By Joel A. Harrison, PhD, MPH
September 2, 2021 (San Diego) - As in many other technologically advanced democracies, the U.S. is blessed with highly trained medical personnel and superb facilities. However, we are also by far the most expensive healthcare system in the world. Our taxes fund 65% of the total costs of our healthcare system (Harrison, 2008). More than 30 cents on every dollar goes to large partly unaccountable administrative bureaucracies that, on the whole, do not make a positive contribution to actual health care (Harrison, 2018).
I have been a Kaiser member for almost 22 years. I have had the same primary care physician (PCP), both trust him, like him and intend to continue with him. And overall, my experiences with various Kaiser healthcare personnel have been positive as have the experiences of friends with their doctors in other health plans.
However, Kaiser administration is another story. The following are two examples:
1. Kaiser Permanente Advantage Monthly Report
Upon reaching 65 I switched from an individual Kaiser policy to Kaiser’s Medicare Advantage plan. I then started receiving a monthly report. It includes the following columns: Date of Service, Description, Billing Code, Provider billed the plan, Total cost (amount the plan approved), We paid, Your share [copay].
The Kaiser “Provider,” e.g., doctors, nurses, physiotherapists, etc. are Kaiser salaried employees and the facilities are owned by Kaiser. I have asked numerous Kaiser personnel about billing. They don’t bill. And “We paid” involved NO transfer of funds. The alleged amounts that the Provider’s billed is what really captured my attention as well as my copay. I’ll give just one recent example.
Percutaneous Tibial Nerve Stimulation (PTNS) for Overactive Bladder
As an old man in my mid-70s I have developed overactive bladder, basically need to urinate multiple times daily and often 6 - 7 times nightly (Kaiser Permanente. Overactive Bladder). Percutaneous Tibial Nerve Stimulation “is designed to stimulate the nerves responsible for bladder control using the tibial nerve in your lower leg. During treatment, a small, slim needle electrode is inserted near your tibial nerve and connected to a battery-powered stimulator. The impulses travel to the tibial nerve and then to the sacral nerve, which controls bladder function. Each treatment lasts approximately 30 minutes, and you would typically receive 12 treatments one week apart (Mayo Clinic).” Research has found it benefits up to 60% of recipients, basically reducing number of times needing to urinate (e.g., Kaiser Permanente, 2001). For each patient the procedure involves less than 5 minutes. The nurse then leaves the room and returns a half hour later to remove the inserted needle. This is done in groups of three.
According to the monthly report Kaiser mailed me:
Provider billed the plan $453
Total cost (amount the plan approved $382)
We paid $367
Your share $15
We can look at the alleged provider billing in several ways:
- For individual patient, $453 for a half hour means a nurse is billing per hour at a rate of $906.
- Since three patients at a time are being seen means a nurse is billing per hour at a rate of $2,718.
- However, if one considers that the actual procedure and time spent by the nurse with each patient is only FIVE minutes, then the nurse is billing per hour at a rate of $5,436.
- And since the nurse is seeing three patients at a time, the nurse is billing per hour at a rate of $16,308.
I was billed afterwards for a $15 copay. I always ask when registering at the desk if there is a copay and each time have been told NO.
Given the PTNS clinic has been in operation for over 15 years, if a copay is required, then it should be requested upon registration as any other procedure. However, a $15 copay for a nurse and especially for five minutes time is ABSURD (see above).
So why does Kaiser administration do this? In an extensive article by investigative journalist Steven Brill, he writes: “The chargemaster, I learned, is every hospital's internal price list. Decades ago, it was a document the size of a phone book; now it's a massive computer file, thousands of items long, maintained by every hospital. [It] assigns prices to everything. . . Whenever I asked, they deflected all conversation away from it. They even argued that it is irrelevant. I soon found that they have good reason to hope that outsiders pay no attention to the chargemaster or the process that produces it. For there seems to be no process, no rationale, behind the core document that is the basis for hundreds of billions of dollars in health care bills. . . No hospital's chargemaster prices are consistent with those of any other hospital, nor do they seem to be based on anything objective — like cost (Brill, 2013).”
Maybe Kaiser administration thinks the insane amounts will impress Advantage members of the level of care they are receiving? But claiming they received a bill, paid certain amounts, then $15 copay for a 5-minute procedure by a nurse and claiming procedures are billed after the fact is just plain wrong.
According to Steven Brill: “Medicare collects troves of data on what every type of treatment, test and other service costs hospitals to deliver. Medicare takes seriously the notion that nonprofit hospitals should be paid for all their costs but actually be nonprofit after their calculation. Thus, under the law, Medicare is supposed to reimburse hospitals for any given service, factoring in not only direct costs but also allocated expenses such as overhead, capital expenses, executive salaries, insurance, differences in regional costs of living and even the education of medical students (ibid).”
I found the allowed amount for Traditional Medicare Part B (Noridian Medicare). Note that higher amounts are paid if not in facility setting, i.e., for private offices because Medicare takes into account overhead expenses (CodingIntel, 2021). Shouldn’t apply to Kaiser facilities; but, to be on safe side, I give both.
For PTNS (CPT Code 64566) the allowed amount is $144.46 (In Facility: $31.99). So, $453 is not even close to the non-facility $144.46. Why would a Medicare Advantage Plan claim 3 times what Traditional Medicare pays?
It would be appropriate for Kaiser to send a monthly report with: Date of Service, Description, and Copay, also giving total copays so far towards the current $4,000 max out-of-pocket. Not the current dishonest document currently being sent and the absurd post-treatment copay.
II. Kaiser’s Negotiated Rate vs Plan Coverage (this is the most egregious problem I’ve experienced with Kaiser administration).
I have suffered from Cluster Headaches (also called Cluster Migraines or Horton’s Syndrome) since my teen years. Cluster headaches have been called suicide headaches: “In the USA, 55% of the survey responders stated they have had thoughts about suicide, and 2% have actually tried to commit suicide (Rozen, 2012; See also Koo, 2021; Lee, 2019).”
According to Kaiser, Cluster Headaches “are severe headaches on one side of your head that happen in groups, or “clusters. They usually occur over weeks or months. . .The pain is often called the worst type of headache pain. . . Most people who get cluster headaches have one or two cluster periods each year. . .As you get older, it's likely that you'll have longer and longer times without headaches. At some point, you may not get cluster headaches ever again. . .The main symptom of cluster headaches is a severe burning or sharp, piercing pain on one side of your head. The pain spreads out from your temple and eye. Your eye may become red, watery, or puffy. The eyelid may droop, and you may have a runny or stuffy nose on that side of your head. The pain usually gets bad very fast. The pain gets worse within 5 to 10 minutes after the headache starts (Kaiser Permanente. Cluster Headache).”
In my case, the above description is quite accurate; for me, they usually last at least two hours, and usually twice daily for 10 - 14 days. For the first 25 years or so, I experienced two clusters yearly, then one yearly, then over the past 15 years, one cluster every 2 years, one of the few positives of aging. When younger they occurred during exams, when working, even in the middle of the night. Over the years I have tried all of the medications listed by Kaiser (Kaiser Permanente. Medicines for Cluster Headaches). None worked!
Several years ago, I discovered research that found breathing pure oxygen for 15 minutes worked in the vast majority of cases and without any side-effects (Cohen, 2009; Sands, 2007). Since then, there have been several review articles (e.g., Gao, 2019; Petersen, 2014).
And Kaiser’s own website gives oxygen as the first choice treatment stating: “High-flow oxygen inhalation therapy, in which you breathe oxygen through a face mask to relieve headache pain. Oxygen therapy is one of the best treatments to stop a cluster headache. Oxygen therapy relieves headache pain within 15 minutes in more than 7 out of 10 people who use it. It works best when started right when a cluster headache starts. But you need to repeat the treatment when the next headache begins (Kaiser Permanente. Medicines for Cluster Headache).
In 2014 another cluster began. I immediately contacted my PCP, requesting oxygen. He ordered the oxygen; but received reply that I was NOT covered. So, I went through about 10 days of hell. Next outbreak was in June 2017 late Monday night. Hoping coverage had changed, on Tuesday I again contacted my PCP. He ordered; but received reply that I was covered; but it had to be ordered by a neurologist. My PCP arranged an emergency appointment with a neurologist for Thursday morning who ordered the oxygen. I phoned Apria Healthcare, the company contracted by Kaiser to supply oxygen, and it was delivered and set up that afternoon. I woke up around 2 am Friday morning in excruciating pain. Put on mask, turned on oxygen, and started stopwatch. The pain started to go down and ended. According to my stopwatch, only eight minutes had passed. Over the next eight days I usually had two outbreaks daily and none last longer than 10 minutes. Since the copay was only $3.44 per month, I decided to keep the oxygen.
When I tried to renew in June 2018, I was told I wasn’t covered. I phoned Apria to arrange pickup of the oxygen. I was asked if I was a Kaiser member. It was then explained to me that as a Kaiser member, even if my plan (Medicare) didn’t cover oxygen for cluster, that I could receive the oxygen for Kaiser’s negotiated rate, which was $17.21. I decided that since I only had been experiencing clusters every 2 years that $17.21 per month would start to add up, so I arranged for Apria to pick up the oxygen.
I then contacted my neurologist, explained what Apria had told me. I was later informed that the Neurology Department had then contacted Kaiser Durable Medical Equipment Department, explained that Kaiser members whose individual plans, whether Medicare or other, weren’t covered were eligible for the Kaiser negotiated rate. The Durable Medical Equipment Department promised to make this policy and notify their employees.
In April 2020, late on a Friday afternoon a new round of cluster headaches began. I phoned Apria, only to be told they had been informed I was NOT covered. Finally reached Neurology on Tuesday and they directly ordered from Apria. I phoned and the oxygen was delivered a couple of hours later. I really don’t understand and it hasn’t been explained to me why for a brief period it was covered then not covered; but more importantly I suffered unnecessarily from all three episodes.
I, of course, appealed through Kaiser member services; but they ignored the eligibility of members to receive for the negotiated rate, for them simply not covered by Medicare. I’ve tried several times to find out who to contact in Kaiser administration about making it policy for ALL Kaiser members, even if their individual plan doesn’t cover, to be eligible at the Kaiser negotiated rate. I was more than happy to pay the $17.22, even if it was needed for several months, to avoid “suicidal” level pain and it would NOT have cost Kaiser a red cent. Kaiser policy should have been decided long ago. I suffered several weeks of suicidal level pain unnecessarily. What does that say about Kaiser’s administration? Certainly not an indication of their caring about members. And just to be absolutely clear, my PCP and neurologist went the extra mile to try to help me.
Even if Medicare were to approve tomorrow, besides myself, it would mean that over the past years numerous other Kaiser Medicare members have suffered unnecessarily and members on some of the other Kaiser plans will continue to suffer.
Summary and Conclusion:
- Kaiser sends a Monthly Report claiming they were billed by Providers and paid approved sums. Neither true. And the exorbitant sums used are absurd.
- Kaiser allows patients to suffer suicidally painful cluster headaches when their individual plan (Medicare) doesn’t cover oxygen, listed as the number one treatment on their own website, though Kaiser members can receive for the Kaiser negotiated rate. Wouldn’t cost Kaiser a red cent.
So, we have a divide between the Kaiser Medical Staff and Kaiser Administration as in all other American healthcare plans. So, as mentioned in introduction, we are blessed with well-trained healthcare personnel who often go the extra mile for their patients; but with the most expensive healthcare by far in the world, with a significant proportion of the extra costs funding to some extent unaccountable administrative bureaucracies that, on the whole, do not benefit us.
Brill S (2013 Mar 4). Bitter Pill: Why Medical Bills Are Killing Us. Time Magazine. Available at: http://content.time.com/time/subscriber/printout/0,8816,2136864,00.html
CodingIntel (2021 Apr 22). Facility versus Non-Facility in the Physician Fee Schedule. Available at: https://codingintel.com/facility-non-facility-physician-fee-schedule/
Cohen AS et al. (2009 Dec 9). High-Flow Oxygen for Treatment of Cluster Headache: A Randomized Trial. JAMA; 302(22): 2451-2457. Available at: http://alcecluster.cefalea.it/images/pdf/1_hight.pdf
Guo XN et al. (2019 Oct). The role of oxygen in cluster headache. Medical Gas Research; 9(4); 229-231. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802413/
Harrison JA (2008 May 8). Paying More, Getting Less: How much is the sick U.S. health care system costing you? Dollars&Sense Magazine. Available at: http://dollarsandsense.org/archives/2008/0508harrison.html
Harrison JA (2018 Aug 10). The Case for A Non-Profit Single-Payer Healthcare System. Physicians for a National Health Program. Available at: http://pnhp.org/news/the-case-for-a-non-profit-single-payer-healthcare-system/
Kaiser Permanente (2020 Aug 4). Cluster Headache. Available at: https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia...
Kaiser Permanente (2001). Evidence Table: Percutaneous Tibial Nerve Stimulation. Available at: https://wa.kaiserpermanente.org/static/pdf/hosting/clinical/criteria/pdf/ptns3.pdf
Kaiser Permanente (2021 Apr 8). Medicines for Cluster Headaches. Available at: https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia...
Kaiser Permanente (2021 Feb 10). Overactive Bladder. Available at: https://healthy.kaiserpermanente.org/southern-california/health-wellness/health-encyclopedia/he.overactive-bladder.av2014
Koo BB et al. (2021 Apr 20). Demoralization predicts suicidality in patients with cluster headache. The Journal of Headache and Pain; 22. Available at: https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-021-01241-7
Lee (2019 Sep). Increased suicidality in patients with cluster headache. Cephalgia; 39(10): 1249-1256.
Mayo Clinic. Percutaneous Tibial Nerve Stimulation. Available at: https://www.mayoclinichealthsystem.org/locations/bloomer/services-and-tr...
Noridian Medicare Fee Schedule for San Diego County (2021). Available at: https://med.noridianmedicare.com/documents/10525/26330949/California%2C+Area+72%2C+2021+Medicare+Part+B+Fee+Schedule+PDF
Petersen AS et al. (2014 Nov). Oxygen treatment of cluster headache: A review. Cephalgia; 34(13): 1079-87.
Rozen (2012 Jan). Cluster Headache in the United States of America: Demographics, Clinical Characteristics, Triggers, Suicidality, and Personal Burden. Headache; 52(1): 99-113.
Sands GH (2007 Oct 25). Oxygen Therapy. National Headache Foundation. Available at: https://headaches.org/2007/10/25/oxygen-therapy/
Shaw G (2019 Sep 5). Coverage for Home Oxygen Therapy Remains in Limbo as CMS Denies Reimbursement Once Again. Neurology Today. Available at: https://journals.lww.com/neurotodayonline/Fulltext/2019/09050/Coverage_f...
Joel A. Harrison, PhD, MPH, a native San Diegan, is a retired epidemiologist. He has worked in the areas of preventive medicine, infectious diseases, medical outcomes research, and evidence-based clinical practice guidelines. In addition, he has lived in 5 other nations, including Canada and Sweden, where he has experienced their respective healthcare systems, and continues to follow them. He is currently active in supporting the adoption of a single-payer health care system in the U.S. For more information on single-payer go to Physicians for a National Health Program’s website at www.pnhp.org. His undergraduate degree was a dual major, Political Science and Social Psychology.
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