peterashkenaz

Around noon on November 22, El Paso time, I hopped a couple of rock walls so I could eat lunch at home, rather than at school, Putnam Elementary in Coronado Hills (if you are from El Paso you know exactly what rock walls are and how easy they are to navigate). Our live-in housekeeper had the Mexican TV news on and I saw images from Dallas reporting that President Kennedy had been shot.

I quickly ate my lunch and rushed back to school, telling everyone on the playground and then in Mrs. Burnam’s 6th grade social studies class what I had seen on TV. Of course no one believed 11-year-old me, at least until an announcement came over the loudspeaker telling us that the President had been shot. We had a moment of silence and some students cried (I don’t remember Mrs. Burnam’s reaction). In a few minutes we were dismissed from school. Being a Friday we had the weekend ahead of us – a weekend with the television on, at least in my house.

My mother was glued to the TV after she got home from work. She watched every single moment she could. In 1963, the information highway was strictly the three TV networks and, in El Paso, morning and afternoon newspapers. And get that information she did (while I was at Sunday school she watched Jack Ruby shoot Lee Harvey Oswald).

Information in those days was mediated by the newspapers and the TV newscasts, providing us with information that was thought to be balanced. At that point assassination conspiracies were few and far between, relegated to late-night Sunday AM radio broadcasts. We just didn’t question the information we read or heard (maybe that’s why so many people believed Martians were actually invading the earth on October 30, 1938).

Just five years later, in 1968, 2001: A Space Odyssey was released, predicting how we would gather information (flat screen tablets) and worry about the impact of artificial intelligence. At 15, I was blown away by the fact that I would be 49 – ancient by my young teen standards. I had no idea how my world, or the world at-large, would change. Or even if I would be functioning or even alive.

As news consumers we saw coverage changing; just look at how TV news was able to report and show the Vietnam War. Would JFK have escalated the war? Jeff Greenfield in Politico questions whether that would have happened. https://www.politico.com/news/magazine/2023/11/22/jfk-assassination-60-anniversary-00128153. But I remember my father telling me that the goal was to end the spread of communism because that was how he was interpreting what he heard on the news at the time. My father believed much of what he heard on TV, in fact when the Medicare prescription drug benefit launched in 2006 he refused to enroll because the Democrats kept saying it was a bad deal – and I was a spokesman for Medicare at the time! (and contrary to his belief, while not perfect, the Part D program is a good deal).

A lot has changed since November 22, 1963. So what do I take away from the past 60 years? First of all, I think I have come to better understand the impact of politics and policy on the American people. Secondly, I have come to see how important it is for me and others to access information that can be used to make right decisions – and I mean decisions that are right for each of us as individuals. And finally, I have seen many of the predictions of 2001 come to fruition.

And you know what? It’s all pretty exciting.

This year we spent 2 days at the Minnesota State Fair with about 100,000 of our new friends each day. It’s encouraging to see the number of people who visit the fair, many of whom are carrying shopping bags (which is good for the economy), eating and drinking lots of beer. It is Minnesota after all. A couple of things we learned:

• The Miracle of Birth center is not full of animals raised by the FFA or 4-H kids; the animals are bred to give birth during the Fair. They are all from commercial farms and the center is a nice way to capture city dwellers’ attention and teach them about the business of raising stock. The cute piglets photographed will be ready for market around February or March.
• The Princess Kay of the Milky Way princesses keep their 400-pound butter carvings for as long as they last. According to a story in the Washington Post, some of them keep them for years, others use them until they are gone. The finalists are all trained in public speaking, responding to media and other skills to prepare them for their future. One of the princesses we visited with told us she is majoring in Agriculture Communications at the University of Minnesota.
• There are really only so many fried foods (or just foods) one can manage in a day. We’d like to say that we tried a lot of the new foods and returned to some we had in the past, but with the heat and the crowds, it was really hard to meet even our own expectations. So for everyone who turns up their nose at the thought of all the available foods, we didn’t even come close to what you think we all actually ate. Our favorites were the Amish Donut (but not the filled one), the Cheese Curd Stuffed Pizza Pretzel (basically a calzone turned into a pretzel), the Mina-Sota Sticky Ribs, Nashville Hot Chicken-on-a-stick and the Meatloaf-on-a-stick.
• The daily parade is actually worth it. The high school band members actually seem to enjoy it and it is just like an old-school, small-town extravaganza. And you get to see the Fairchild and Fairborn, the Fair’s mascots who make a whole lot more sense than running sausages at the Twins’ games.
• It’s also easy to remember that it is a state fair with lots of competitions and judging, like quilts and other fabric arts (things we used to call *shmatas* – thanks dad), seed art (this year’s poster was based on a seed art picture), woodwork and lots of food. Pictured are the jam and syrup entries, not pictured are the cakes, cookies, pies, breads and other stuff sitting in cold storage that everyone wants to taste. Really.
• It seems like a good place to catch up with friends or just spend a little time resting and people-watching.
• While getting to the Fair early in the day might mitigate dealing with the crowds, you will miss the nightly fireworks display. And if one wants to see any of the Grandstand concerts, tickets MUST be bought as soon as the performers are announced.
• There is nothing wrong with being a cheerleader for the Fair. As recent transplants to Minnesota, we are actually look forward to attending.

I am pleased to see the Consumer Financial Protection Bureau and other federal agencies requesting information regarding medical credit cards. I hope that any proposed and final regulations prioritize the needs and actions of actual people.

Taken from our own experiences, the role for medical credit cards occurs when someone is truly in need (sort of like making decisions about a funeral without ability to plan ahead). People who require a medical credit card are those who:

1. Are usually trying to figure out how to pay for medical or dental needs “right now”;
2. Have no support to make a good or informed decision (most Americans are not financially proficient and are even worse under stress);
3. Want to cover their bills and don’t intend or want to default on payments;
4. Usually are living paycheck to paycheck where even a new bill will hurt financially and cause emotional stress;
5. Are generally extended on other credit cards and tend to make only the minimum payment, not thinking about the deferred interest requirements of any card and how that affects their credit or their total amount due;
6. Looking for ways to pay off their credit card bills, but are caught in the credit spiral; and
7. Want to make sure the provider they are seeing gets paid for rendering service so they will continue to be seen by their provider.

None of these concerns can truly be addressed through public policy. Still, the request for information and any subsequent rulemaking that attempts to address policy solutions will most likely result in locking in interest rates or possibly putting more hurdles directly on those individuals the regulations purport to help. Any of these regulatory efforts will only make it harder for customers and patients to do what they and their providers need and want: to pay their health-related bills.

My Personal Experience

When we applied for a medical credit card, we met most of the items listed above. In the 1980’s we filed for bankruptcy protection as a result of high medical bills we were unable to cover. While we did come out from bankruptcy, continuing health care costs made it even harder to make ends meet. We were enrolled in fee-for-service health plans which meant we had to pay the providers upfront and wait as long as 90 days for reimbursement. Guess what that did to our cash flow with one of us living with a number of chronic conditions?

Even before applying for the Care Credit card we had used one of our Visa cards to cover physical therapy costs; by the time the insurance payments of only 40% came in, we were unable to cover all the PT costs, thereby building up a hefty balance.

Then a new dental emergency came about and we just didn’t have the savings to cover the new costs. The dental practice would not provide the care until the payment would be made so we applied for and were approved by Care Credit. We knew that if we didn’t pay it off within the 12-month deferral period the interest rate would skyrocket, but when that time came, we were still only able to cover the minimum costs. So now we had two credit cards paying for health care expenses, along with other expenses.

I believe the weaknesses in the system is the overall cost of health care. Although the health insurance market has improved over the years, more and more providers are accepting insurance at the point of care resulting in fewer people have to pay all the costs out of pocket. But for many who tried to save money by buying bare-bones plans or health savings accounts, the cost of catastrophic care is when the cash register begins ringing.

Medical Credit Cards in Real Life

As reported by the CFPB, medical credit cards are not like bank credit cards because of their use requirements. One doesn’t really have the ability to compare the differences in medical credit cards at the point of sale, like when a customer is being pushed into signing up for an affinity card at a retail chain (“if you sign up for the [store name] card, you will immediately get a 20% discount off your purchase today and you can defer interest for [# of months].”). Yet for a patient, they may not be thinking of what happens in 12 months: they need the care today.

Many of the public comments being published in news stories look at how medical credit cards are helping to pay hospital costs, but the problem is much wider – it is all health and health-related costs: the cost of glasses, dental care, physical therapy services; not just a doctor visit or hospital visit, or costs of prescriptions and anything needed as a medical device or other therapeutic. A perfect candidate for a medical credit card would be someone with physical limitations who not only needs to pay for medical visits, physical therapy, and prescriptions, but also needs to see an occupational therapist and purchase devices to help manage life needs, such as cooking, dressing, and bathing. All of these costs can be an unwelcome shock that no one ever truly prepares for, or for their family members.

It has been established that outside of Medicare, most health insurers do not pay health care providers timely. A medical credit card resolves that problem. Our experience found that dentists and many independent physical therapists don’t accept any insurance, or the insurance payments are so low they require additional co-payments up front from patients, so the medical credit cards ensure they will be paid for providing care. Since health care is challenged by both access and affordability, solving at least one part of the challenge can help many people get the care they need. Having a medical credit card can alleviate at least one of these challenges for many people, as long as using the card doesn’t result in additional unintended consequences, such as a decline in one’s credit rating or additional stress-related conditions.

Regulatory Solutions?

First in any regulatory solution is managing health care costs, especially at the point of care for patients. Health care consumers are not usually well-informed about their health care or the actual costs they may incur. While Medicare and other insurers have been looking at ways to make costs more transparent, that transparency will not reflect the actual cost a patient may be required to pay for a specific treatment. Furthermore, if a provider tells a patient that a certain treatment is required, there are very few times when someone will actually be able to shop around for a better price because that means finding a new provider, being examined by that provider and then getting the price from them. In the current health care market, just getting a new appointment can takes weeks, if not months, even when someone lives in an area where multiple providers accept new patients, and by then a health issue will most likely be exacerbated. A patient is not going to go online in an ambulance and ask the EMTs to take them to the hospital with the lowest costs, nor even worry about how to pay for the ambulance trip.

Second, there are no strong policy authorities in place – the current legislative proposal, the Credit Card Competition Act of 2023, will not address any of the concerns raised by this request for information. The proposed legislation is designed to implement competition in the credit card networks in an effort to reduce costs for merchants which could possibly lower costs for consumers (but most likely won’t). The proposed legislation does not appear to impact medical credit cards.

I suggest that any regulatory actions require additional training of health provider staff before allowing them to offer patients an application for a medical credit card. Staff should be trained to help patients investigate or even apply for other financial aid programs before suggesting the medical credit card. I would be surprised if a practice would ever train staff to be financial planners, but in an effort to care for patients, financial needs must be addressed along with their health care needs.

HHS can propose requirements for health care providers to better explain costs under specific diagnostic codes to the patient and the impacts of waiting for care, similar to how some clinicians actually look at a patient’s insurance plan’s drug formulary to see if a medicine is covered under the plan. This would fit under existing rules requiring providers to post information about consumers’ rights, and would also advance the current focus on patient-centered care and shared decision-making. It would be impossible for patients or providers to have honest conversations about health choices when the prices for services are hidden and patients have no way to make informed decisions. Significant changes in banking and financial services occurred over the past decades to protect consumers but no consideration has been taken to look at the impact of health care costs on patients at the point-of-care.

While this request for information is a good first step, it is only part of the wide range of policy improvements that consumers need to make health care and financial decisions today, especially since health care and financial decisions are closely intertwined.

The overcast, smoky skies hanging over much of the US (and especially downtown Minneapolis, only a couple of miles away), brings to mind a morning when I was shooting photos for the Lubbock Avalanche-Journal (which covered the plains like an avalanche!). It was a foggy morning and the cloud cover did just that, covered the Lubbock skyline. I thought that since the skyline disappeared into a cloud made for an interesting photo, so I shot a number of images, ran into the darkroom and handed in a shot of what we called “wild art” in time for publication in the afternoon edition. The photo was not accepted because, I was told by the photo editor, it did not show the tall buildings (which the fog had covered) and therefore didn’t look like downtown Lubbock.

I also remember the same news editor had concerns about a photo I had shot earlier from a Cong. George Mahon town hall where I stood on the stage and looked out over the crowd (I thought the crowd shot was more interesting than a head-on shot of the congressman, which I also shot). That shot had a highlight from a TV light in the frame, so the editor took a grease pencil and colored over the stage light (can you see me shaking my head even now?).

Now its encouraging to see all of the photos of hazy, smoky skies, telling me that the photo editors across the news media are publishing photos that actually depict was millions of us are seeing.

The recent burst of news about former President Jimmy Carter brought me back to that time when he campaigned in El Paso, showing me how federal government officials (staff?) interact with the American public and the hope of something better.

It was October 8, 1976 and I was one of the three El Paso Herald-Post photographers assigned to cover arrival at the El Paso airport. Of course my first memory of the day is all about food – I stopped at the Campus Queen for 2 beef and cheese burritos because they were easy to eat while driving. These weren’t so perfect though; the first one dripped cheese on my pants. I didn’t have time to go home to change, so off I went to the Transient Terminal.

When I got to the airport terminal in my grease-stained Levis cords I was told that I could either be on the tarmac where the national press corps would be gathered (penned?) or in the crowd (I did snap some photos of the crowd as I walked to the pen) .

We couldn’t move between the candidate meeting the Democratic Party greeters at the base of the airplane or into the crowd (it was either because of security or crowd control, but I blamed the campaign). So, like most of the local press, I decided to wait at the base for Peanut One.

The plane arrived, the national press corps disembarked and everyone got into position. As a still photographer I knelt in front of the scrum and when Mr. Carter descended the stairs to greet the local dignitaries I started to stand, but found a foot in my camera bag holding me down. I figured it was one of the national photogs, but no, it was El Paso Channel 9’s Jeff Gates who was shooting silent film behind me (using one of the Bell & Howell hand-crank camera that I later used when I went to work for him a couple of years later).

Should I have been surprised how we were treated by the national press, the Secret Service and the campaign itself? Nah. The campaign’s goal was to control the media and control the message (there’s another story about how we were treated by the Ft. Bliss PIO but that’s for another time); the national media was just attempting to capture the moment. But the fact that a presidential candidate came to our town was big news for us, no matter how small it was for the campaign.

In my time working in the small media market of El Paso at both a daily paper and the number three rated TV news station in the 70’s and 80’s, I was frustrated whenever I had to interact with the feds.

Not a lot has changed since Jimmy Carter came to El Paso in 1976. The perpetual campaign persists. And I don’t think I was ever able to get that stain out of my pants.

We’ve all been there – we enter a shop or restaurant and … no one seems to care. We’ve all just learned to deal with that type of an experience.

But what happens when you encounter this environment in a doctor’s office or a clinic? If it’s the first visit, we are undoubtedly anxious. We also might be anxious because something hurts and we have no idea what’s happening. Isn’t that why we came to see the doctor in the first place?

That anxiety is exacerbated by how we are greeted at the front door, whether through the all-unknowing telephone audio response system, or the actual door. If we are not necessarily used to using electronics, we don’t know to look for the kiosk, although we might be lucky if there is a tablet set in front of the door. If we are anxious, we generally look for a friendly face to help us navigate. Or at the very least, we’d like to see someone who might smile and say “hello.”

Then, once you sign in, what happens next? Take for example, something that happened to my wife and me recently – she was referred to a world-class specialist for a very scary eye condition. The appointment was scheduled for 9AM and when we got to the clinic, the very large room was packed, which heightened our anxiety. The electronic kiosk was almost hidden (if you didn’t know where to look) and then finding a seat was difficult. Roughly an hour and half after registering, she was called into an exam room for an initial evaluation and then sent back to the waiting room. But no one told her what was next. An hour or so later she was escorted for another look into an ocular machine and then she came back to the waiting room. At 3PM she was escorted to the final treatment room and told the doctor would see her next. The wait there was only 30 minutes (!) before she saw the doctor. At least someone told us what to expect, mostly.

The care was phenomenal, but the packed waiting room heightened her anxiety. Conversations overheard in the waiting room included: “it’s always like this,” “no one tells you what to expect,” “they schedule everyone at once and then you have no idea when you might get seen,” and “I take the entire day off from work because I just can’t plan.”

This is an extreme case, but not dissimilar to what we’ve experienced when visiting our primary care doctors. You’ve been seeing this clinician for years but the front office staff seems to change every couple of visits so no one even says, “Hello.” While this doesn’t really affect your care, it does affect your state of mind.

Every patient has a different reason to see the doctor, and in most cases, that visit brings its own levels of anxiety. Some people had to spend hours just getting ready for the appointment.

For some this is a highlight of the week and preparation is important. Do you need assistance to get to the appointment? Do you have to take public transportation and how long will it take – how many bus transfers will you need to make? Should the front office staff be more cognizant of those concerns, and is this addressed in training and orientation? Would treating patients with a minimal amount of respect help to relieve some of the stress and anxiety?

There is very little research surrounding how patients and their caregivers are treated by medical office staff. Medicare’s Consumer Assessment of Healthcare Providers & Systems (CAHPS) does not include specific questions about patient experience with the front office; however, there are two questions in the CAHPS for Merit-based Incentive Payment System (MIPS) participants. Those questions address whether the front office staff were helpful and if they treated the patient with respect. I have not seen any data aggregating the findings from these questions and the research points to patient experience only in hospital settings.

In 2013, Merlino and Raman wrote about the drivers of patients hospital experience. They report that if patients don’t “feel that … caregivers are compassionate, that may heavily influence … overall perception of the experience. Since his relationship with health care givers is more prolonged (or permanent), he may need more of the ‘human side’ of caring.”

The Agency for Healthcare Research and Quality (AHRQ) developed the Ambulatory Care Improvement Guide to help health care providers. Chapter 6 of the Guide offers standards for customer service, explaining they may be “similar to ‘service guarantees’—a concept that frightens many health care employees because they do not trust that the systems they need to meet ‘guarantees’ that are in place. Organizations that maintain their focus on service often find that the standards evolve over time.”

AHRQ includes examples from organizations including Kaiser Permanente’s Pharmacy Department: “We will greet our members in a courteous and professional manner. We will listen effectively to our members’ requests and promptly take the necessary actions to assist them. We will keep our members informed of unexpected delays in service.”

As an aside, I don’t believe that new technologies will offer the personal solutions. Entering a clinic or doctor’s office is a human experience and presenting a patient an opportunity to “sign-in” online or check in at a kiosk removes the need for a personal interaction.

My personal experience is that within a strictly fee-for-service payment structure, the front office is not incentivized to treat patients or family members in any particular way. But my wife and I have seen, at least in the Minneapolis area, where most health care is provided through health systems, the competitive nature of the health systems almost require a high level of friendliness and respect. These systems could perhaps collect and use the CAHPS for MIPS data which may be why we have not experienced what we consider a lack of respect like what we saw in small or medium-sized practices while living in the DC area.

What this tells me is that, currently, any patient experience or satisfaction with front office staff is strictly anecdotal, reflecting personal satisfaction or dissatisfaction. And one of the few solutions we have received when issuing a general inquiry is “find a new doctor.” Like the example I shared above, many times that option is just not available – the physician is a specialist, other clinicians won’t take the patient’s insurance, or there are too few providers in a patient’s community.

I don’t believe that my wife or I are the only people who have experienced a lack of customer service in health care. I am interested in seeing if this is an underreported or under researched issue or just a personal concern. If you are aware of any research into customer service in health care or have your own experiences, I would appreciate hearing from you.