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Hospital Price Transparency in Delaware: The Ideal and the Reality

By: Dr. Stacie Beck

You usually know what you are going to pay for purchase before you buy. That makes sense. But have you ever tried to determine how much a medical procedure is going to cost before you undergo anesthesia? It can be frustrating.

Well, at last, the federal government has come to the rescue – sort of. The Center for Medicare & Medicaid Services (CMS) now requires hospitals to post all their prices in a machine-readable file (for the highly computer literate) and a selection of “shoppable services” (essentially, non-urgent procedures) in a consumer-friendly format (for the rest of us).

We compared the CMS ideal and the Delaware reality by pricing three procedures that may be familiar to readers: a colonoscopy, vaginal delivery of a baby without complications and a simple cardioversion. The third is an electric shock administered externally to the chest while under anesthesia to restore a regular heartbeat to a patient with a heart flutter.

The Ideal

              The CMS requires that a common price list of 70 shoppable services (or as many as the hospital provides) to be posted. An additional 230 or more, totaling 300 services, chosen by the hospital, must also be posted, reflecting the most common procedures done at the hospital based on local demographics or hospital specialization. Of the three procedures we considered, two (colonoscopy and vaginal delivery) are on the required list and one (cardioversion) is not.

The format can be either a cost estimator tool or a ‘flat file’ with links prominently displayed on the hospital website. The hospital is not allowed to require you to set up an account, use a password or any personal identifying information to access the list.  Four prices should be displayed: the cash price, the payer-specific price, and the minimum and maximum prices negotiated by the hospital with all its payers. ‘Payer’ usually means a health insurance company. Medicare/Medicaid prices are not required to be displayed because they are publicly available elsewhere, although CMS encourages these to be included.

Hospitals must identify and include ancillary services, such as laboratory tests, radiology, drugs, anesthesia services, etc., it provides as part of a shoppable service. Beware: hospitals differ in the ancillary services that are included. Moreover, their negotiated contracts with payers could differ in ancillary services that are included. Though not required, CMS ‘strongly encourage(s) and recommend(s), …(hospitals) indicate any additional ancillary services that are not provided by the hospital but that (hospitals) know the patient is likely to experience as part of the primary shoppable service, and to indicate that such services may be billed separately by other entities involved in the patient’s care’ that are not employed by the hospital.

CMS helpfully suggests a format for each situation, as depicted below.

If all ancillary services are included in the contract negotiated with Health Insurer X:

If ancillary services are included but negotiated separately by the hospital with Health Insurer Y, then:

If only some ancillary services are included by hospital in its contract with Health Insurer X:

While a health insurance plan member may be able to request an estimate of total cost from the insurer, the self-paying patient must be savvy enough to request the cost of all services: those provided by the hospital and those billed separately. The latter requires the patient get the contact information of those the hospital has contracted with (e.g., pathology and/or anesthesia practices, etc.).

The Reality

The hospitals surveyed here are: Christiana Care, Bay Health, Beebe, Chester County-Penn Medicine, and UM Upper Chesapeake Medical Center.

The good news is that all have links to a cost estimator tool on their main websites. However, they are mostly buried under obscure headings, sometimes at the top or bottom of the page in small print, e.g., Billing and Financial Information (Bayhealth) or Resources (Beebe). Christiana Care buries it the deepest, and one has to know whether a colonoscopy or vaginal delivery is an in-patient or out-patient, medical or surgical service. Upper Chesapeake’s link for ‘guests’ is inoperative.

It is important in most cases to have the billing (CPT or DRG) code rather than the procedure name. For example, there are several types of colonoscopies. Most cost estimator tools include statements that certain services may be billed separately, such as physician and anesthesia, but are not specific by procedure. No name or contact information for these outside services is listed, despite being contracted by the hospital, except for Bayhealth in an online brochure.

Few follow CMS’s suggested formats. Below the colonoscopy (CPT 45378) estimate for a self-paying patient is shown for our sample hospitals.

Christiana Care:

It appears that all ancillary services are included in the self-pay price but this is not clear. The cost of vaginal delivery (CPT 59400) without ancillary services is $4,430 and no estimate is provided for a cardioversion (CPT 92960)

Bayhealth

It is not clear what ancillary services are included from this estimator tool. No estimate was available for vaginal delivery and cardioversion costs $1737.

Beebe

No estimate was available for vaginal delivery and cardioversion costs $652. Again, it is not clear what specific ancillary services are included for each procedure from this estimator tool.

Chester County Hospital (Penn Medicine)

Penn Medicine provides estimates specific to each location (here Chester County Hospital) whereas Christiana Care and Bayhealth do not. However, it was easier to find the flat file than the estimator tool. Notice that the prices appear to be far apart for the cash-paying patient from each source. No estimate was available for vaginal delivery and cardioversion costs $688. The latter estimate was available in the ‘flat file’ but not the estimator. There were three entries under cardioversion (CPT 96920) with prices ranging from $1264 to $4477.

UM Upper Chesapeake Medical Center The cost estimator tool is unavailable to non-patients. Only the rather useless chargemaster list is accessible as a machine-readable file.

Conclusions

The CMS has made a valuable advance in health care price transparency. However, our local industry is dragging its feet in obeying the spirit as well as the letter of the law. All the hospitals here list phone numbers for patients to get more precise estimates, however this does not fulfill the intent of the regulation. The ideal is for information to be conveniently available for comparison shopping. Other industries with multiple and complex inputs, e.g., construction, education, etc. have achieved this. The health care industry can too.

Dr. Stacie Beck is an Associate Professor of Economics at the University of Delaware. She has a BS in economics from Boston College and a PhD in economics from the University of Pennsylvania. She has been published in many peer review journals and currently serves as an editorial board member of Eastern Economics Journal.

 

 

 

Health Care Commission: Lack of Independence from the Governor

By: Alexandre Kittila

The Delaware Healthcare Commission (DHCC) is the executive authority on healthcare in the state of Delaware. When it was established in 1990, the founding legislation stated that the Commission shall “serve as the policy body to advise the Governor and General Assembly.” To meet the DHCC’s important duties, members are “to collaborate with other state agencies and the private sector, to initiate pilots, and to recommend policy changes to the Governor and General Assembly.”

A substantial addition to that mission occurred in 2022, when the legislature granted additional authority to the Commission to “be responsible for establishing and monitoring the State of Delaware Health Care Spending.” Giving the Commission direct control over establishing pilot programs and affecting spending, grants what was an advisory board much more influence than the term “commission” would lead you to believe.

A real concern is not the establishment of the DHCC, nor its duties, but, rather, the fashion in which its board members are selected, and who is selected to serve. An executive commission separate from the branches of the Delaware government to establish pilots and spending could encourage decisive action and less entanglement in the bureaucracy; in its current state, however, it simply works as an extension of the Governor’s power over the healthcare industry in Delaware. Separation of the commission from the influence of bureaucrats in our government is crucial to ensure its proper function and fidelity to the goal of meeting the health care needs of Delawareans.

There are eleven members of the Commission. They are: the Insurance Commissioner, a representative of the Speaker of the House, a representative of the President Pro Tempe, the Secretary of Finance, the Secretary of Health and Social Services, the Secretary of Services for Children and Youths, and five individuals who are chosen by the Governor. Therefore, fully eight out of the eleven members are directly selected by the Governor. This compromises the independence of the Commission and can lead to the Commission becoming simply a rubber stamp for the Governor’s preferred policies and spending priorities.

If we truly want the best outcome for Delaware citizens who seek health care, the Commission should be a think tank to consider how we can best provide timely access and quality care at a fair and reasonable price. That is, the best way to spend the taxpayers’ money.

There is potential for independence of the Commission from the Governor in a provision of the Delaware Code that requires that “no more than 3 of the Commission members appointed by the Governor shall be of the same political party.” Of course, in Delaware, for nearly a decade now, the leadership of the House and Senate, and the Insurance Commissioner, have all be of the same political party as the Governor, And, given that the three cabinet members are appointed by the Governor, they will likely be of the same political party.  So, while the law may seem to create balance, consider that, even adhering to this requirement, the balance of the Commission could be 9-2. And, even if the Speaker of the House, the President Pro Tempe of the Senate, and the Insurance Commissioner are all of the opposite party of the Governor, and two of the five individuals selected by the Governor are of the opposite party, the balance would still be a majority of the Governor’s party, 6-5.

So, has the government followed their own laws? Currently, the cabinet members and government officials holding the designated positions are all members of the Democrat Party, and 4 of the 5 persons named by the Governor are Democrats, the only exception being the former Democrat mayor of Lewes, Theodore Becker, who is now registered as a “NO PARTY.” There clearly is no balance.

Additionally, many members of the Commission have a vested interest in the outcome of the decisions the Commission makes because they are affiliated with a health care provider or service in Delaware.  The Commission is mandated, in 16 Del. C.  §9903(e)(3) to act “in such a way that fosters creative thinking and problem solving.” A commission in which a nearly singular policy affiliation reigns does not “foster creative thinking”, but rather becomes an echo chamber effect, not receiving or considering competing or alternative viewpoints.

An executive authority on healthcare is not inherently a bad idea but the fact that nearly every member serves, for all practical purposes, at the pleasure of the Governor makes it dangerous. It allows the Governor and the government a more heavy hand into places it ought to be restrained. The Commission needs to be nonpartisan and independent, and motivated by the best interests in meeting the health care needs of our citizens.

So, what would be the best solution?  Perhaps we should make the five Commission members currently chosen by the Governor, selected and voted on by the General Assembly. Perhaps adopt an ethics rule to eliminate self-interest. Maybe allow a single selection by the Governor, other than his cabinet members, similar to the ones for the President Pro Tempe and the Speaker of the House.

All of those ideas will improve the Commission’s ability to meet the statutory mandate. But the most important takeaway is that since the DHCC is meant to be for the people, it should also be by the people. Establishing the DHCC in a more balanced structure will not only lead to more ideas, but also better ideas, hopefully leading to better healthcare for everyone in the state of Delaware.

.Alexandre Kittila is Senior at Tower Hill School. Kittila served as an intern for A Better Delaware in the summer of 2023.

Consolidation of Healthcare Services and Financing in Delaware: The Inherent Risk of Monopoly

By: Christopher Casscells, M.D.

Delaware is a small state, both by size and population. As our elderly population grows and the state’s economy shrinks, a larger percentage of our economy will be dedicated to healthcare because, necessarily, older people require more healthcare. None of this is disputable.

Delaware residents have limited choice of providers, especially of hospital systems: only Bayhealth, Beebe, Christiana and St. Francis are options. Christiana is dominant, and the others generally co-exist. Delaware’s certificate of need laws discourage further outside competition from entering the marketplace.

A predictable result of the implementation of the Affordable Care Act (Obamacare) is the trend of consolidation of healthcare providers, nationally. There are fewer and fewer independent practices, as they are bought up or driven out by the hospitals. Again, policy drives that result, as the hospitals are paid a larger premium by Medicare, Medicaid and private insurers for exactly the same service provided by an independent practitioner. So, the trend is toward a day when all healthcare is delivered by hospitals and their employees.

The issue looms large for Delaware patients.  In most places, patients still have choices between competing large systems, and oversight is in place to screen for price-setting collusion between these entities.

Delaware’s size, both geographically and in population, limits those “remedies”. There is very limited choice of hospital and provider, especially, regionally, in some of our rural areas.

Additionally, in Delaware, there is limited choice of health insurers. The state is dominated by Highmark Blue Cross Blue Shield (BCBS), a Pennsylvania company that acquired BCBSDelaware over a decade ago. Highmark is effectively the only health insurance company in Delaware. Highmark manages portions of Delaware’s sizable Medicaid and Medicare patient population in addition to being the sole health insurance contractor for the State of Delaware, its employees, and retirees. The State is the largest employer in Delaware. Several other entities have tried to make a go of it, including Aetna, Principal, Coventry, Cigna, Care First, US Healthcare and United Healthcare, to name a few, but none has been able to compete. There should be competition, however, Delaware law requires a minimum of 3 choices of health insurer, but the Delaware Insurance Commissioner simply ignores the mandate.

And, even with multiple hospitals, our choices are shrinking. Increasingly, there are “collaborations” between Highmark and Christiana Care, Beebe and BayHealth. Delaware policy leaders need to take note. In Pennsylvania, Highmark ‘collaborated’ with the Allegheny Hospital System in PA before taking over and creating a vertical monopoly which successfully competes against other insurers, hospital systems and combinations. While a system like Pittsburgh’s UPMC in Western Pennsylvania might be able to compete with that large a competitor, Delaware has no other competitive choices. If left unchallenged, a vertical monopoly would worsen an already less than ideal situation.

There are those that argue that such a collaboration would lead to economies of scale with better access, lower cost, and higher quality. But those metrics have been the goal of the Delaware Healthcare Commission for well over a decade, and the only result has been the steady worsening of all three metrics. According to Forbes Advisor, Nov. 2022, Delaware already has the 8th highest cost per capita of healthcare in the nation. Our wait times in Emergency Departments are dismal, and securing an appointment with a provider is increasingly difficult. Those advocates need to be asked to account for these results, in spite of the increasing consolidation of the healthcare marketplace.

Regardless of the intentions of those responsible for the oversight of the state’s health policy, the Department of Health and Human Services, the Insurance Commissioner, and the Healthcare Commission, they must be more vigilant to protect the options patients have for care.

History has demonstrated consistently that monopolies in a service industry are ill-advised. Delaware policy makers need to prevent further consolidation, bring more insurance options to Delaware citizens, and prevent a vertical monopoly that will adversely affect precisely those goals our policy makers are seeking to achieve.

Dr. Christopher Casscells, MD, Policy Director, Center for Health Policy, Caesar Rodney Institute. Dr. Casscells was one of Delaware’s leading Board-Certified Orthopedic Surgeons. He graduated from the University of Virginia School of Medicine and did his residency at Yale-New Haven Hospital. After a distinguished 30-year medical career, Dr. Casscells retired from practicing in January 2020.

Medicare Advantage Plans: Are We Doing Our Best for Our Seniors?

By: Glenn Brown, DPT, PT, MMSc, ATC

Medicare provides health insurance coverage for 65 million people in the United States.  But Medicare has changed, and today, over 30 million seniors, (nearly 51%) are covered under a Medicare Advantage Plan. The number of Special Needs Plans available has doubled since 2018.  Even government retirement packages are looking at Medicare Advantage as an alternative. It is well known that in Delaware, state retirees are facing a considerable battle over being forced into a Medicare Advantage Plan as opposed to the promised benefits of traditional Medicare and supplemental insurance coverage.

Given the increasing popularity of Medicare Advantage, we must consider how and if this transition in the Medicare market is beneficial to both patients and providers.  Significantly, we must consider the impact of the rising percentage of the Medicare market share captured by for-profit companies versus nonprofit, or government plans.  Currently, for-profit insurers account for 72.9% of all Medicare Advantage plans, with an annual growth rate of over 11%.

Medicare Advantage plans purport additional benefits and coverages for subscribers compared to traditional Medicare. These plans boast lower prices for prescription drugs and lower premiums with expanded coverage options such as vision, fitness, telehealth, hearing, and dental benefits. Despite these additional bells and whistles, beneficiaries in Medicare Advantage and traditional Medicare reported similar rates of satisfaction with their care. Regarding affordability, a slightly smaller number of beneficiaries in traditional Medicare with supplemental coverage than Medicare Advantage enrollees reported having cost-related problems.

However, many Medicare Advantage plans create cost and convenience issues for subscribers. These include limited network coverage, high out-of-network costs, prescription drug formularies that do not include their needed medications, preauthorization, and utilization management processes that can lead to delays in care and administrative burdens for both patients and healthcare providers. In my practice, Highmark Medicare Advantage subscribers encountered an unexpected increase in out-of-network copayments. These copayments, which previously were 20% co-insurance payments, now range from $35-$50 per visit depending on the plan selected by the subscribers.

While there are pitfalls for subscribers in Medicare Advantage, the challenges it creates for providers are so great that many providers are unwilling to accept their fee schedules and billing/reimbursement policies. Large provider groups are leaving the Medicare Advantage market because of low reimbursement and prior authorization hassles.  Providers also experience much greater complexity in the billing and collection process which involves greater resources allocated to obtain payment for services. They expose themselves to greater financial risk because of the increase in complexity and the risk of unpredictable plan changes, including reimbursement rates, utilization management programs, and other billing and collections process burdens.

Medicare Advantage plans give the perception of being an appealing alternative to traditional Medicare.  These plans promise additional benefits and cost savings, but they also come with a range of disadvantages. These disadvantages include limited network coverage, higher out-of-pocket costs, geographic and prescription drug restrictions, and the potential for plan changes and disruptions.  Additionally, a growing number of Medicare subscribers are covered by “for-profit” companies.  Recent evidence indicates that “for-profit” consolidated companies result in elevated physician charges and costs. Prudent and forward-thinking decision-making must occur now. We must drive more of these plans back to traditional Medicare or at least force them to operate in a manner similar to traditional Medicare.  Failure to do so will result in these profit-driven companies creating a system that transfers greater costs to those on a fixed income and greater limitation of provider access for a population that has notably more serious conditions and/or multiple medical issues. We owe it to our seniors to create a system that properly cares for them versus a system that sees only the GOLD in the “Golden Years”.

Glenn Brown DPT, MMSc, ATC, SCS is the co-owner of CORE Physical Therapy in Dover.  Dr. Brown has been in clinical practice for 38 years as a physical therapist and athletic trainer and has been a Sports Certified Specialist since 1993.  Dr. Brown currently serves as the Legislative Chair of the Delaware Chapter of the American Physical Therapy Association.

 

Are Certificate of Need Laws Relevant in Delaware’s Healthcare Marketplace?

By: Jane Brady, Chair, A Better Delaware

You may have never heard of a Certificate of Need (CON) if you do not work in healthcare in Delaware. Yet, these requirements within CON regulations can affect your access to, and the cost and quality of, patient care you receive.

The law adopting a Certificate of Need requirement, now called a Certificate of Public Review in Delaware, was intended to improve access, costs, and the quality of care for patients, generally in hospitals and nursing homes. The law has failed to achieve those goals.

A Certificate of Need is a regulation that requires healthcare providers to get permission from the state before adding or expanding the type of services they offer or before acquiring expensive equipment, building new facilities, or expanding existing ones. Upon passage of an Act of Congress, certificate of need laws were passed by 49 of the 50 states in the early 1980s.

Over the intervening years, research has shown that the goals the laws sought to achieve were not reached, and many states now have repealed the certificate of need statutes. In fact, even Congress repealed the law that compelled states to adopt a certificate of need law – in 1986!! Yet, like many other states, Delaware still has the requirement in place. It should be repealed.

There have been studies of the impact of certificate of need laws. The Kaiser Family Foundation did a study that found that states that have certificate of need requirements had 11% higher healthcare costs than states that did not have it. An additional study by George Mason University found that there were 30% fewer hospitals per 100,000 residents in states that had a certificate of need requirement. Additionally, rural areas, with smaller, localized populations, were more poorly served.

Certificate of need laws are structurally flawed. They limit competition. They allow the state to pick “winners” and “losers,” with the existing facilities having the political connections and favor to “win.” The certificate of need restricts who can participate in competing for your healthcare choices and as a result, there is no incentive to be innovative or even cost-conscious when they appeal to you as you make your health care choices. When businesses compete for you to choose their services, they will try and find the most cost-effective way to give you a product that you want, when you want it. Without competition, there is no need to be responsive to your demand for a specific service or to be more cost-effective. You get what they have decided to provide at the price they decide to charge.

Importantly, access includes timeliness. Recently, CMS, the company that manages Medicare and Medicaid nationally, conducted a study of emergency room wait times in all 50 states and the District of Columbia. Delaware ranked 47 out of 51, with an average wait time for emergency room services of over three hours.

It is good governance to eliminate certificate of need laws. Since the laws were passed, the government has taken a much larger role in providing health care.

In an attempt to assure continuing use of these competition – limiting laws, advocates claim they are necessary for more effective care for indigent patients. It was not one of the original stated goals of the legislation but has been used to try and justify retaining these laws on the books. However, if you wish to help the indigent access health care, and most would accept that is a desirable social goal, the best course is to require the expenditure of public funds for that purpose to be transparent and accountable. Currently, the way reimbursements are being made, the hospitals effectively become a smokescreen, and the public cannot discern easily where and how the money is being spent.

The absurd argument some of those who favor using certificate of need laws to help fund indigent services argue is that if you restrict the amount of healthcare available, the healthcare providers who are lucky enough to be in the market can charge higher rates to the people with private insurance, and that will subsidize the care for poor patients without any insurance.  Maybe a day long ago when providers actually decided what health care would cost.

Now, Medicare and Medicaid have changed the economic environment in which healthcare is provided and costs are highly regulated. In truth, Certificate of Need laws are now essentially outdated for any purpose. Delaware should repeal the laws providing for a Certificate of Public Review, our equivalent of a Certificate of Need, and allow the health care providers of our state compete fairly to provide the public, timely, the quality health care they need and want.

Jane Bady serves as Chair of A Better Delaware.She previously served as Attorney General of Delaware and as a Judge of the Delaware Superior Court.

 

Healthcare Challenges Should be a Priority

By: Dr. Greg DeMeo, D.O., Advisory Board Member, A Better Delaware

For more than 20 years, the American Medical Association (AMA) has warned of a pending physician shortage. Many practitioners suggested this was nothing more than a marketing ploy to drive membership. Sadly, the AMA was correct, and there are shortages of medical doctors throughout the country, in some areas, severe. The occurrence of the pandemic has exacerbated and likely accelerated the problem. Access to care for both insured and uninsured individuals has become quite difficult.

Delaware, like many states, has varying access to health care, depending on your location. Located in New Castle County, ChristianaCare, the largest health care system in the state, enjoys a favorable national reputation. Kent County is much more rural, but also enjoys a large medical system, BayHealth. Sussex County has challenging demographics that, while slowly changing, are mostly Medicare and Medicaid insured populations. That County’s healthcare needs are supported by Bebee Medical Center.

In all regions, however, and in all specialties, physicians are in short supply. Most critically affected are Primary Care Medicine, Women’s Health, and medical specialties such as Cardiology and Neurology.

Women’s Health Care has always been a medical specialty in which Delaware physicians have practiced at a very high level. ChristianaCare has always enjoyed a strong residency training program in Women’s health and graduates 7 residents per year in the specialty. However, on average, about 50% of those graduates go on to further train in sub-specialty practice and leave the area after graduation.

Even prior to the pandemic, it was difficult to secure an appointment in a reasonable period of time for well women visits. New patients often had to wait 2 or 3 months for an appointment, although pregnant women and patients with perceived gynecologic problems were seen in a more timely manner.

The pandemic truly took a toll on medicine. Physicians in all specialty areas have retired or left the practice of medicine in numbers that have never been seen before. Consider that, as well as the natural aging of the workforce, and the prediction of the AMA is simply coming to fruition. This has left healthcare for women in Delaware at a crisis level. Presently wait times for well women visits can easily approach a year if you are lucky enough to get an appointment. Many women need to seek care in Emergency Rooms and Urgent Care Centers. This reduction in the work force and the demand, that simply exceeds what medical practitioners can meet, have contributed to the access to care issue.

But there are other issues that have led to this crisis. Delaware has limited competition in certain areas of business directly related to healthcare, such as insurance. This limited competition directly correlates to the increased cost of care, as well as limited access.

As a practical matter, all healthcare is paid for by insurance, whether commercial or government funded. Medicare, which is a federally funded and administered program, essentially establishes reimbursement rates for Medicaid and commercial insurance. Unfortunately, physician reimbursement rates under Medicare have increased by just 8% over the past 22 years, while hospital rates as well as rates for skilled nursing facilities have increased by over 60% in the same time frame.

Delaware, with limited options and with Highmark as its largest commercial insurer, provides little opportunity for physicians to negotiate. In some instances, Highmark pays consistent with Medicare and in almost all cases, Highmark tends to reimburse towards the lower end of the scale.

While New Castle County is fortunate to enjoy ChristianaCare as its major hospital system, this benefit comes with a double-edged sword. ChristianaCare, with its vast scope, power, and wealth, clearly dominates the healthcare marketplace for the entire state and has the leverage to benefit from “preferred” reimbursement rates under the state Medicaid system – to the detriment of private practice physicians in our communities. In addition, ChristianaCare’s size enables it to control competition regarding the development of new ambulatory surgical centers as well as free standing specialty hospitals. Finally, Highmark and ChristianaCare have initiated numerous joint ventures, which allows them to disqualify community-based physicians in favor of hospital employed physicians. What does disqualify mean?

As a result of the disparity in reimbursement increases, physicians are unable to compete with the hospital system for new hires. Over the past 10 years, hospitals have enjoyed the increased control and revenue stream that employing additional physicians brings. In addition, these physicians are highly likely to refer patients to hospital- owned facilities for any additional treatment, which further closes the loop on fair competition. In our community, ChristianaCare has aggressively gone into the marketplace and offered very high starting salaries to recent graduates. This business model even further reduces access. Clear data exists that shows hospital employed physicians see many fewer patients per day than private practice physicians.

All in all, the unfair reimbursement practices supported by government policies are slowly, but surely, decreasing access to care at all insurance levels. Hospitals take advantage of their size and scope to further benefit from this broken system. Legislators need to make better and informed decisions about competition, fair reimbursement, and referral for profit in order to give everyone who needs a doctor, better access to health care and at a reasonable cost.

Dr. DeMeo is the medical director of Christiana Care’s Labor and Delivery Department and represents The American College of Obstetricians and Gynecologists at the national level where he focuses on issues related to Medicare reimbursement.