victim through the system. It may cost money. You know, you have to pay this person per hour. But it could actually help people get the care that they need by having a patient advocate who knows the ins.

And the outs of the system.

So one of the arguments, European countries basically have a centralized health system. And then like they talk about Canada, centralized health system, then they say, well, our hospitals are better, but in actual fact, our outcomes are worse in a lot of cases than most of these countries.

Right.

People are much unhappier with the health care system systems.

Right.

I have a friend in France saying, you know, I don't mind paying higher taxes. I have good schools, I have good health care, and I can see doctors.

I know Bernie Sanders and others advocated for Medicare for all universal health care. Is that a better system than what we have now?

Well, you know, I think the thing.

Is, is that first of all, it's.

Just a fact that if we had better efficiency with the way we pay for health care alone, it would save us hundreds of billions of dollars a year. At least that's what researchers say. When you talk to doctors, like, let's just take a primary care doctor who has to deal with dozens of insurance companies and hundreds of different insurance plans. They have to hire multiple staff people just to process their bills. Then the doctor submits the bills, and then a bunch of those get bounced back because the insurance company says it wasn't filled out correctly or for whatever reason, they deny payment on it. All of our frontline clinicians are dealing with these battles with the insurance companies just to get paid. That is driving up the cost of care in this country by massive amounts. Look at prior authorization. Prior authorization is a giant game where doctors are required to call insurance companies and get things approved. And the insurance companies say they're doing it because some doctors are abusive in the way they prescribe drugs or the way they prescribe tests or the way they do operations. Well, it's true that some of them are bad apples and they're over treating patients, but many, many of them are not. In fact, you would know that most of them are not. But they make all of them run through the same prior authorization game. And studies show that doctors and other frontline clinicians are spending hours a week just trying to get care approved. The doctors and the clinicians are victims of this system, too. They're very frustrated with it. That's why I do have hope that the forces of employers and consumers and patients pushing back, combined with the frustration of the doctors and the other clinicians who are actually providing care might motivate some alternate arrangements that exclude some of these middlemen who are marking up the costs and sucking so much money out of the system without providing any value. So I do think that something like Medicare for All, I feel like that's a political football where people put it out there so that the people on the left and the people on the right can argue about it, they can fight about a free market versus government health care. It becomes a battle where people end up discussing a bunch of things that politically would be very difficult to put into place. I mean, I'm not sure how the giant insurance companies and hospitals and doctors and everybody else are going to allow something like that to happen. So that's why in my book, I haven't really gotten into these policy debates because you could go on and on about debating policy and then meanwhile you do nothing to show what people on the ground suffering through this system can actually do to make it better for themselves and their families.

Well, there are doctors. I mean, it's very important to see an in network doctor if you can.

Definitely.

I was reading that there's a Wall Street Journal article that during surgery you'll have an in network surgeon, you're in network internist, but they will hire an out of network anesthesiologist and they will split the fee with them. Wow, that was uncovered. And so you're paying. So the patient is paying for the out of network anesthesiologist and the anesthesia is probably covered, but the anesthesiologist isn't. So the, you know, that was, you know, scandals made legal. But.

You know, you can't, you know, if you're, you know, if you're in a terrible accident, you can't always decide which hospital you're going to go to.

That's right. That's right. And that's why I think small claims court would be a nice self defense move against these surprise bills. Now, you know, we have legislation now that's put into place that will hopefully eliminate some of these egregious surprise bills. But imagine if every out of network anesthesiologist who sent some absurd bill to a patient was responded to with a small claims lawsuit. It's almost like jujitsu, you know, where they hit you with something aggressive and then you turn it back on them and make them justify it and make them respond to it. I think that that would be a nice response from consumers to the problem of surprise medical bills. And I know that many consumers are not going to do that, right?

Let's say there's 180 million people who are either in employer sponsored plans or they're uninsured. Maybe 155 million in employer sponsored plans, another 30 million uninsured. I know that most people are not going to file small claims court lawsuits. Right? It's too stressful. They don't have the luxury of having the time to devote to it. Maybe they don't have the personality to do it because you do have to have a lot of courage and a lot of backbone to take that on. But let's just say that 1% of the people who are getting ripped off and really cheated in this way, tricked. That's what a surprise bill is from an out of network doctor. It's a deceptive tactic to extract more money than they should from us. It's not fair. So imagine if that was met by 1% of the patients with a lawsuit back to that emergency room doctor or anesthesiologist. Now that doctor has to pay hundreds of dollars an hour to an attorney to defend something that's indefensible in front of a judge. I think it would be tremendously effective. And, and I think that there is 1%, maybe 5%, maybe 10% of the patients out there who would deploy this tactic to defend themselves. I think it would be a game changer. It would penalize them properly for what they're trying to do to patients.

What else can you do to save?

So you talk about prescription drugs, save money on.

I think one thing that's really important is avoiding unnecessary care. You know, I devoted a chapter to this in the book. There's about 25% researchers say of all healthcare that's provided is unnecessary.

And these are things like, you know.

Mammograms for young healthy women, prostate exams. These kinds of things often lead to over treatment. They're not Recommended by the U.S. preventive Services Task Force for all patients. I recommend people check out the U.S. preventive Services Task Force because that's an organization that's doing an independent evaluation of the best medical evidence to make advice about things like screening tests. If you go to a doctor or even let's say something like the American College of Radiology. They would recommend that a lot more women at a much younger age get mammograms than the independent guidance of the U.S. preventive Services Task Force. Make sure that whoever's giving you advice on things like preventive screenings is independent.

And not motivated by the financial incentives that they have to do these Tests. Another type of over treatment or a way to avoid over treatment is to ask your doctor if your doctor is recommending a surgery or a medication or a particular lab test or a CT or MRI imaging test. Rather than saying, okay, Doctor, what's the risk of doing this? Ask what the risk is of not doing it. Ask the doctor what happens if we wait. Am I going to die when I walk out of this room right now? Am I going to have some growth inside of me that's going to cause my body to shut down and kill me? Or could we maybe call a timeout right now and say, let's not do more treatment right now. Let me research it, let me get a second opinion, and let's maybe watch and wait and see what happens. Or take a break by asking your doctor, what's the risk of waiting? It reframes the whole conversation so that you're talking about, you're talking about it as if you're not going to do it instead of just assuming that you're going to do it.

Yeah, but one thing that I've learned is that someone recommended me getting tests. And I said, you know, it's very hard to argue with a doctor when they recommend something. They, you know, they have more knowledge than you are. So I'm pretty knowledgeable. I looked it up. It was kind of split. You know, I mean, should you take a baby aspirin? Some people say yes, some people say no. The guidelines change all the time. It's like cholesterol. Should you eat eggs? Some people. All right, so here's the question. Is there any way to get Medicare reimbursement for doctors who don't accept Medicare patients? I know that there's a process for trying. I did it once successfully and tried it again with the same physician and was rejected. I can answer this if you can.

I would love to hear your answer.

Because I don't know. What is the answer there?

Okay, so in Medicare.

The doctor can say, I don't accept Medicare. But if they don't formally opt out of the system, you can apply just like at a network doctor, and you can send, you can send the bill into, you know, into Medicare.

You know, a physical bill into Medicare. And if the doctor is not formally opted out and they deem it it's care that you would need, then they will pay it. If the doctor is formally opted out of Medicare, then they won't pay it. But a lot of doctors haven't.

That's really interesting. So in other words, it's a little.

Bit like the scenario where your insurance.

Company, company denies payment for something. You need to make sure that you.

Can convince them that they have an.

Obligation to provide this care with this particular doctor.

And maybe that doctor has a special.

Type of expertise so you can convince them so that they can see why it's urgent that you do that.

Well, it's like seeing, it's like seeing an out of network doctor.

Right.

You know, a lot of hospitals, they don't accept the Cosmos special surgery. They're basically all out of.

Yes.

Now, another thing I would recommend is.

Ask that doctor what their cash price might be. You'd be surprised how many doctors are eager to take cash from patients. And the reason they are is because then they don't have to route the payment through the insurance company. They're very frustrated with insurance companies.

And so I don't know what, you know, looks like it's.

David has submitted this question. David, I don't know your financial situation and whether you'd be able to offer a cash price. And I obviously don't know what the.

Procedure is, but I would inquire and.

See if the cash price might be something that you could afford.

Okay.

Oh, he did ask the cash price.

Well, that's. Cash is as good as money, as they say. So it's a good thing.

Right?

Good thing to do.

You know, the other thing is that, you know, really, you know, before you see a doctor, you know, make sure they're in your health plan.

Yes.

Make sure that, you know, if you have Medicare, they accept Medicare or Medicaid.

And also, you know, because a lot of times in a practice there'll be six doctors and the doctor you were given the name of doesn't. But there's in that practice who does.

That's right.

You know, so I think it's, I think it's, it's hard and it's tiring and you know, you're. I know I've, you know how to write appeal letters now. My docs write appeal letters to make a drug from tier three, where it's very, very expensive. Tier one or tier zero.

Right.

After a while it's just like you just feel like you're always battling and it seems it should be easier way.

Well, it can be overwhelming, especially when.

You'Re dealing with something more complicated.

But a lot of these things can.

Be really, really easy to correct.

Like I had one case where my.

Son went to an urgent care. I got sent a bill for $250 where they said on the bill that my insurance plan had paid nothing.

Well, I knew that wasn't accurate.

I mean, I have really expensive health insurance premiums, and so I actually have coverage that does cover pretty much everything. I just pay a lot up front for it.

Well, so when they said that my plan had paid nothing, I called my insurance company and I said, did you guys not pay anything for this? Well, it turned out they had not even submitted the bill to my insurance company. So in that case, I called the urgent care. I said, hey, you need to send this to my insurance plan. They had made a mistake. They sent it to the insurance plan, and I never saw the $250 bill. When it's a simple case like that, if you're engaged and paying attention, you can get these things corrected. Sometimes it's a real pain, sometimes it's really easy. You don't quite know until you try. But you're right, it's fatiguing. It is fatiguing to be a patient in the U.S. health care system where unfortunately, we have to defend ourselves against all these different schemes that are, that are trying to take our money.

So I got a notice once that my insurer rejected, and I realized I had not had that insurer for 10 years.

Wow. But it's.

But they stay in the system. They're still part of your records. And so I would just look at them, just say, and say, please submit it again.

1.

Do you believe that changes in medical malpractice laws can help reduce unnecessary procedures and treatment?

You know, I've done a lot of.

Stories about medical malpractice. And I think that the defensive medicine that's done to protect doctors against malpractice claims is largely a myth. It's based on fear that the doctors have of getting sued. That's largely baseless. I mean, there are not. From what I've seen, there are not a lot of frivolous lawsuits being filed against doctors or hospitals for alleged medical malpractice.

And the reason that's uncommon is because the attorneys who take these cases take them on a contingency basis. They don't just take a case that they don't know will be a slam dunk victory for them because they have to invest money to depose.

To bring in experts and have experts do review of cases. They have to depose the doctor or people at the hospital. So attorneys are turning away 99 out of 100 cases that even come to them. This whole idea that doctors have, well, I had to do all these tests because I was afraid if I didn't I might miss something and then get sued. I think that's a bit of mythology that the physician community and the clinicians have created to say that they are protecting themselves from medical malpractice. But it's a threat that does not really exist. And I would love, if some doctors want to send me all these frivolous malpractice lawsuits, I would love to see them. But I've talked to hundreds of patients who have been harmed and none of them could find an attorney. I mean, it's very difficult to get an attorney. So I don't know if changes in the med mal laws would, would reduce the over treatment or not. I just think that we need to stop accepting the excuses that they have to over treat because if they don't, they'll get sued. I don't, I really don't buy that.

So a lot of my friends who are doctors say that they, their practice has been brought out by hospitals around them. And at first they were very upset about that, but now they like it because they don't have to deal with the billing they don't have to deal with. They go home at 5 o', clock, they're not on, you know, they're on call certain nights, but not every night. Yeah, and that's kind of like the Mayo Clinic model where all the doctors are employees. Do you think that's a good system?

I think it changes, it changes the incentives in a way that is productive. You know, if you can get away from say a fee for service payment system and put doctors on salary, well then the doctors have a much different incentive structure in terms of providing the care that people need. I think moving to more global payments, moving to more salaried doctors is really important.

But you still need to make sure.

That the doctors are providing quality care. The system to do that is really quite broken in this country as well.

But I do think that having doctors.

On staff can be a way to make sure that there's less over treatment in terms of what the doctors do.

Or you also see is in hospital.

Systems they incentivize more things like CT scans and MRIs for the machines that they own. So that can also be a problem in that direction too.

Before I let you go, I wanted to.

I think it might have been a question.

Okay. Before I let you go, I want to say next week I'll be speaking with Katherine Even who is wrote the book the Bottle of Lies. But her latest article in.

Vanity Fair is. Vanity Fair is about the origins of the pandemic and it's really, really, really good article.

It's a, It's a breathtaking article.

Breathtaking article. Scary article. So. And then after that, we're talking about tuberculosis, which I know something about, having worked with Hmong associations long, long time ago. But when I worked there, there was a turkulosis outbreak in New York City.

Wow.

But that still kills millions of people worldwide. So.

Final question. Did Obamacare help this situation? Or is Obamacare basically.

Is Obama.

Is Affordable Care act helping?

You know, unfortunately, the Affordable Care act had some wonderful things that it did, but one thing it hasn't done yet.

Is really brought down the cost of care.

And so there were. There were not a lot of cost.

Controls put in place with the aca.

And so I think we have seen.

A great increase in costs since the Affordable Care Act. But that's not to say that the law didn't have a lot of great things in it. It was a massive, massive piece of legislation that had a lot of great things in it, but it did not have a lot of price controls. And so we've seen costs go up a lot since then.

But once you have a bill, you can always make it better.

I mean, the first smoking laws in New York.

They only covered you could smoke on half of the restaurant, but not the other. But the other half you couldn't.

Same thing with airplanes.

You could smoke in the beginning. And you can strengthen laws that exists.

Yes, hopefully.

But if there's no law, you can't strengthen it. So I think Obamacare has been a good thing for people overall. So I want to thank you. Why don't you show your book again?

Well, so the book is Never Pay.

The First Bill.

Right here.

And when. Yeah, my copy is over there.

But where can you get this book?

You can get it.

You can get it everywhere.

I mean, I know different bookstores have it.

Amazon, Barnes and Noble, and then I've.

Heard it's in BJ's. I mean, I don't know all the places that it's at, but it's widely available. The publisher is Penguin Random House, so you can go to their website and look it up. And they have a lot of links to retailers all over the country.

This was just published last week.

Tuesday. Yeah, just five days ago or six days ago. Yeah, it's been a fun week.

So are you writing another book?

Oh, man, I'm just trying to get through this one. I have no plans for book two at this point, but this one has been really fun. I've also started really a health literacy push I created a side business called Allen Health Academy. And I'm really trying to push more healthcare literacy for employers. So we're putting together a video series. It'll be short 3 to 5 minute videos based on the principles in the.

Book that I'm trying that I really.

Want to roll out to employers for employer sponsored health plans so that they can equip and empower their employees to save a lot of money on their healthcare. And for more info, people can go to my website, that's marshallallen.com and you can sign up for my newsletter and then you'll have the latest updates from me.

Okay, Well, I want to thank you for spending some time with us tonight on this hot day in New York City and have a great rest of the summer. Everyone go out and buy this book. It's a great read, easy read, it gives you a lot of good practical tips and it's also very well written.

Thank you.

So take care and thanks again and I will see you soon.

All right, good night, everyone.

Hopefully in person. Okay, bye.

Bye.