Archive for the ‘Access to Care’ Category

Healthcare insurance but no healthcare access

Wednesday, February 13th, 2013

Lucy VanPelt The Doctor is INCalifornia doesn’t have enough doctors to provide healthcare to newly “insured” patients under the UnAffordable Care Act.

California state senator Ed Hernandez asks “”What good is it if they [state citizens] are going to have a health insurance card but no access to doctors?”

Wait. Health care insurance doesn’t mean that patients will have access to health care? Where have I heard that being said for more than 3 years?

The government is going to give patients their medical “insurance,” but access to physicians is limited by government policies, payment cuts, and administrative red tape — which are driving many doctors from the primary care business and are, in effect, rationing care to patients.

California’s grand plan is to allow physician assistants, nurse practitioners, optometrists, and pharmacists to provide primary care services. I liked one of the commenters who said that he went to see the doctor, but was referred to the janitor who gave him a bag of medications for $5. These other health professionals and their organizations seem to naively think that the patients they will treat only require management of simple medical problems. In reality, most patients have multiple interrelated chronic medical problems that must be managed together.

Take diabetes, for example. Will it really be cost effective to have an optometrist manage a patient’s diabetes and perhaps monitor the patient’s diabetic retinopathy while the patient still has to be assessed and monitored for diabetic nephropathy, diabetic wounds and wound care, diabetic neuropathy, the increased risk of heart disease, oh and the impotence that often accompanies diabetes? Should the optometrist prescribe Viagra for a diabetic patient with heart disease or not?

If the optometrist refers the patient to a bunch of physicians to make those decisions, then the government has just created an additional layer of bureaucracy which will cost more money.
If the optometrist just blissfully monitors the patient’s glucose levels, prescribes insulin and doesn’t regularly evaluate the patient for diabetic complications, then the patients are receiving government-sanctioned poor medical care. That should make the trial lawyers happy … if the optometrists have insurance for the millions of dollars in damages when bad outcomes occur.

These health care providers are begging to get in over their heads and we need to let them do so. The medical establishment should really stop fighting this idea.

Allowing governments to implement a system that reduces access to doctors, increases complexity in medical care, and that will likely increase bad outcomes will eventually create patient outrage with government officials who adopt the idea.
We all should be part of a team, but not everyone is able to play quarterback.
I predict that these types of policies, if implemented, will ultimately increase the demand for physicians.

Unfortunately, the underlying problem is that most of us will be expected to pay more in “taxes”, insurance premiums, and other fees … for less medical care.

But remember that everyone will be insured, so things will be OK.

In anticipation of hate mail from nurse practitioners, physician assistants, optometrists, pharmacists, and possibly even Lucy VanPelt expressing outrage at my unprofessional stance because there aren’t any studies showing worse outcomes in medical care provided by those with less medical training, I’ll quote a comment that I posted on KevinMD’s site a couple of months ago in response to a nurse practitioner who asserted that he had “the same ability to provide patient care [as physicians] based on the evidence.”

You’re right about all the studies, I’m sure. In fact, I bet there aren’t any studies showing that treatment rendered by grade schoolers is any worse than that rendered by nurse practitioners, so next down the line to help patients save money will be gifted grade school student phone advice and then Shaman Skype toddlers with their magical rattles of health. Goo goo ga ga.

I don’t care how good you think you are, if you can’t pass a doctor’s board exam, you shouldn’t be [independently] treating patients, so lose the ego. Actually, the law says that you can treat patients, but you damn well better tell the patients that you aren’t a doctor and then let the patients decide whether they trust you with their lives. But lose the ego, anyway. It’s a team sport and you don’t get to be the captain just because you think you’re better than everyone else. When there’s an emergency in the hospital, no one goes running to find the nurse practitioner.

CMS Offering Us Some Rope

Sunday, December 9th, 2012

Our beloved government is now seeking comments on how it can deny payments to hospitals through patient assessment of the emergency department experience.

According to this entry in the Federal Register, the “Consumer Assessment of Healthcare Providers and Systems” (“CAHPS” for short) doesn’t address patients’ experiences with emergency department services. So the Centers for Medicare and Medicaid Services (“CMS”) is seeking “a rigorous, well-designed emergency department survey will allow us to understand patients’ perspectives on their experiences in emergency departments and how such experiences change over time” … and that will allow them to deny or reduce payments to emergency departments that don’t comply with its arbitrary and irrational standards.

In other words, CMS is saying “Here’s a bunch of rope. See if you can form a knot that will form a big loop at one end and that will support the weight of an average human.”

And I’m going to snap if I hear one more person say that “we need a seat at the table or the decisions will be made for us.”

Newsflash: We’re not invited to be “at” the table, we’re what’s on the menu. They aren’t doing this to make medical care “better.” They’re doing this to find a way to justify cutting payments further.

You want to see your emergency medical care funding dry up because you had to wait too long or because you didn’t get your Dilaudid shot soon enough, that’s your business. As more and more hospitals close because the government pays them less due to your bad scores, you are essentially rationing your own care.

I’ve had people argue that emergency departments need to be evaluated and regulated.
Stop for a minute and think about why you go to the emergency department. Do you go there just to be seen quickly? Do you go there just to get pain medication? Do you go there just so that people will respect your privacy? Do you go there so that people will listen to your complaints? If that’s all you’re rating, the medical system will adapt to meet solely those expectations. Look at how businesses are adapting to cope with the Affordable Care Act’s new requirements. If ratings are based solely on non-quality measures, you’ll get someone that sees you right away, gives you a pain shot quickly, makes sure that your gown covers you, holds your hand for a minute, maybe gives you a prescription for an antibiotic or two, and discharges you to some other doctor to find out what’s causing your problem. And you’ll pay more money for it because the hospital will need to make up its losses on those who pay for their care.

Therein lies the problem. If surveys de-emphasize quality care, then hospitals will de-emphasize quality care. Think I’m wrong? Watch what happens when government pays hospitals based on capitation.  Remember the old HMO days? They’ll return with a vengeance. With decreasing reimbursements, there won’t be any way not to decrease the quality of care. Remember the engineer’s triangle?

When the government comes up with a “Consumer Assessment of Government Providers and Systems” that allows us to pay taxes based upon how satisfied we are with our government providers, I’ll listen. Can anyone come up with any reasons why such a rating system will never happen?
Now apply those same reasons to the hospital and emergency department rating system proposed by CMS.

More patients, fewer hospitals, government mandated “insurance” that pays less than the cost of care, and more ways to cut payments to providers. What could go wrong?

Boy am I glad I’m a doctor.

Why Bundling Payments Won’t Reduce Costs – Part 1

Thursday, December 8th, 2011

Probably one of the largest pending changes in health care is payment reform.

Right now, payment for medical services is essentially a fee for service model. Patients (or their insurers) are generally charged for the services utilized. If a patient goes to hospital for chest pain, and a physician evaluates the patient, either the patient or the patient’s insurer pays the physician for those services. If the physician orders an EKG and lab tests, either the patient or the patient’s insurer pays the hospital for the EKG and lab tests. If the patient is admitted to the hospital, the hospital gets paid a given fee for the admission. It goes on and on.

The feds want to reduce costs by changing the payment model for medical care to a “bundled” approach. I don’t think it’s going to work. Bundling won’t change the behaviors necessary to save money. This will be a two part post on why. This part will discuss incentives and how they drive utilization of health care. Next part will apply those concepts to bundled health care.

Why is our current system going bankrupt? It is all about incentives. There are three main concepts driving health care costs: profit, demand for services, and fear. Before we can see the effects of a policy change on health care costs, we need to understand how these concepts drive the actions of the major players in the health care market.

For Providers, the incentive is currently to provide more services.

  • Demand for services is created by illness. When ill, patients often demand as many medical services as the providers are willing to provide. Patients may seek alternative providers if their demands are not met. There is little incentive to provide less care with increased demand.
  • Profit is created by providing services. In a fee for service environment, the more services that are provided, the more that the providers are paid. If patients want the testing or services, more often than not, they get the testing or services. Unhappy patients tend not to come back. No patients = no income.
  • The most pervasive fear for providers is fear of liability – either legal or professional. This fear is often mitigated by providing more services. Increased testing decreases the fear of liability because if there is a bad patient outcome, the provider can point to all the testing and argue that they should not be liable because “we did everything we could.” It is uncommon for a provider to suffer adverse consequences for performing too much testing. Fear of liability may lead to extremely expensive and questionably beneficial medical care.
    Hospitals also fear regulatory sanctions. It is comical to watch hospital administrators scurry about when there is a JCAHO survey. Poor performance on a JCAHO survey threatens a hospital’s Medicare reimbursement.

For Insurers, there is an incentive to increase customers who pay into the system, but who do not take money out of the system.

  • Demand for services is still created by illness, but as demand for services goes up, insurer profits go down (or, in the case of government insurance, debts increase).
  • Insurers profit by having healthy and wealthy subscribers. Healthy subscribers pay into the system, but don’t take as much out of the system. Insurers can increase profits by raising insurance premiums, but must be careful when setting prices. If premiums are raised too high, healthy insurers may drop their coverage because they perceive too much of a disconnect between the premiums that they are  paying and the services that they are utilizing. In that case, the profits from increased premiums may be diminished because the insurer has fewer subscribers and proportionately more “unhealthy” insureds who utilize more services that the insurer must pay for. Insurers increase their subscribers by contracting with employers to provide services to employees. If an employer chooses a specific insurance company, it would be a huge financial burden for an employee to try to go with another company not offered by the employer. There are even tax disincentives from purchasing your own insurance instead of using your employer’s insurance.
    Insurer profits also increase when insurers deny care. Insurers have an incentive to deny claims to subscribers or to create roadblocks to providing care (also known as “pre-authorization”) in order to discourage people from taking money out of the system. A patient’s MRI doesn’t meet medical necessity — the insurer refuses to pay for it. Expensive cancer treatment is “experimental” — the insurer refuses to pay for it. Patients need an expensive medication? The physician has to call and pre-authorize the medication — which is uncompensated time spent away from caring for patients. However, too many inappropriate refusals may cause the insurance company to get a bad reputation with its insureds and may cause further attrition – or may cause a corporation to drop its affiliation with the insurer. Underwriters make a determination whether the risks of denying care are worth the potential financial benefit
    Finally, insurers increase profits by paying less to providers. Providers need patients in order to make money. If insurers have control over a large proportion of a market’s patient population, then providers may be financially forced to contract with the insurer on the insurer’s terms so that the provider has access to the insurer’s patient base. Sometimes the providers have unconscionable contract terms to which providers will not agree. For example, Medicaid pays such little money that many providers will not accept patients who have Medicaid. The government gets around this conundrum by creating laws that force certain providers to provide care to Medicaid patients and by giving states funding to provide care to Medicaid patients.
    Some private insurers also create unconscionable terms in their contracts in order to increase profits. In our area several companies have a reputation for low reimbursements and long reimbursement delays. Therefore, many providers simply refuse to contract with those companies. Think about it. Would you work for an employer who paid less than minimum wage and who didn’t give you your paycheck for 120 days? But insurers that cut corners then market lower cost products to employers who purchase their product to save money. Then the employees get “insurance,” but that “insurance” has less options and less physicians than other insurance plans.
    For the most part, providers can still care for patients under private insurance plans, but patients must pay proportionately more for “out-of-network” physician services. In other words, if an insurer is only willing to pay a physician $20 for an office visit costing $150, the patient may being billed for the $130 balance. This is so-called “balance billing.” When patients pay a substantial amount of money in insurance premiums, they become upset by having to pay more than a small co-pay for provider services. Private insurers then blame “greedy” providers for charging too much and have successfully lobbied many state legislatures into making balance billing illegal and forcing some providers to accept whatever amount of money the insurance company chooses to pay. In other words, states such as California make it so that if an insurance company wants to compensate a physician 10 cents for providing medical care to a patient, the physician has to take the 10 cents and cannot bill the patients for the difference.
    Medicare has also outlawed balance billing. Providers either agree to what Medicare pays for services or they don’t accept Medicare patients. Because of Medicare’s large patient base, it has considerable influence over medical providers. All patients over age 65 are eligible for Medicare. Because these patients typically are high utilizers of medical care, a hospital’s refusal to accept Medicare could threaten the hospital’s financial viability. Medicare knows this and it creates arcane rules that enable it to refuse payment or diminish payment to providers if the rules are not followed. For example, failing to note that a patient is a smoker may cause a provider’s payment to be diminished by up to 40% per patient. Hospitals have “chart police” who are hired solely to make sure that providers properly document everything that Medicare wants us to document.
  • Insurers fear financial risk. If a patient has a history of a potentially costly medical problem, an insurer will not contract with that unhealthy patients. Try getting a private insurance policy if you have a history of diabetes or cancer. Fear therefore diminishes the availability of care to patients who need it most.
    Insurers also fear legal liability. In many cases an insurer can be successfully sued for refusing to pay for medically necessary services. To mitigate this risk, a law called ERISA was created that minimizes insurer liability for refusing payment for services when those payments are for an employee-sponsored health plan. ERISA doesn’t apply to private insurance plans, so insurers have less fear of employed patients than they do of private patients.

For Patients, there are mixed incentives, depending on their insurance status and ability to pay for care.

Well-insured patients or patients on government insurance have an incentive to demand comprehensive medical care. If they are paying large insurance premiums, if they can afford to pay out of pocket, or if someone else is paying for the cost, why shouldn’t everyone have the latest and greatest testing, medications, and treatments?
In addition, patients with government insurance have no disincentive to seek medical care for trivial complaints or for secondary gain (such as narcotic prescriptions or work notes). With no financial risk involved in seeking medical care, the only disincentive for those with government insurance is time spent obtaining the medical care. The only time a monetary disincentive comes into play is when government insured patients seek care from a provider who does not take their insurance or when a government insured patient is prescribed a medication that is not on the government’s formulary.
Monetary issues aren’t a much of a concern for well-insured patients. If there is no out of pocket cost, very few patients even question how useful a test is or how much the test costs.
Patient fears drive increased utilization. Perhaps a relative just had a stroke or died from cancer. If an insurance company is picking up the tab, fear may cause the patient to demand that those same diseases be ruled out or that low-yield testing be performed, or that a family member be inappropriately admitted to the hospital.
Patients who pay out of pocket or who have high insurance deductibles have an incentive to obtain the minimum necessary care. Medical care is extremely costly and medical costs are behind a large proportion of bankruptcies in this country. Those who pay face value for their medical services avoid any services that aren’t essential – sometimes to the point of letting a treatable disease become worse or even become untreatable. To illustrate, consider a patient with good private insurance who has a $3000 deductible. Before the deductible is met, testing is kept to a minimum. Providers may have some difficulty obtaining co-pays or other payments. Toward the end of the year, when deductibles are met, there is a rush to have testing and procedures performed before the end of the year and the onset of a new deductible. Another example might be a patient who requests a questionably necessary service or test. If a patient or family member is given an Advance Beneficiary Notice to sign, acknowledging that they may personally be responsible for payment if the government does not pay, a large proportion of patients decide to forego the service or test.
Monetary concerns are a large disincentive to patients who pay out of pocket. Medication prescriptions may not be filled if they are too expensive. If pre-authorization for testing is needed, patients often forego the testing if pre-authorization cannot be obtained. Often patients become angry at physicians because they are not able to obtain pre-authorization so that the patient does not have to pay for the test.
Fears of monetary outlay serve as a disincentive to care for patients who pay out of pocket.

That’s it. I think that these are the main market forces at work in determining the cost of medical care. The examples certainly aren’t exhaustive. I’m interested in seeing comments on what other forces people think may contribute to medical costs.

The second part of this post will use the above concepts to show how the current proposed payment reforms will have little effect on controlling costs.

Healthcare Update — 10-03-2011

Monday, October 3rd, 2011

More medical news from around the web at the Satellite Edition of this week’s update on ER Stories

Australian emergency physician punches and slaps restrained patient who spat in his face. He was terminated from his position. A court held that the termination was unfair. Australian doctors considered going on strike after learning how the doctor was treated after the incident.
When you read the comments section of articles describing patients who assault emergency department staff, many people seem to think that staff should accept abusive behavior due as being “part of the job.” Shouldn’t patients therefore accept abusive behavior from medical staff as being “part of the visit”?

A view of medical malpractice reform misconceptions from physician-attorney William Sage. I disagree with several of his premises. For example, one question Dr. Sage asks “How likely is it, really, that ‘sinister forces’ outside [of medicine] are the reason why tens of millions of Americans lack access to services, or why even those who can afford it often get mediocre care at inflated prices?”
Ask physicians who don’t provide care to patients with certain government insurance plans and who stop taking emergency call or stop performing certain procedures (such as brain neurosurgery) due to liability concerns. Ask doctors who won’t or can’t prescribe medications that are safe through billions of prescriptions because the FDA issues a black box warning that the drugs might have caused adverse reaction in one millionth of a percent of the people receiving them. Then ask patients who can’t afford to purchase certain drugs such as albuterol, colchicine, or (soon to be) Primatene Mist because drug companies jacked up their prices based upon a governmental technicality in approving the medications.
Nah. No “sinister forces” here.

Recent Massachusetts Medical Society survey shows many interesting findings. Specialties in critical short supply included internal medicine, urology and psychiatry. Primary care specialties had severe shortages for 6 straight years. More than half of physicians would be unwilling to participate voluntarily in either global payment programs or accountable care organizations. Oh – and “the fear of being sued continues to be a substantial negative influence on the practice of medicine, affecting access to and availability of physician services.”
Nah. No “sinister forces” here, either.

Another timely rebuttal to some assertions in Dr. Sage’s article. Study in Archives of Internal Medicine shows that 42% of physicians believe that their patients are receiving too much care. Guess what factor contributed to more aggressive care in 76% of cases. Click this link to find out. Hint: “Sinister force” alert.

CMS coming out with bundled payment plans for 2012. Look for the pendulum of clinical care and testing to swing the other way. And look for more people to accuse “greedy doctors and hospitals” of limiting care in order to make more money when, in reality, the government is limiting care through underpayments to providers.

Another reason that getting a ZeePack for your cough might not be a good idea (aside from the fact that it won’t work) … it might cause you to get Crohns disease or ulcerative colitis. Twelve percent of patients diagnosed with Crohns or UC had been prescribed three or more doses of antibiotics in the two years prior to their diagnosis. Only 7% of patients who had developed Crohns or UC had not been prescribed antibiotics. In other words, people prescribed frequent antibiotics were up to 50 percent more likely to get Crohn’s disease or ulcerative colitis within next two to five years. My guess is that they were more likely to get MRSA and C. difficile as well. Study abstract here.

More Florida shenanigans. Physicians Regional Medical Center in Naples, FL has tells specialists that they have to take call for the emergency department in both the system’s hospitals or resign. Many doctors call the hospital’s bluff and resign or change to inactive status. Now emergency patients have less access to specialist care. The comments section has many people blaming “greedy doctors” for the problem.

This case was from last year, but still surprised me. A physician was sued and settled for $500,000 after failing to recommend a pneumococcal vaccination.

Excellent post over at ACP Internist about the costs of medical malpractice.

LA Times reporter gets a glimpse of an evening in one of the busiest emergency departments in the country. Read her story here. Then read the comments section for insight into how “illegal aliens” are causing the problem. The multimedia presentation also has some great pictures.

$4.9 million awarded to patient who suffered brain injury in hospital.

$4 million verdict against emergency physician who diagnosed a 42-year-old patient with “chest pain of unclear cause and bronchitis.” Patient found unresponsive at home 11 days later. Jury decided that a more thorough examination in the emergency department “would have revealed warning signs of an impending heart attack.”

Finally, if you want to learn a more about evidence based medicine, go check out Graham Walker and company’s site at TheNNT.com (the number needed to treat). Lots of new studies and interesting information that is in an easy to understand format for physicians and patients.

Refusing to Treat Obese Patients

Tuesday, May 31st, 2011

I discussed whether or not ambulances should be required to add equipment costing $12,000 in order to be able to transport 850 pound patients in a previous post, so I won’t belabor the point here. Providing medical care to morbidly obese patients presents multiple challenges.

Then I read an article in the Florida Sun Sentinel about how some obstetrician/gynecologists in South Florida are refusing to provide medical care to obese women. Fifteen out of 105 Ob/Gyns refuse to treat patients based upon either weight or BMI. Some won’t take any patients who weigh more than 200 lbs.

In the article, other obstetricians without such a policy state that “no doctor should be unable to treat patients just because they are heavy.”

The “ability” to treat patients is only one of the issues involved, though.

Morbidly obese patients are more likely to develop surgical and post-op complications.  One of the physicians in the article mentioned that ultrasounds are more difficult to perform and interpret in obese patients. If a physician misses a critical finding on ultrasound due to a patient’s obesity, a plaintiff’s attorney will argue that the patient should have been referred to someone with more experience under those circumstances.

Malpractice insurance costs in Florida are some of the highest in the country. In fact, the costs are so high that the article states that half of Florida obstetricians go without malpractice insurance.

If physicians want to decrease their risk in managing patients by excluding patients who are at higher risk for complications, shouldn’t they be able to do so?

Many commenters to the article have harsh words for doctors who are unwilling to treat obese patients. The article itself cites physician groups, medical ethics experts and advocates for the obese, all of whom said that refusing to treat patients based on obesity would “violate the spirit of the medical profession.”

Insurers can refuse to provide insurance based upon pre-existing conditions (at least for a few more years) or can jack up premiums so high that the insurance is unaffordable. Good luck getting life insurance or disability insurance if you have a history of cancer. Airlines can refuse to transport people that are deemed an excessive “risk.” Banks can put limitations on those who enter their premises. Try walking inside a bank wearing a ski mask some day. Lawyers can reject any potential client for any reason. I don’t understand why people find it morally reprehensible if some doctors want to try to limit their liability by refusing to care for patients who are a higher risk for adverse outcomes.

This whole situation is a perfect example of the “perfect care” or “available care” paradigm.

The more that physicians who care for higher-risk patients are sued for less than perfect outcomes, the less that those physicians will be willing to treat higher-risk patients.

Gaming ObamaCare

Thursday, January 27th, 2011

Remember my post a few months back about how some large companies were getting waivers so they didn’t have to pay into the new health care system? Things are getting worse.  According to this article on The Hill, the feds just granted new insurance waivers to more than 500 groups, bringing the total number of individuals covered by waivers to 2.1 million.

The system just isn’t going to work.

Let me get my soapbox out here. [Tap tap tap] Is this thing on? Good.

First, there’s still this misconception that the “mandate” to purchase insurance will somehow translate into accessibility of medical care. It doesn’t work that way. I’ve said it before. Purchasing health insurance doesn’t mean that you have access to health care any more than purchasing car insurance means that you have access to a car. If your insurance is cut-rate,  chances are that your medical care will be cut-rate. You can’t make a silk purse out of a sow’s ear.

The general idea of “insurance” is conceptually sound. Everyone pays into a system to spread the risk of paying for a catastrophic event. You pay$100 per month to presumably avoid having to pay $100,000 or more if you have a major medical event. The amount of money paid into a system is dependent upon how much money is taken out of the system. If there is a surge in the number of people needing medical care, one of two things happens: More money has to be paid into the system or less money has to be taken out of the system through rationing of medical care or providing lower quality less expensive medical care. There aren’t any other variables to change. Cost, availability, and quality. That’s it.

The proposed system creates too many loopholes. It caters to special interests. It changes the cost/availability/quality variables in ways that the public doesn’t realize. So lets look at a few examples.

First, what exactly are we getting for our money in the current system – or in the proposed system? Many people don’t know. With regular insurance plans, your policy guides coverage. Maybe you have exclusions for certain conditions. Maybe there is a limit on how much the insurance company will pay for a certain type of care. Maybe certain types of care (like dental care or vision care) is unavailable. But at least you know what you’re getting. Can anyone say with certainty what type of medical care they’re going to get once they start paying into the new and improved health care system? I sure can’t. The lack of specifics opens everyone up to being refused care once they’ve paid into the system. After all, the feds and/or insurance companies can just say “We never agreed to pay for that type of care.” In essence, we’re paying for what’s behind the curtain without really seeing what’s behind the curtain.

Speaking about “exclusions” on insurance, under the current plan, “exclusions” on insurance policies will be limited. True that insurance companies have used exclusions and rescissions unethically in the past, but when used appropriately, exclusions keep people from gaming the system. If you’ve had a bum knee for 20 years, you shouldn’t be able to pay one month’s insurance premiums and then be entitled to the newest titanium replacement, the services of the best orthopedist, and unlimited therapy. If everyone gamed the system that way, the system would collapse because there would be a tremendous funding input/output mismatch that couldn’t be sustained by just increasing insurance premiums. No one would purchase “insurance” because they know that they could just get a policy once a catastrophe either occurred or was about to occur. Outlawing or severely limiting insurance exclusions essentially amounts to allowing people to purchase homeowner’s “insurance” while their house is burning to the ground. Result: Quality of care will decrease or costs of insurance will skyrocket – or both. Our family’s health insurance premiums have jumped about 30% in the past 8 months, so we know where this is headed.

Then there is the issue of spreading risk. Remember how everyone needs to pay into the system to spread the risk? When fewer people pay into the system, either the amount of care decrease to create a new equilibrium point with input/output of funding  -or- everyone else must pay more into the system to maintain the status quo.  Look at all of the waivers that have been granted under the new health care legislation thus far. Multibillion dollar companies like Blue Cross Blue Shield, Cigna, Aetna, and McDonalds are all getting a pass on purchasing insurance. When people want to use the system but they don’t pay into the system, they create a greater expense for those who do pay into the system. Why there are so many insurance companies and unions receiving these waivers, anyway?
There is also a religious exemption to purchasing insurance. Whether Amish, Muslims, or other religious groups will be exempt from purchasing insurance under the new health care plan remains to be seen, but ultimately if they do receive care and don’t pay into the system, those extra unfunded participants will result in additional increases in expense and/or decreases in care.

Yesterday, I posted a comment to ERP (from ER Stories) on Kevin’s blog about ERP’s notion that the “mandate” was a good thing. In that comment, I noted that one of the other issues that we have to address is the tremendous amount of inefficiency in our current system. Bureaucracy has to diminish, not increase. Empowering the IRS to enforce the insurance mandate is heading in the wrong direction.

We also need to learn to say that we aren’t going to pay for medical care that has a negligible effect.
Providers have to be comfortable doing that and the public has to become comfortable hearing that.

End of life care needs to be compassionate, but made with the understanding that everyone is going to die. We need to become comfortable with the ideas of hospice care. Yes, maybe we can eek another few weeks out of your loved one’s life, but what will the quality of that time be? How much should we pay to keep the shell of the person that was once your loved one alive? There have to be checks and balances in place to prevent “death panels” but we can’t afford the system of end of life care as we know it. It’s a tough question, but it is one that needs to be asked and one that needs to be addressed.

Medications are another huge expense. Track medication use. Have a national database of what patients are getting what medications at what pharmacies. This will decrease multiple prescriptions from different providers and decrease adverse medication interactions or overdoses from the little old ladies who can’t remember their medications. If you aren’t taking your medications, a national registry will also let us know that you aren’t filling your prescriptions.
If you can’t afford your prescriptions, you can go to the federal medication dispensary inside the federal health care clinic at the free VA system and get your medications for free. They will have a limited formulary with mostly generic medications. If you don’t want to wait in line at the federal dispensary, then you go to the pharmacy and pay for the prescriptions out of your pocket. If you want the new designer medications that have the same effect as WalMart’s $4 medications, that’s fine. You need to pay for them out of your own pocket. If your doctor won’t work with you to find a medication on the $4 list, then find another doctor.
Introduce free market forces into the medication market and prices will have to come down. Pharmaceutical companies can’t make money on their blockbuster drug if no one can afford to purchase it. Want to hedge your bet against being stuck purchasing outrageously expensive medications for an orphan disease? Maybe there’s an insurance policy for that.

Stop playing semantics regarding the need to fund the system. The administration has already admitted that the “mandate” is really a “tax.” Call it a tax and implement it like a tax. If the public wants access to care, we need to increase everyone’s taxes. Kick up the Medicare tax deduction from everyone’s paychecks by 10% and forget about the “exemptions” and waivers from the “mandate.” Everybody pays their fair share. Tie the Medicare tax to costs of care. If costs go up, the tax goes up, but if costs go down, so will the taxes. Maybe we implement some type of consumption-based tax so that even those who are in this country illegally, who are visiting from other countries, or who do not work will still pay something into the system when they purchase groceries and other necessities of living.

Then do something to actually increase ACCESS to care. Open up the VA System to every citizen in this country. Expand the system to include county hospitals as well. Fund the systems exclusively with the new tax money. Then, if you walk in the door with your verifiable US ID, you get free care. All those taxes you paid are now funding your care. If you are visiting this country, you purchase insurance before your trip or you pay with a credit card – just U.S. citizens do when they visit your country. If you’re here illegally, you still get care, but then you’re getting detained, processed, and deported once you’re discharged from the hospital or you’re stable for transfer. You’re breaking our laws, so it’s about time that we either enforce our laws or we change our laws.

What would happen if we repealed the health care law and put the system above in its place?

Caring for Morbidly Obese Patients

Wednesday, January 12th, 2011

Not sure how I feel about this.

Boston Emergency Medical Services debuts an ambulance with a mini-crane and reinforced stretcher to transport patients weighing up to 850 pounds. It cost $12,000 to retrofit the ambulance.

My problem is this: I think we need to do our best to provide medical care to all patients. But patients need to take some basal level of responsibility for their own health. If you’re saying that you got to be 850 pounds due to a “glandular problem,” you’re blowing smoke. See this post (hat tip to MDOD) and then come talk to me.

Let’s say you want to go hiking in some secluded location or you want to go spelunking far beneath the surface of the earth. When you take those risks, you implicitly accept the chance that if something happens to you, there’s not going to be an acute care clinic at the 3,000 foot mark on the mountain you want to climb. If you get hurt, you aren’t going to have access to the medical care that might otherwise be available to you. You may take your cell phone with you and may make arrangements for air medical transport if needed, but even with those precautions, you just might die from your injuries based solely on the risks you took – and no one is to blame but you.

If alcoholic patients drink to the point that they develop liver failure and then they continue drinking alcohol, most hospitals will not perform liver transplants. You got yourself into that situation, you refuse to help yourself get out of that situation, the system isn’t going to invest massive amounts of resources into your care – and no one is to blame but you.

Should people who eat themselves to death be treated any differently?

Should it ever be right to tell patients that if they let themselves get so obese that traditional ambulances can’t carry them that dispatchers will tell refuse transport and they will be responsible for their own transportation to the hospital?

If we continue down the road that we must accommodate the medical needs of every morbidly obese patient, are we then going to require that all hospitals purchase CT scanners and MRI scanners to accommodate patients of all weights – if those scanners even exist? Will every hospital be required to maintain an additional set of beds, commodes, bathroom fixtures, blood pressure cuffs, and a plethora of other utilities solely to treat morbidly obese patients.

Or perhaps we create regional system of care for morbidly obese patients. One regional hospital gets all the necessary equipment to manage the medical needs of morbidly obese patients and any morbidly obese patient requiring testing or admission must be transported to one of these centers. Hospitals can transfer trauma patients if they don’t have a trauma surgeon, shouldn’t they also be able to transfer bariatric patients if they don’t have a bariatric specialist?

This post is not meant as an attack on morbidly obese people, but more intended as a reality check. What should be a rational method of dealing with morbidly obese patients? If we require EMS and hospitals to make all these expensive modifications for morbidly obese patients, where do the accommodations end for other patients with other medical conditions needing costly medical care?

And how long is it going to be before the Law Firm of Dewey, Cheatem, and Howe files a claim against a hospital when a patient dies because the hospital didn’t have those modifications?

Death Panels and Access to Care

Saturday, December 4th, 2010

I read an article in the New York Times that underscores my argument that health care insurance does not and never will equal health care access.

Our federal and state governments are being crushed by debt. There are many reasons for that debt, and addressing the reasons for the debt are a necessary aspect of decreasing the debt. For example, if a family household had overdrawn its checking account by several thousand dollars and their credit cards were maxed out, most people would consider it foolish for the family to purchase expensive cars, to donate large sums of money to charity, to go out to eat at expensive restaurants, or to continue purchasing large amounts of weapons to stockpile in its basement. When in debt, there are two options – earn more money or reduce spending. Using the example of the family in debt, perhaps they sell their assets and move into a smaller house. Perhaps they eat macaroni and cheese for dinner. You get the picture.

But if we assume that the family has cut all of its non-essential spending (and many would argue that this part of the analogy fails when applied to state and federal governments), yet is still in debt, then how can the family further reign in costs?

That is the problem with which most governmental entities are now faced.

Arizona has taken a drastic step to reduce costs. It is now refusing to pay for expensive medical care to some Medicaid patients in need of organ transplants. According to the article, the decision amounts to “Death by budget cut.”

Patients such as a father of six (pictured at the right), a plumber, and a basketball coach all need various types of transplants, but are no longer eligible to receive them. The state estimates it will save $4.5 million per year by not providing these services to roughly 100 Arizona citizens. The state also warns that “there will have to be more difficult cuts looking forward.” Read that as Arizona being poised to cut funding for other types of expensive care.

Going back to the analogy about the family – is it morally appropriate to just let family members die because you don’t want to pay for the cost of caring for them?

This fairy tale about providing “insurance for all” is the biggest problem with the health care overhaul. We can strive to provide “insurance” for everyone, but “insurance” is only as good as what it insures you for.

If you are on Medicare and need expensive care or if you live in Arizona and need a transplant, you still have insurance, but that insurance just doesn’t pay for your medical care. Even though patients pay into the system all of their lives, they get nothing out of it when they actually need the care. Ponzi medicine?

If governments were serious about providing medical care for patients, they would create a system similar to the VA Hospital system that is available to every citizen in this country. You walk in the door, you get medical care. Perhaps the care wouldn’t be as good or as fast as care available at private facilities, but care would at least be available.

As the implementation of health care reform takes place, it begins to appear that our new health care system may provide the most benefits to the people that use it the least.

Don’t get sick and you’ll be just fine.

Healthcare Update — 12-02-2010

Thursday, December 2nd, 2010

Also see the satellite edition of this week’s update over at ER Stories.

Problems with Canadian health systems getting worse.
“We’re trying to get a Size 13 foot into a Size 8 shoe.” Emergency department overcrowding increasing due to lack of available beds. The president of the Edmonton Emergency Physicians Association described the situation as a “potential catastrophic collapse” of emergency medicine. Edmonton plans to decrease hospital emergency department crowding by moving patients out of the emergency departments sooner once the hospitals meet certain criteria such as the ED being 110% full or there are more than 35% boarding patients in the emergency department.
Five times this past year, Dr. Raj Sherman’s 73-year-old father almost died after waiting hours on a stretcher in an ambulance parked outside the hospital waiting for a bed. As a parliamentary assistant on health, he decided he had had enough and blasted the government, the Alberta Health Services chairman, the former health minister, and Premier Ed Stelmach. As a result of his statements, he has been fired from his government position.

California emergency physicians sue to keep the state from cutting reimbursement – and win.

Medicaid insurance versus Medicaid access. Yes, they have insurance, but one patient had to drive 2.5 hours to see an orthopedist that would accept her insurance. He fitted her with a brace and sent the patient for physical therapy. Now the “insurance” won’t pay for the brace. Plans that are running Medicaid managed care plans are viewed as “managing costs, not managing the care.” When patients can’t get the care they need, where will they end up? Emergency department waiting rooms.

Six California hospitals fined because employees inappropriately accessed patients’ medical information. How do we change the system to prevent this from reoccurring?

Malpractice judgments and settlements in the news:
$16.2 million Chicago settlement for neurosurgical injury after patient sustains a brainstem herniation.
$6 million Wisconsin settlement in birth injury case where patient born with cerebral palsy.
Largest verdict in Belize history for child who was delivered 2 weeks early due to miscalculation in gestational age and premature Caesarian section.

Maine preparing to repeal its universal health care plan due to funding issues. The Governor elect states that the state has paid $160 million to cover 3,400 eligible residents. The outgoing governor disagrees with the numbers.

Girlvet has another intriguing post about those warning labels on cigarettes. If cigarette packs are required to have graphic pictures on them, why aren’t beer cans required to have graphic pictures of DWI accidents? Why doesn’t McDonalds have to put graphic pictures of obese people on their bags?

A real life “Catch Me If You Can.” Fake doctor works in Fayetteville, NC emergency department for 3 weeks before getting caught.

SWAT team descends on hospital as Florida gunman fires shots in hospital cafeteria and then barricades himself inside hospital room.

Canadian man has diabetic “seizure” while visiting his wife and newborn daughter. Instead of bringing him to the emergency department, the hospital calls an ambulance and paramedics bring the man to the emergency department where he is later released. Now there’s the little matter of that $400 ambulance fee that he’s being charged – even though he never set foot in an ambulance.

One reason that some medical providers are reluctant to disclose errors: 25% of patients stated that they would file a medical malpractice lawsuit if they were told about a medical error. Many actions considered “medical errors” have no effect on patient outcomes. Giving a medication five minutes after the time it was ordered is a medical “error”. Giving ice chips to a patient who is “NPO” is a medical “error.” Giving NSAIDs without checking a creatinine may be considered a medical “error.” Giving a patient medication to which the patient has claimed an “allergy” may be considered a medical error – even if that allergy is nausea. Heck, failing to disclose a medical error may be considered a medical error. Should there be full disclosure of even inconsequential errors? If so, how many professionals are going to want to practice under ubermicromanagement every day of their careers?

Odd news story of the week:
Hey doc – be careful of those sharp points on the fork. You could poke your eye out (remember the scene at the right from Dirty Rotten Scoundrels?) Doctor Arturo Carvajal is suing a restaurant because, after Dr. Carvajal ordered a grilled artichoke and was served a grilled artichoke, no one showed him how to eat the grilled artichoke. He ate the whole artichoke and later was found to have artichoke leaves lodged in his bowel. The restaurant’s lawyer issued a statement warning restaurant patrons not to eat the bones in the barbecue ribs – which I thought was pretty damn funny.
Even though the news article was dated November 19, Walter Olsen had the story published on his “Overlawyered” blog November 5. I just can’t beat him to the scoop on these stories.

More Visits, Less Availability

Friday, August 13th, 2010

A new study released in JAMA shows that the number of annual emergency department visits between 1997 and 2007 increased from 94.9 million to 116.8 million — nearly twice as much as would be expected for population growth.

Also published recently was the Department of Health and Human Services’ 2007 Emergency Department Summary (.pdf file here). Lots of interesting statistics.

Most of the increase in ED visits were due to Medicaid patients. One quarter of the 117 million visits to the emergency department in 2007 were made by patients with Medicaid or SCHIP. Seventeen percent of visits were covered by Medicare. In other words, 42% of hospital ED visits (50 million or so) are paid for by the state or federal government.

The graph to the right from the San Francisco Chronicle shows how emergency department use by Medicaid patients is now more than five times the rate of emergency department use by patients with private insurance – and since they are from 2007, these numbers don’t include the impact from the recession.

Further breakdowns in demographics from the DHHS report include high ED utilization rates for children less than 1 year old (88 visits per 100 US infants), patients older than 75 (62 visits per 100 US persons),  homeless persons (72 visits per 100 population), blacks (74.6 visits per 100 black persons), and nursing home residents.

In addition, the number of “safety net” hospitals – defined as those who treat patients regardless of the ability to pay – increased by more than 40% from 2000 to 2007.

Before you start blaming Medicaid patients for health care crisis, think about why there is a disproportionate use of emergency departments by Medicaid patients. If you or your child has a medical problem and few private physicians will accept your insurance, what are you supposed to do? You go to a place where they will accept your insurance and you get relatively timely care (as opposed to an appointment 4 months in the future). Although there are undoubtedly people that abuse the Medicaid system, in general, it isn’t the patient’s fault for having Medicaid. It is the fault of the government for failing to adequately fund and monitor the Medicaid program.

With the increase in visits, there are longer waits and less availability of medical care.

Because the JAMA study was based in California, I did a little searching and found that 61 California hospitals closed between 1998 and 2008 and 14 more California hospitals closed their emergency departments. That’s a loss of 75 emergency departments in 10 years.

The San Francisco Chronicle article notes that California hospitals are facing an additional $17 billion in payment reductions over the next 10 years. I’m sure that will translate into many more hospital closures.

Oh. And health care reform will add between 11 and 22 million additional patients to Medicaid – you know … that good insurance that all the doctors’ offices take. Then what?

I know this is another “sky is falling” post. But I think that it is important to show how health care policy changes are affecting access to medical care in this country.

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