Ohio’s Healthcare Price Transparency Law- What are the Hospitals Afraid of?

Price Transparency advocacy is not new and not just in Ohio. This graphic is from a 2013 Forbes article.You can read here.

In June 2015, the Senate and House of Representatives in the state of Ohio passed unanimously the Healthcare Price Transparency Law. The law was signed by Governor John Kasich shortly thereafter. This law would require hospitals and physicians to provide a reasonable estimate to patients prior to procedures and tests. This would allow the patient to make decisions on whether or not to have the services, to shop for a lower price, or to determine how they are going to pay for this bill.

Our own local State Representative Jim Butler, Republican from Oakwood and Kettering, offered and sponsored the law. Mr. Butler has worked with the Ohio State Medical Association (OSMA) and the Ohio Hospital Association (OHA), as well as a number of lobbying organizations to help implement the Healthcare Transparency law so it is workable for both healthcare providers and patients. Jim Butler’s letter to the President of the OHA can be found on his website.

Now 18 months later, OSMA recently joined a lawsuit with the OHA to block the implementation of the law. They argue that it is not possible to get this reasonable estimate in a timely manner because insurance carriers determine the out of pocket cost and there are simply too many insurance plans. In late December, Williams County Common Pleas Court judge J.T. Stelzer issued a 30 day restraining order blocking the law from taking effect on January 1, 2017.


The Ohio Hospital Association now argues that insurance carriers ‘set the price’ and the hospitals have no control over these prices. But this is false. It is the hospitals who negotiate a contract with the insurance carriers to determine the cost of each and every procedure. While the insurance carrier negotiates a contract with the patient regarding co-pays and deductibles, it is the hospitals who are responsible for the cost. Most people do not realize that the same test procedure will cost different amounts from one facility to another. Sometimes up to 75% more. For those with health insurance such as Medicare where you have a 20% responsibility, a $2500 CT scan and a $400 CT scan is a significant difference; a $500 out of pocket bill in the hospital or a $80 bill at an independent outpatient facility.  People have a right to shop around for quality and cost.

A staff member of mine recently sent her son to a physical therapist at a local hospital while she herself was seeing a physical therapist in an independent practice. Her son’s bill for a 15 minute appointment to have his pinky finger worked on cost her $250. While her 1 hour appointment for her back cost only $65 at the independent practice. She tells me had she known the high cost with the therapist working for the hospital, she would definitely made him go to the other facility.


Those opponents argue that this will delay treatment because the information is not readily available. This is not true. Most insurance carriers have online system that practices can use to plug in the patient’s exact insurance plan along with the ICD-10 procedure codes that will be used. That system , in existence for years, will provide an estimate of cost based on the current contract with that facility.

First Dayton Cancer Care has been providing these estimates to our patients since opening in 2003. Radiation therapy is one of the most complicated set of billing codes in any specialty, yet we manage to provide estimates within 24 hours. Most of our patients appreciate knowing what their out of pocket expense will be so that they can begin planning for it. Many insurance carriers provide a website where their members can do a cost estimator and it will show them what each facility in their surrounding area charges. The information is readily available. In the past 13 years our billing company, MAXX Medical states that providing these estimates has gotten easier. They are able to provide an estimate within an average of +3%.


I do agree that there are specifics to the Healthcare Price Transparency law that need to be worked out. But the state of Ohio, the OHA and OSMA have had 18 months to work this out. The state needs to establish guidelines that relieve some of the burden on the provider and to ensure that the language protects the provider if the insurance carrier provides incorrect information. However, the OSMA and the OHA needs to be advocating for the patient first. Patients do not have lobbyists fighting for them. They need to be told of their right to ask for a cost estimate.

Patients also need to respect that when an estimate is given, it does not mean that we value their payment more than we do providing quality care. We feel by providing this estimate we are helping the patient make informed decisions about both about their health and their family finances. But in all things you purchase, you demand quality and a fair price. Your health should be no different. Price transparency in healthcare is critical in today’s world.

If you are in need of excellent cancer care, call me today at 1-855DAYTON1. Not only will I see you in 1-3 days for an initial visit, but I will provide you with an estimate before treatment begins!

America’s War on Doctors

a-chart-dr-and-adminIt is a shocking fact.  The US now spends more on the administration of healthcare than on the treatment of heart disease and cancer combined.  Cancer and heart disease are the 2 major killers of Americans. 

Want to know another shocking fact?  The top 10 paying jobs at most hospitals are administrators, not doctors.  More and more administrators are needed to enforce government regulations and “quality assurance” programs.  The growth of healthcare administrators has outpaced doctors more than 10 to 1.  The chart says at all.  And all the while, healthcare costs have exploded.  But the mainstream media points the finger clearly at doctors. 

Won’t Obamacare Fix It?

President Obama’s Affordable Care Act (ACA) ignored what needed fixing and doubled down on regulations.  The major side effect of Obamacare has been an explosion in regulations  and administrators who oversee these regulations.  And it is not without financial cost.  In fact, the financial cost of healthcare administration more than accounts for the explosion in healthcare costs over the past 20 years.  President Obama is not the only one.  The explosion in healthcare administration started in the 1990’s. 

Dr. Thomas Sowell, a noted Stanford economist, said “It is amazing that people who think we CANNOT afford to pay for doctors, hospitals, and medications somehow think we CAN afford to pay for doctors, hospitals, medications, AND a government bureaucracy to administer it.” 

Obamacare may have contained costs somewhat, but at the expense of patient care and treatment.  Remember that graph the next time your insurance company denies your medicines and your care.  Instead of blaming the doctor who sits in front of you, try blaming the real culprits, the regulators and administrators of healthcare. 

Unless we start reducing healthcare regulators and administrators, all the Congressional bills and Presidential plans won’t amount to much. 

When we are with our families this Thanksgiving week, we need to pray for a reduced diet on government regulation and administration of health care. You and your family’s lives depend on it.

Have a Happy Holiday.  Please feel free to call me, Dr. Edward Hughes, at 855-DAYTON1 about your cancer’s diagnosis and treatment.  I guarantee that I will see you within 1-3 days.

The Fight for Freedom from Insurance Companies

USA-Independence-day-best-greetings-2014Independence is the freedom from dependence on or control by another person, organization, or state. Unfortunately today physicians and patients have lost their independence. Physicians are now controlled by hospital administration, government policies, and insurance companies. Patients are dependent on their insurance company. This lack of independence has placed a great strain on how medical care is given in the United States of America. First Dayton Cancer Care is fighting for the right to practice medicine in a way that is best for our patients, not someone’s bottom line.


Any person with insurance who has tried to have a procedure should know the term prior-authorization. This is where the patient and the physician must ask the insurance carrier permission to give treatment. This authorization is solely based on the ‘plan’ that patient has contracted and the formulary that insurance carrier has established for the diagnosis and the treatment requested. They can deny authorization regardless of what the physician feels is the best medical choice. This authorization can take up to 30 days; if initially denied, the entire process can take 60 days. And if authorization is given, there is no guarantee of payment.

The Ohio State Medical Association (OSMA) and First Dayton’s practice manager have spent the past year fighting for Ohio Senate Bill 129 which would regulate how carriers handle prior authorizations. While not every agenda item was approved, we will see an improvement in this process over the next two years. The two key items that will affect the patient the most are more timely decisions and payment for authorized procedures and medications.


Insurance carriers now must give authorization in a timelier manner. For urgent care services consideration must be given within 48 hours of initial request and within 10 calendar days for non-urgent care. This will allow the patient and the physician to move forward with treatment quicker so that a patient is not anxiously waiting to begin very important treatments like that for cancer.

If prior authorization was given, insurers will no longer be able to retroactively deny payment for a claim. This is excellent news for patients and physicians. It basically means that insurers must do what they promise and pay for what they should.

We hope that this change to the authorization process will help patients and physicians alike. Physicians have the training and experience to make the decisions for that individual patient. The doctor to patient relationship is so important to quality health care. We must continue to fight insurance carriers and the government from dismissing the importance of this relationship. The beauty of medicine is treating the entire person not simply the disease on paper. This can only be accomplished when a physician is able to get to know this individual person and work together for their health.

First Dayton stays independent of the hospital systems so that our patients maintain their right to choose the best radiation therapy available today and we will continue to fight insurance carriers for this choice.

Take Back Control of Your Healthcare from Insurance Companies

OSMA Logo w 3D State - Blk & Lt Blue - Drop ShadowPlease join the Ohio State Medical Association to take action today to stop Medical Insurance companies from practicing medicine!

OSMA Government Relations Team is working overtime to get SB 129 passed out of the Ohio House by the end of May.  We need your help to give one final push to your Representative to pass this legislation in the next three weeks! The insurance industry has continued to voice concerns with the bill following its unanimous passage out of the Ohio Senate. The current prior authoirzation system’s administrative burden and impediment to quality care must end.

Currently they require your physician to ask PERMISSION to treat you. The insurers decide what type of medical care you are allowed to receive.

Plus they may or may not pay for the services that they have promised to cover. This leaves you, the patient, with a huge bill or you the physician unpaid.

We are asking that insurers respond to the authorization request in a timely manner. In 2012 the average wait time for our patients was around 4 days. Now our patients wait on average of 23 days for authorization. This delays treatment and causes a lot of anxiety in people who are already anxious because they have cancer.

This Senate Bill is vital to health care in Ohio. While it doesn’t solve all of our problems with Prior Authorizations, it certainly is a giant step in the right direction. Insurance companies need to allow our physicians to treat our patients the way that their experience and expertise tells them is best for that individual person. Plus, our patients deserve timely answers and your doctors deserves to be paid what has been promised to care for you.

Senate Bill 129 will help us to achieve all of this. Please take a few moments to send a letter to let your voice be heard!

I also encourage you to send this email to everyone you know. Each one of us is a patient. Send it to everyone on your email list.

Let’s tell the insurance companies that we do not want them practicing medicine. Go to the OSMA Advocacy Center to send a letter to our government right now! Time is running out to have your voice heard.

Cancer Care in the US 2016: The Good, the Bad, and The Ugly

good-bad-uglyThe Good News

So the good news is that America is winning the war against cancer, slowly but surely, especially for the so-called “Big Four” – lung, breast, prostate, and colo-rectal cancer. Dr. Julie Vose, the current president of the American Society of Clinical Oncology, commented in her society’s recent report entitled “The State of Cancer Care in America, 2016”. Dr. Vose said last week “We have seen mortality rates decline on the average of 1.5% annually over the past decade, even greater declines for the 4 most common cancers.  Additionally, the number of survivors is expected to grow from 14.5 million to 19 million in 2024.”

The Bad News

Despite President Obama’s recent announcement of a near billion dollar “Moon-Shot” against cancer, Dr. Vose went on to say “However, all of the advances are set against the backdrop of unsustainable cost and a volatile practice environment.”

So what does that mean in plain English?  The cost of cancer care is skyrocketing, especially the cost of chemotherapy drugs.  And so many patients simply cannot afford to pay.  In fact, medical bills represent one of the single biggest causes of a family’s financial stress. Dr. Blase Polite, the immediate past chair of the American Society of Clinical Oncology’s government relations committee, said “It is the cost of cancer drugs themselves as well as the increased burden the patient’s face with rising deductibles and higher cost sharing by insurance companies.”

So in plain English again, insurance premiums are going up and deductibles are going up even faster-all costing the cancer patient more money.

The Ugly News

Whatever your politics, ObamaCare has dramatically changed the landscape of cancer care in America.  Independent community practices-once the mainstay of cancer care only a decade ago-are vanishing.  The independent cancer clinics are either closing or being bought out by hospitals where the cost of cancer care is much more.

Despite the passage of ObamaCare, 35 million non-elderly people remain uninsured, and 31 million more are “underinsured” because their deductibles, the actual out-of-pocket costs, are many thousands of dollars.  A $5,000-$6,500 deductible with an ObamaCare insurance policy simply cannot be paid by many Americans.

And for our senior patients, Medicare Advantage programs that now comprise 30% of all Medicare patients can be problematic.  For example, our own senior men with prostate cancer are shocked when I tell them that I provide 3 different types of radiation for their prostate cancer, but their insurance companies will decide on whether or not they undergo Cyber Knife, IMRT, or implants.  So access to the right treatment is now a major concern. Often times insurance carriers ignore which treatment actually costs less and which is more effective.

So with more pressure on cost and access, can quality be far behind? Are we setting ourselves up for insurance carriers making your medical decisions? Simply put, I never thought I would be posing that question.  I wonder whether President Obama’s Moon Shot has already missed its target?

If you have any questions about your cancer, please feel free to call me, Dr. Edward Hughes, at 855-DAYTON1.


dr smashing computerIn 2013, two key studies highlighted an alarming conclusion: The electronic health record or EHR may be hindering the quality of healthcare.  One study found that the EHR was the main culprit in doctor “burnout.”  The second study found that emergency room physicians click the computer mouse 4,000 times during a 10 hour shift. The EHR and its truckload of computerized quality measures are turning away doctors and nurses from the true essence of their work – Caring for the patient.

Just last week,  Mr. Andrew Slavitt, Medicare’s acting administrator, announced the end of a Federal program that tied Medicare payments to a long list of quality measures demanded by users of the EHR.  Mr. Slavitt stated, “We have to get the hearts and minds of physicians back.  I think we’ve lost them.”

At First Dayton Cancer Care, over $250,000 and hundreds of hours of work have been spent to get the EHR up and running – quite an accomplishment for an independent office.  I witnessed how “making the EHR look good” impacts on the time that may be better spent with patients.  It has changed our workflow greatly. The clinical staff is required to check a lot of boxes, often on items that are irrelevant to the reason the patient is seeking our help. I still refuse to go into an exam room with a computer. I learn so much about what is truly going on with my patients when I can look them in the eye and watch their body language. These computer prompted questions do not tell the whole story. Fortunately, First Dayton Cancer Care selected a EHR that is specific to radiation oncology. We are able to obtain the necessary information to take excellent care of our patients in addition to everything the government demands of us.

But through all the trials and tribulations of the EHR, I have not seen a single report showing that the EHR is saving lives or improving the quality of care. On a nationwide level, billions of dollars have been spent on the EHR, with little to show for the time and cost. And your medical records are still not all in one place because hospitals and physician group EHRs do not allow secured integration of Personal Health Information (PHI).

While I’m am not advocating that measures of quality can simply be thrown away, I am urging the people in Washington to talk to doctors, nurses and patients, so-called stakeholders in the game, to measure clinical outcomes that truly matter.  And in a simple way that does not take away from face to face time with patients. I think we need a revolution in technology so the doctors and nurses do not spend all their time “box checking” on the computer.

In a recent New York Times opinion essay, Dr. Robert Wachter of the University of California San Francisco Department of Medicine quoted a late leading figure in the field of quality management.  “In 2000, shortly before Professor Avedis Donabedian died, he was asked about his view of quality. What this hard nose scientist answered is shocking at first then somehow seems obvious.  ‘The secret to quality is the love’, he said. “

So for all the time and expense of measuring what the ‘experts’ call clinical outcomes, clinical processes and clinical organizational structure, what it seems to come down to is to CARE.  This is the root of why I will not do a patient visit with a computer in my hand. I only hope that “Digital Medicine” does not drive out truly caring doctors and nurses from the field and does not discourage bright young people from entering medicine.

If you have any questions about your cancer, please feel free to call me, Dr. Edward Hughes, at First Dayton Cancer Care at 855-DAYTON1.