WhiteCoat

Healthcare Policy Roundup 7/22/09

The Mayo Clinic – touted by the Obama administration as a system that provides quality care at a reduced cost – turned around and smacked House Democrats in the face over the recent health care reform proposals. A Washington Times article quotes Mayo Clinic officials as stating that the plan will lower quality and increase costs because the outcomes are not patient-focused or results-oriented. “The real losers [with this plan] will be the citizens of the United States.” Ouch.
In other news, President Obama mentioned in a White House press conference that he changed his mind and now thinks that the Mayo Clinic sucks.

Comparing healthcare systems in different countries may help the US come up with a viable alternative to our current system. John Aravosis from America Blog describes a situation in France where his emergency department visit at a specialty hospital cost him a rocking $32. Something doesn’t sound right about that story. If it is really true, insurance companies would spend less money by purchasing an air fleet and sending patients with potentially expensive medical problems to France for emergency care. Anyone else have experience with the French system that could comment more about it?

More violence in the emergency department. An ED admitting clerk was shot three times by her former boyfriend outside the hospital and then stumbles inside full of blood.

I usually don’t believe that the number of malpractice suits against a physician should be used as a measure of a physician’s competence. I know several excellent physicians who have been sued 5-10 times. I have been sued several times myself. Unfortunately, when there’s no reliable way of measuring a desired metric such as physician quality, pencil pushers will take things that can be measured and try to make the argument that the data apply to the metrics. That being said, should an ophthalmologist who has been sued 50 times be subject to discipline just because of the number of lawsuits against him?

The largest medical malpractice verdict in Tennessee history was just handed down against an OB/Gyn physician that allegedly ignored a patient’s complaints about an unusual breast lump, stating that the lump was probably a cyst or a fatty deposit. Instead, the lump was a cancer that later spread to the patient’s liver. The jury awarded almost $24 million to the patient and her husband.

Here’s a WTF moment for you. Two nurses wrote a complaint with the Texas Medical Board after they became concerned with patient safety when a physician kept trying to sell patients herbal medications. Kind of like an IRS agents offering to sell you tickets to the IRS ball just before an audit? The nurses included patient identification numbers, but no names, with the complaint. The story isn’t clear, but apparently medical records were also sent to the Medical Board. When contacted by the county sheriff, none of the patients complained about their care. The District Attorney then filed criminal charges against the nurses after the doctor complained about being “harassed”.
In other news, the Winkler County District Attorney could not be immediately reached for comment, but later was found at home taking a chamomile extract bath with vanilla bean infusion prescribed by the involved physician.

Defensive medicine may not exist, but this doctor does a pretty good job of describing this figment of our imagination. Interesting that Congressional Budget Office statistics show that $30 billion was spent to defend against and pay malpractice claims in 2008, but that money was only 1.5% of the total 2008 healthcare expenditures. Also interesting that hospitals provided more than $35 billion in uncompensated care in 2008.

I admit that this ACEP article isn’t a “news flash” and leans toward being propaganda. Even if it is propaganda, the article and the story it tells raise a valid point. In some larger cities, ambulance diversion is a huge problem. According to this Washington Post article, diversion happens all the time in Washington, DC. You may not get to go to the closest hospital if you are having an emergency. In addition, the overburdened EMS system may not be able to get to you in a timely manner. Will these problems improve with socialized medicine?

The medical practice climate is tenuous in the Los Angeles region. LA hospitals are reportedly having difficulty finding subspecialists willing to take call for emergency department patients. Big problem. For example, even if patients make it to an emergency department with a life-threatening subdural hematoma, it won’t do them much good if there’s no neurosurgeon there to operate on them. ED physicians can try to stabilize patients, but we can’t do the lifesaving surgery. To maintain coverage, hospitals are paying physicians $250 to $4000 per day to take call and provide patients with care. How long will they be able to continue those payments with massive state budget cuts?

California’s attempts to erase a $26 billion budget deficit by cutting health care will likely push California’s economy further toward bankruptcy according to this LA Times article. Instead of paying for home health care, California will force patients receiving those services to go to nursing homes – at triple the cost. Poison control services and insurance for children of low-income families will be eliminated ending up in more of those “low cost” visits to the emergency department. California’s plan may be as much about cost shifting as it is about cost saving, though. If California cuts payments to the hospitals for emergency services, the hospitals eat the costs of indigent care, not California.
There’s more to the game than direct costs, though. According to the article, a 2006 study tracking similar budget cuts in New York City back in the 1970s found that less than $10 billion in cuts to healthcare, education and law enforcement in New York City over four years led to at least $54 billion in additional costs over a 20-year period. Consequences included higher rates of HIV, a worsened tuberculosis epidemic and a spike in homicides.
Looks like a good trade-off to me, there, Arnold.

New Brunswick, Canada apparently has a poor reputation with Canadian physicians and not too many docs want to work there. ED physicians working in clinics and smaller hospitals are then pulled to work in larger regional emergency departments. Then the clinics and hospitals close. Guess what happens next? All the patients go to other nearby emergency departments and cause an even greater crowding problem. “Then the waits just get longer and longer and there’s more consequences and more possibility, or probability, that something might happen while you’re waiting.” Sound familiar?

19 Responses to “Healthcare Policy Roundup 7/22/09”

  1. Liz says:

    California is imploding, and apparently none of the politicians responsible will be satified or happy until they’ve laid waste from one end of the state to the other. We’ve already planned our move to another state, as soon as we get our ducks in a row.

    While small businesses and low wage earners fall by the wayside due to increased costs of living and taxes, wealthy enclaves will survive with all luxuries intact, no doubt. After all, those politicians, those public servants (don’t make me laugh), have to live somewhere.

  2. Matt says:

    “Interesting that the Congressional Budget Office spent $30 billion to defend against and pay malpractice claims in 2008,”

    I don’t think the CBO actually spent that money. It would also be interesting to know how much of that $30 billion goes back into the system for past and future medical bills.

    I thought tort reform was the cure to all that ails medicine, from cost to physician supply to physician happiness. California’s had this “reform” longer than any other state. I’m so surprised at these results.

    • WhiteCoat says:

      You are right about CBO. Typo corrected. Thanks.
      You keep harping on California’s MIRCA reforms as being the holy grail. If physicians were completely immunized from any liability for medical malpractice, those changes alone would not make up for a lousy practice environment, poor working conditions, and low pay.
      Would you be content to work for clients that could never sue you but who paid you 10% of your stated fees, who often paid late, who questioned every legal decision you made in the case, and who threatened not to pay you or to even charge you with fraud if your legal briefs were not formatted to their exact specifications?
      That’s what doctors deal with.

      • Matt says:

        Your tort reform campaign literature fails to make such fine distinctions. In fact during the last “crisis” California was repeatedly held up as a model.

        Are you suggesting we can’t trust your promises on the campaign trail?

      • WhiteCoat says:

        Not sure what “crisis” you’re referring to. If it was a malpractice crisis, I agree. California gets high marks for tort reform.
        Apparently you didn’t catch the article above about how California is attempting to erase a $26 billion budget deficit by cutting health care.
        I’ll put it in simple terms.
        Think of a hand.
        You may have the best looking pinky finger in the whole world. But if the rest of the fingers are missing or non functional, you’re going to have trouble doing too much with the hand. Can’t knit. Can’t play guitar. Can’t type pithy responses to blog postings. You get the idea.
        Now let’s look at California. MIRCA is the pinky finger. Micromanagement, low payments, poor practice environment, and crumbling infrastructure are the other fingers.
        You can’t even flip me the bird using that hand.

  3. Anon says:

    The number of malpractice suits against a doctor, by itself, shouldn’t be grounds for disciplinary action.

    But it is not unreasonable for the number of suits to be grounds for a review by the medical board. I’m not sure what a reasonable number would be to trigger a review would be, but I think less than 50 would definately be reasonable and less than 5 is probably unreasonable.

    • WhiteCoat says:

      I agree that some number should trigger a review. The problem is how to find the “sweet spot.”
      Also a problem is how to make sure that cases are reported from state to state. A doc may leave one state after being named in 15 suits, but then have no suits in the next state.

  4. Matt says:

    Like I said. You guys promise tort reform is the be all end all in reform and every backwoods town will have a neurosurgeon if you get those damage caps. You don’t mention any other factors when you’re pushing it. We both know it’s just lobbying BS.

  5. brighid says:

    For the cost of medical care in France, I can refer you to two books I’ve read lately:

    The Sharper Your Knife, the Less You Cry: Love, Laughter, and Tears in Paris at the World’s Most Famous Cooking School
    by Kathleen Flinn
    ISBN: 9780143114130 Paperback
    Published: 2008 by Penguin Books

    French By Heart: An American Family’s Adventures in La Belle France
    by Rebecca S. Ramsey
    ISBN: 9780767925228 Paperback
    Published: 2007 by Broadway

    Flinn (an American) lost her job in London and decided to devote her severance pay and savings to living in Paris attending Le Cordon Bleu. In the course of her stay she developed a kidney infection for which she needed emergency care and several follow-ups.

    Ramsey and her family were transferred from Greenville, SC to Clermont-Ferrand in the Auvergne region of France by her husband’s employer, Michelin. She had three small children, and during the several years the family lived in France they needed both routine and emergency care.

    Flinn and Ramsey both told similar stories about receiving care in France that was competent, compassionate, unhurried, down-to-earth and ridiculously, almost laughably, inexpensive by American standards.

    Robert K. Massie, who wrote “Nicholas and Alexandra,” and his first wife, Suzanne, had a son born with hemophilia. They wrote a book called “Journey,” a very moving account of what their family’s life was like as they worked on the book and raised their son. They struggled constantly to keep up with medical bills, and one of them always had to keep a corporate job while they researched and wrote the book because they could only get health insurance while working for a corporation. Eventually they moved to France and their life was simplified by orders of magnitude. Their son received excellent medical care, there were no more big medical bills, and they were much freer to devote time to their writing.

    Americans who insist we have “the best health care system in the world” simply don’t understand what they’re talking about. Our doctors, nurses and hospitals are superb. Our health care system is profoundly dysfunctional. Sad to say, I don’t think the current proposals are going to fix it. I wish I were smart enough to figure out what WOULD fix it!

    • Nurse K says:

      I assume that $32 was a co-pay of some sort; I believe foreigners are still covered under the socialized medicine crap. Obviously, hospitals are highly subsidized, not posh, and taxes on all goods and services are extreme.

      When I was in France, I stayed at a rural B&B and an American who had a country house fell down the stairs and called the B&B since the owner was bilingual in French and English. She and I went over there; I did an ER trauma assessment and thought that she likely had no serious injuries. The B&B owner phoned her personal physician to determine if an “ambulance was necessary” (apparently talking to the doctor before calling an ambulance is preferred if no OBVIOUS life-threatening illness). I talked to this family practice-y doc on the phone in French and described in my broken-ass French my lack of physical findings. He told me that he would call an ambulance for us if necessary, but he thinks we should go to XYZ hospital instead and gave us directions. She apparently was fine and got an XR of something and NON-NARCOTIC pain pills.

      I thought it was kind of nice how the family doctor took time to talk to us and help us at the very least. UNCOMPENSATED, as Happy would put it.

  6. MikeMD says:

    I lived in France in the late 90s. The father of the family who hosted me was a general practioner, and we had some conversations about health care there and here.
    If you’re interested, here’s an article from pub med central concerning the setup of French health care. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1447687

    The attitude is that everything should be covered, period, and they consider their care to be much better than in the U.K. because there are no ‘gate keepers.’ Most people buy supplemental private insurance (which is tightly regulated by the government) to extend coverage, which does take some of the pressure off of the government expenses, and outcomes are good, with little direct expense to the consumer.

    Still, it’s important to remember that France is politically socialist as well as medically (the two don’t have to come together). The government is heavily involved, and what you don’t pay for individually is paid for in taxes. They have very high income taxes, especially for the rich, and about 50% of the public plan is taken out of employer paychecks. The government states what you can charge for a procedure or an office visit, but there’s some amount of legal ‘extra billing,’ to supplement income. Physician salaries are limited (average is around $55,000, but subspecialists do a good deal better). Still, medical school mostly free, as is higher education, so physicians aren’t acquiring the debt we are here.

    France spends about 10% of GDP on health care, which is less than we do, but more than the rest of Europe. As with the NHS in England, there are concerns about how to continue funding it (but there’s always more taxes).

    I will say that the father of my family had a great lifestyle, despite the lower pay. He worked no more than 40 hours a week (tops) and got 12 weeks vacation a year. We lived in a nice house with a pool. But again, he had no debt.

  7. Max Kennerly says:

    Oh noes! Legal fees, insurance premiums, and administrative costs make up well under 1% of healthcare costs! (As that study notes, the other half of that “1.5%” is direct compensation to injured patients. If you re-read the Coase Theorem, you’ll see such is a transfer of wealth, and not really a cost to society.)

    Well, let’s move malpractice “reform” right to the top of the list, it’s obviously what’s driving costs up.

  8. PJ says:

    Just a note…that Washington Times article you cite is really a Washington Post article, and both parties would probably be miffed at the juxtaposition…

  9. Jim Hall says:

    I don’t know that this real-life tale has any actual value, but it may at least be interesting.

    A few years ago, I worked for a firm based in Montreal. In order to provide for us few U.S. employees, they had created a company in Cincinnati that basically existed only to administer our payroll & medical benefits.

    As was often the case, I was working on a project in Toronto. I slipped and fell on the ice, cracking open the back of my head and bleeding profusely. The hotel where I was staying, and where I fell when leaving, called an ambulance for me. The EMT crew did what they could to stop the bleeding and whisked me off to the local ED.

    Upon arrival, and the discovery that I did not have a “Health Ontario” card, they took my insurance information. Surprise to me, the insurance I had, through a Canadian employer, did not cover any medical care in Canada. So, BEFORE I could be seen in the ED, I had to whip out my American Express card (ironic?) to prove my ability to pay.

    I will admit that the care I received was top notch (after I paid for it). 14 staples later, I was on my way.

    14 days later, I was at home in Grand Rapids, MI and it was time to get the staples removed. I called the nearest “Doc In A Box” to see if I needed an appointment. The charming and delightful person on the phone informed me that since they had not put the staples into my head, they would not remove them.

    Being a quick thinker, I thanked her and hung up. I then called back immediately and told her that my idiot friend had hit me in the back of the head 14 times with a staple gun, and I would really like to get the staples out. She scheduled an appointment for me in an hour.

    But wait, there is more! I submitted my bill, which I paid, from the “Doc In A Box” to my wonderful insurance plan. Before they could pay for the staple removal, they had to see the paperwork from the Toronto hospital where the staples were applied. Then they denied my claim because the hospital in Toronto, Ontario, Canada did not use the correct set of codes in describing my procedure. They had used the correct codes by the standards of the Ontario Ministry of Health, but NOT the correct codes used by whatever American insurance standard that my insurance company wanted to apply. They refused to pay until the hospital in Toronto used the correct American codes. So of course I never got reimbursed.

    Is there any part of the “health care system” in this story that isn’t broken? In either country?

    • WhiteCoat says:

      I think that this example is very pertinent.
      You were someone that did not pay into the Canadian system and therefore you did not receive the benefits from the system.
      Another issue we have to figure out is how the US will deal with providing care to visiting foreign nationals and illegal immigrants who do not pay into the system.

      • Matt says:

        Foreign nationals and even illegals would most likely pay into the system through payroll deductions just as most do now.

  10. Mass says:

    This article is too good, let me post the first few paragraphs:

    http://www.marketwatch.com/story/study-confirms-health-monopoly-fears

    “Data from the American Medical Association shows that in each of 43 states, a handful of top insurers have gained such a stronghold that their markets are considered “highly concentrated” under Department of Justice guidelines, often far exceeding the thresholds that trigger antitrust concerns.

    The study also shows that in 166 of 294 metropolitan areas, or 56%, a single insurer controls more than half the business in health maintenance organization (HMO) and preferred provider networks (PPO) underwriting.

    “This problem is widespread across the country and it needs to be looked at,” said Dr. Jim Rohack, an AMA trustee and physician in Temple, Texas. “The choices that patients have now are more difficult.”

    The AMA study cited a Justice Department benchmark in citing antitrust concerns, the Herfindahl-Hirschman Index, or HHI. A score above 1,000 shows “moderate” concentration. Those scoring above 1,800 yield a “high” concentration.

    Figures show that 95% of the 294 HMO/PPO metropolitan markets studied were above 1,800. Raise that HHI bar even higher to 3,000 and yet more than half, or 67%, rise above it.

    The AMA study is the latest piece of evidence — and most comprehensive to date — showing the market power of a few companies, and a large number of regional non-profit Blue Cross operations, is formidable and growing. And it comes at a time when premiums continue to grow at near double-digit rates. “

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