Marshall Allen on how to contest hospital bills and avoid treatment you don’t need [PODCAST]

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“It’s rare for anyone to try and tally the precise cost of unnecessary care. But when they do, the estimates are staggering. The Washington Health Alliance, a nonprofit dedicated to making care safe and affordable, analyzed insurance claims from 1.3 million patients who received one of 47 tests or services that are considered overused or unnecessary. What they found should make patients and doctors rethink that next referral. In a single year, more than 600,000 patients underwent a treatment they didn’t need, costing an estimated $282 million. More than a third of the money spent on the tests went to unnecessary care, their study found.

Unnecessary medical care has ‘become so normalized that I don’t think people in the system see it,’ Dr. Vikas Saini told me. Saini is president of The Lown Institute, a Boston think tank focused on making health care more effective, affordable and just. Lown researchers have shown how overtreatment happens across the spectrum of medical care. Doctors may push for Caesarean sections for their own convenience, not so moms and babies can be healthy. Breast cancer, prostate cancer and thyroid cancer get over-diagnosed, leading to harmful and costly treatment. Around a third of colonoscopies are unnecessary, research has shown. That’s not just wasting our money. It’s also putting us at risk of harm.”

Marshall Allen is a journalist and author of Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win.

He shares his story and discusses his KevinMD article, “How to avoid treatment you don’t need.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Marshall Allen. He spent 15 years as an investigative journalist and is the author of the book Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win. He wrote an excerpt on KevinMD, and that’s titled “How to avoid treatment you don’t need.” Marshall, welcome to the show.

Marshall Allen: Thank you, Kevin. It’s a pleasure to be here.

Kevin Pho: So we’ll get into your excerpt and book in a little bit, but first off, can you share your story and journey to where you are today?

Marshall Allen: I feel like it’s just a completely wonderfully accidental journey, Kevin. I actually studied English in college and got a degree in English. I ended up going into full-time ministry for five years, because my wife had been a missionary kid and had lived overseas. So I spent three years in Nairobi, Kenya, and five years in ministry. I thought I would continue that, and I went and got a master’s degree in theology, but I started freelance writing during this time, and that led me into journalism. I spent five years doing just small community news kind of journalism.

Then in Las Vegas, at the Las Vegas Sun, in 2006, I started covering health care, and I was introduced to what was like the Wild West of health care in Las Vegas, where there was a lot of profiteering and there were a lot of patient safety problems. I have always written about health care from the point of view of the patient. You know, the patient is engaging with the system. It’s very fragmented, it’s super complicated, and it’s ridiculously expensive. So I’m always writing stories thinking about what this is like for the patients who are navigating and paying and who are at risk when they undergo any health care.

So that’s led to 15 years of investigative reporting, including 10 years at ProPublica. I recently just left ProPublica. I now work for the Office of the Inspector General. I’m obviously not speaking on behalf of the inspector general’s office, but I literally just started this job, and so I’m looking forward to continuing to look into the health care system, now on behalf of beneficiaries, you know, more people in Medicare and Medicaid plans, looking at how taxpayer money is spent. So my mission has changed a little bit in terms of the platform, and I’m working in a much more collaborative way now.

But the book came out of these 15 years of investigative reporting. It just published in June, and the book is really trying to equip and empower individuals and employers to fight back against these really unjustifiably high health care costs. So that’s what led to the book. I’ve been really excited by the reception of it, and I really am excited to talk to you about that today.

Kevin Pho: What would you say are some of the biggest challenges that you face as a journalist covering our health care system here in the United States?

Marshall Allen: I think the biggest challenge is understanding what is actually going on. It is incredibly complicated and confusing, and that’s where I have to thank people like the experts in your audience. It’s the clinicians on the front lines who are generating every story. Every story that I’ve ever written about health care has come from someone on the front line who saw something that was going on that they were not comfortable with, and even when they tried to get it corrected within the system, usually they got rebuffed. You know, it’s the type of thing where, if they saw a patient safety problem or they saw some issue with wasted health care spending, the system often doesn’t look kindly on people who are trying to be change agents. And so those people end up becoming sources for journalists, you know, sometimes off the record, often on the record.

But no matter what story I did, I always knew I was outside of my area of expertise. I’ve never been a frontline clinician taking care of patients. I’ve never had formal medical training outside of a first responder course, you know, that I took when I was a rafting guide, right? So I don’t know the complexities of this. I’m not an expert in health care finance, you know? So I’m always needing insiders in the insurance companies, in the hospitals, and the frontline clinicians to guide me and show me what’s the most important thing to write about and how do I write about it in a really fair and accurate way. You know, you want to focus on the right thing. You don’t want to sensationalize something that’s a minor point. You don’t want to be used by people who have agendas. So I’m utterly dependent on and appreciative of the clinicians out there for guiding me, and they guide other journalists too. I mean, we could not do our work without the frontline people showing us what to do.

Kevin Pho: All right, so let’s go ahead and talk about your book. It’s titled Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win. There’s an excerpt on KevinMD that was published in June. It’s titled “How to avoid treatment you don’t need.” Now, for those who didn’t get a chance to read that excerpt, can you just walk my audience through it and share why you decided to share this particular excerpt?

Marshall Allen: Yeah, I was really surprised, when I started covering health care, by the amount of unnecessary care that gets provided. There was a report by the Institute of Medicine back in 2012 that I spent a whole year writing about in 2017. I called the series “Wasted Medicine,” and it’s looking at all of the money that’s spent on unnecessary treatment, administrative complexity, high prices, and the complexity in the payment system, you know, dealing with all the insurance payers and all the prior authorization and everything else. I spent a whole year digging in on that.

And the unnecessary treatment, you know, we Americans say that the high cost of health care is our number one financial concern, year after year after year. Well, they estimate that maybe 25 percent of all health care might be unnecessary. If we could just eliminate the unnecessary care, we could reduce health care spending by a lot and really lighten the burden for the American people. So I focused on some of the experts from the Lown Institute, who have done a lot of interesting research into the problem of unnecessary treatment.

And then I tried to show people what are the questions you can ask. Patients need to engage in their care. They are the ones responsible for giving consent, and they’re responsible for being informed patients, right? And so what are the questions that they can ask their doctors or other clinicians before they undergo something that is discretionary? Let’s say it’s a procedure or a treatment or a drug that they’re considering taking, or maybe it’s being recommended to them. Rather than just automatically saying yes, explore this issue with your clinician, with your doctor. Ask them some key questions.

And one of the main key questions, maybe the most important one, that I found the most insightful, is to ask your doctor, “What happens if we wait?” You know, sometimes this conversation with the doctor is steered toward taking action and doing something, and when you ask the question, “What happens if we wait?” it reframes the conversation in a way that says, “OK, let’s not assume that we’re going to do something. Let’s just look at the worst-case scenario if we don’t do something.” In other words, if I don’t get this MRI right now, am I at risk of some great catastrophe, or is it just that this is like a belt-and-suspenders type of an approach, and maybe we could wait? Maybe we could take another approach. Maybe there’s a less expensive type of scan that would be just as good. Same with drugs, same with procedures. So that was the guidance that I tried to share in that excerpt from the book.

Kevin Pho: Now, can you share some case studies or examples of common instances where care may be deemed unnecessary?

Marshall Allen: Well, mammograms are a really common one. I mentioned in the book my wife’s example, because she’s had this every year when she goes to her doctor for her annual checkups. My wife would be in the category where the U.S. Preventive Services Task Force would say that a mammogram is actually not recommended. She’s under age 50, has no risk factors for breast cancer, and no family history of breast cancer, and yet every time she’s gone to the doctor for the last decade, she has been pressed and encouraged and even somewhat, well, pressured, I guess I would say. You know, she’ll tell the doctor, “Well, I’m trying to follow these guidelines of the U.S. Preventive Services Task Force.”

If people don’t know the task force, they are an independent panel of volunteer experts. Their work is funded by the federal government, and they are looking at the latest guidelines, the latest studies, the most independent guidelines and studies, and they’re trying to make recommendations based on that, especially for things like preventive screenings like mammograms. And I think what their recommendation is now is that they recommend biannual mammograms for women once they hit age 50. I think that’s the recommendation, and I realize it’s controversial. I realize people have differing opinions. Some of the other groups say that you should do them every year or at a younger age. Some of those groups, though, I like to point out, make their money by doing mammograms.

So I also encourage people to look at the incentives of anybody who’s giving you advice, and try and value the advice of people who are independent over the advice of people who are really feeding their families based on whether or not you undergo this treatment. It’s similar for me as an investigative reporter. Nobody ever influenced my work. We had very strict policies. At every outlet I ever worked at, including ProPublica, we were not allowed to take any gift from anybody, whether we were writing about them or not. There was no money influencing any of the stories that we did. It was based on our judgment and based on the information we got from sources. When you’re funded and make your money by doing a particular practice, and then you recommend that practice, it just gives cause for concern about whether those are independently given guidelines.

Kevin Pho: So I want to talk a little bit more about those conflicting guidelines, because as a patient, you see guidelines from the U.S. Preventive Services Task Force, and sometimes they’re in conflict with other professional medical associations. One example, of course, is PSA tests for prostate cancer screening, because you have the U.S. Preventive Services Task Force saying one thing and the American Neurological Association saying another. So as a patient, these are all professional physician organizations. How are patients able to sort through all these guidelines that may tell them different things?

Marshall Allen: Well, that’s why I say value the independent guidelines more than the guidelines of groups that are not independent. That is just the bottom line. We have seen over and over again the influence of, say, payments to physicians related to pharmaceuticals or devices influencing the recommendations made by physicians. So it’s just a fact that we get influenced by the way that we’re paid or the way that we’re funded, and so I encourage people to give higher weight to the independent guidelines. That does not mean discard the other guidelines. There’s a tension here, right, between what one guideline says versus another guideline, and that’s also why I like to ask that question.

So let’s say your physician is saying, “Well, look, this guideline says you should do this every year.” This other independent one says you should do it every other year or past a certain age, and you haven’t yet met that age. That’s why I like to ask the physician, “What happens if we wait? What’s the biggest risk if we don’t do this right now?” So I understand, let’s say, the American College of Radiology or whatever is saying do this every year, do this now. Well, I would like to know what happens if I don’t do it now. “I don’t have a risk factor for this. I’m under the age that the independent guidelines say I should get this test. So what happens? Can you just tell me what’s the risk here? Is there going to be a rapidly forming growth within me? Is there any sign that I have something growing inside of me that needs to be discovered by this?” Because a lot of times people also don’t focus on the risk of the false positives, or the overtreatment that occurs with false positives, and the harm that that causes to patients.

And so it’s a balance, right? And ultimately, the patient is the one who needs to make that decision, and even the U.S. Preventive Services Task Force says it should be an independent decision by the patient: “But here’s what the recommendations say based on our independent analysis of the research.” Ultimately, it comes down to what that patient wants, and if the patient wants to do that, then I think that the patient should go ahead and do it, if it’s recommended by their clinician.

So it’s definitely a tension there, and this is why I think we end up with a lot of overtreatment, because people want to have that belt-and-suspenders approach: “Well, just in case.” Or doctors or others might be afraid of medical malpractice, so they say, “Well, I don’t want to miss anything, so I’m going to go ahead and do this.” I understand the fear there and the concern, but I think we need to always let the evidence and the science and what’s seen by the best, most independent research guide what we do, not something like the fear factor.

Kevin Pho: Now, in your excerpt, you talk about some of the causes of unnecessary care, and clearly one of the causes is the fee-for-service system that pervades American health care. I was wondering, do patients play any role in pressuring the health care system for more tests? Because there’s a perception among some patients that more care is better care, and now, with things like patient satisfaction scores, a lot of physicians may feel pressured to acquiesce to patient requests for more tests. So through your years of investigative reporting, can you comment on that? Does that play a role?

Marshall Allen: I think it plays a huge role, and that’s why, in my book and in that particular chapter, I’m trying to help educate patients so that they understand more care is not necessarily better care. And many times it is the patient demanding that they do something. I think when we look at the overprescribing of antibiotics, that’s a huge factor, right? You’ve got the mom or the dad, you know, I’ve been there. My kid is sick, and I’m like, “Just give them something.” And the doctor’s telling me, “Well, actually, you need to understand that’s not how it works. Your child doesn’t have something that would indicate giving an antibiotic.” And then of course I back off, but I also know that urge, that feeling that you just want it to be fixed.

And so there’s a tremendous amount of pressure put on the medical community by patients, and my book is really an attempt to help people understand. In all ways, patients need to be more engaged, and so I’m trying to spur the public along to get more engaged with the financial side, particularly the financial side of their health care, because that’s the focus of my book. But certainly, you know, the pressure provided by patients is a huge factor in a lot of the overtreatment, and that’s something that needs to be corrected: Help patients get more educated about that.

Kevin Pho: You’d be surprised by how many billing questions I get in the exam room. So patients receive a bill from their hospital, and sometimes it’s not just one bill. When you go into the hospital ER, you get a bill from not only the hospital but the emergency physician group, the radiology department, and the lab department. They’ll get four or five separate bills. So if patients get this plethora of bills from a simple hospital visit, what should they do?

Marshall Allen: Well, the first thing you should always do is ask for an itemized bill that includes the billing codes. That itemized bill breaks down all the individual charges that make up the total, and that allows you to make sure that everything you’re being charged for is something that actually occurred, because, believe it or not, there are a lot of bills that include charges for things that did not occur. The billing codes also help people price their bill to make sure that it was priced fairly, and I call a fair price the lowest available price that a hospital will give to any of its patients.

So I don’t accept the line where people say, “Well, your insurance company negotiated this massive overpayment with the hospital, so we’re just following their contracted rates.” I’m sorry, if my insurance company’s contracted rates are two, three, four, five times higher than those of other commercial insurers or Medicare patients or cash-paying patients, and then I have a deductible and I have coinsurance, hospitals do not have a right to just charge people whatever they want just because the insurance company gave them a sweetheart deal. The patient needs to be involved in approving these prices. And so the book really shows patients how to identify these errors and overcharges, and also what to do about them and how to contest them, and I even recommend suing in small claims court if your hospital or your clinician or whoever it is, your dentist, will not be fair with you in correcting an inaccurate or overpriced bill.

Kevin Pho: So if a patient gets an itemized bill, and you talk about ways of contesting it, is this something where they could simply call the billing department of a hospital? Do they need to hire a lawyer? What’s the next step?

Marshall Allen: You call the billing department of the hospital to get an itemized bill. Your insurance company, if you’re insured, can also provide those itemized charges with the billing codes, so you can go two different routes there if the hospital is not cooperating. And then with the contesting, that’s a negotiating game, right? But what you need to realize is, let’s say that the procedure is a colonoscopy, and they’re taking $2,000 from one commercial insurer and they’re charging you $4,000. You know, if they’re taking $2,000 from one, they can take $2,000 from another. So that’s my line of thinking. There’s no reason why I should get charged more, or one patient should get charged more, because they’re covered by UnitedHealthcare or whatever. These are pricing games that the insurers and the hospitals have been playing based on their leverage and negotiations. That has nothing to do with the care that’s provided. It has everything to do with extracting as much money as possible out of the patients’ pockets. And so I don’t accept that.

And I encourage patients to understand how they’re being overcharged. And then tell them, show them: You can now look on hospital websites, because of the hospital price transparency rule, and you can see what their individual insurer-negotiated rates are for their services. It’s in a spreadsheet on all the different hospital websites. It’s supposed to be, if they’re following the federal rule, and sadly many are not, but that’s coming online now. You can also look at the website fairhealthconsumer.org, and that will give you the average price that insurance companies in your ZIP code are paying. So those are ways you can tell if your bill has been priced fairly. If it’s priced fairly, of course pay your bill. I’m definitely not saying don’t pay your bills. I’m saying don’t accept it if they’re price gouging you. That’s really my argument. If it’s an unfair bill or an inaccurate bill, that’s when you contest it.

And in small claims court, you know, the limits in small claims court are actually quite high in a lot of states. They’re high enough to cover a lot of these, you know, kind of one-off type of situations. Like in Texas, it’s $20,000. In Tennessee, it’s $25,000. I grew up in Colorado. It’s a little lower there, $7,500. But these limits on small claims court are small enough that they cover a lot of these bills, and we don’t need an attorney when we go to small claims court. We can file a case for about $30, and then the hospital needs to respond and treat us. They need to be accountable then to the justice system, and they need to possibly even hire an attorney to defend themselves, which is going to cost them a lot of money. So it gives us a lot of leverage, because you don’t really want to go to small claims court, but you need them to take you seriously when you say, “I need you to give me a fair deal.”

Kevin Pho: Now, it sounds like a lot of work for patients to do all this. This is on top of whatever reason they went to the hospital or office for. In general, when they contest these bills, how successful are the outcomes?

Marshall Allen: Well, I don’t think there’s data that shows, you know, in a really quantifiable way how successful they are, but anecdotally, I can tell you they’re very successful. I’ve helped two different people with small claims court myself, and I’ve documented a lot of cases in the book where advocates and other individuals have used small claims court to sue hospitals. One was a dental billing dispute that I helped with. But it’s incredibly successful, because it flips all the leverage in favor of the consumer, and it’s not worth the hospital’s time and money to fight, to spend hundreds of dollars an hour to hire an attorney to defend themselves when they’re doing something that’s not defensible. So it’s very successful.

Now, is it a lot of work? Yes. It’s not a lot of work, I would say, on the logistical side, but on the emotional side, it takes a lot of courage. It’s stressful, and it creates anxiety. So a lot of people won’t have sort of the aptitude to go that route, and a lot of people are disabled, they’re sick, you know, they’re not well. They really won’t be able to do it. But my perspective there is that we have about 180 million Americans who are in this situation. These are working Americans who are covered by employer-sponsored plans, or uninsured, or their families. If just 1 percent of those people were to contest their bills, demand itemized bills, check prices, and sue in small claims court when the prices are inaccurate or unfair, that would overwhelm the hospitals who are doing these unfair bills and this price gouging. It would give them the incentive that they need to treat the consumer fairly.

And look at out-of-network bills, like these surprise medical bills. If each surprise medical bill, and I’m talking about a price-gouging surprise medical bill, if each of those was met by a small claims court lawsuit in response, I think it would no longer be in the incentive and in the interest of the doctors, or whatever other type of clinician it is sending a surprise bill, or their doctor group, or their private equity company, whoever it is. It would not be profitable for them to do that if they were responded to with a small claims court lawsuit for overbilling and for violation of the contract with the patient, by charging an unreasonable and non-customary price for a procedure that the patient could have gotten for a lot less money somewhere else.

So there’s a doctrine in the law called the open price contract rule. This is part of our Uniform Commercial Code, and it says if a price is not given to anyone up front, a consumer up front, it’s assumed to be a reasonable and customary price that’s set in good faith. A lot of these surprise bills are not set in good faith. They’re price gouging, and they’re done because they think they can just set it however they want because they’re out of network. But actually, that’s not OK. It’s really not fair to the consumer, and so my book really shows how people can defend themselves against these practices.

Kevin Pho: We’re talking to Marshall Allen. He spent 15 years as an investigative journalist, and he’s the author of the book Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win. Marshall, what are some of the things that clinicians can do in the exam room to help patients with their potentially exorbitant medical bills?

Marshall Allen: Well, so here’s my message for clinicians. I think the time has never been better to position yourself as somebody who’s going to be fair to patients in a financial way. With all the price transparency coming on board, I think that a progressively minded doctor or other clinician should post their prices. They should have a cash price available that’s a fair deal for them and will not make it necessary for them to go through the ridiculous insurance company system.

So I think that clinicians have a great opportunity right now to treat patients fairly, post prices that are transparent, that are still fair to them, of course, and be very open about the pricing. And I think if they did that, that would help move these middlemen, these insurance companies and others, out of the way, so that the doctors can be working directly with the patients and with the employer-sponsored health plans, maybe through direct contracting relationships or center of excellence relationships, or just by having posted prices to draw patients in by showing them, “I’m going to treat you fairly financially.”

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Marshall Allen: My take-home message is that you can fight back and win, in my subtitle. So the book is Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win. The winning is the key part. When I say “win,” each individual can save hundreds or even thousands of dollars with every health care interaction if they avoid unnecessary care, if they avoid the variation, kind of the high end of the price gougers, and go to the places with value. And that’s why I hope that more doctors will position themselves as the places where you can get good care and good value for that care, because people can’t afford the way it’s been going so far. So people are looking for something different right now.

Kevin Pho: Marshall, it’s wonderful talking to you. Thank you so much for sharing your time and insight, and thanks again for being on the show.

Marshall Allen: My pleasure. Thank you, Kevin.

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