WhiteCoat

Archive for the ‘Funding Crisis’ Category

Free Market Medicine and Lab Tests

Thursday, May 26th, 2011

As my surgical experiences come to a close, I have now begun to receive all the bills for services that were provided to me.

One bill shows what one national health care provider considers “fair payment” for laboratory testing performed prior to my surgery. I matched that bill up with my insurance explanation of benefits to determine which prices go to what tests. Click on the picture below to enlarge.

Fees for the lab testing were discounted anywhere from 70% to 90% off the provider’s published rates.
A CBC cost $8.12
PT/PTT (coagulation studies) cost a total of $10.15
A basic metabolic panel cost $8.12
Nearly $200 in “handling fees” was waived.
They accepted five bucks instead of the $16.70 they charged for drawing my blood.

In summary, it would have cost me $350 for the tests if I didn’t have insurance.
Instead, it cost me $31.46 for the tests since I do have insurance – more than a 90% discount.
Great for me, but a gouge to patients who don’t have insurance.

The thing is … if the medical provider advertised these rates to all the patients who don’t have insurance or who have high deductible plans, it would probably have lines of customers out the door waiting to have their blood drawn. In fact, they would probably still have lines out the door if they doubled the prices below.

I don’t care how much providers want to mark up their prices. That is their business and they can keep that secret.

We go to a grocery store and purchase products at the advertised price, yet few of us know how much the grocery store has marked up the price. The ability of shoppers to vote with their feet keeps prices down.

In order to decrease costs of health care, health care reform must include some form of transparency in pricing.

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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?

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.

I Suppose It’s Better Than Death Panels …

Monday, July 12th, 2010

Revealing article in Bloomberg online today about the latest way in which elderly patients are getting screwed by the system.

Medicare reviews all admissions and if the patients don’t meet indications for admission, the hospital doesn’t get paid by Medicare. Medicare has also recently implemented a mercenary system called Recovery Audit Contractors (or RAC for short) in which third parties audit hospital charts to see whether Medicare “overpaid” for a patient’s visit. If the auditor finds an “overpayment”, the auditor gets to keep a percentage of that overpayment.  Just as an aside, most states have laws against percentage “fee splitting” such as this since paying someone on a percentage basis creates a conflict of interest that encourages the contractors to do things to enhance their income.

Hospitals have the ability to classify Medicare patients as an “observation” admission during the patients’ stay. “Observation” admissions are apparently paid at a lower rate, but don’t come under as much Medicare scrutiny. Additionally, under Medicare rules, “observation” patients may have to pay a 20% co-payment that wouldn’t be required if they were admitted. Medicare “observation” patients also have to pay full price for any subsequent care that is rendered after they have been discharged. For example, if a Medicare patient needs a nursing home care or physical therapy after a hospital stay, Medicare will pay if the patient has been admitted for three days or longer and will not pay if the patient is classified as an “observation” stay. The Bloomberg article gives an example of one 76 year old patient who was saddled with more than $36,000 in bills based on his “observation” stay for eight days.
Another 90 year old woman was billed more than $11,000 after fracturing her hip and then undergoing five weeks of physical therapy so that she could walk again. Sorry, grandma, you weren’t admitted. You were only “observation.” Pay up.

If a patient is a borderline case, hospitals appear to be leaning toward keeping patients in “observation” status. The number of patients receiving the “observation” designation doubled between 2006 and 2008.

Also note how Medicare is planning to penalize hospitals that re-admit too many patients, which will only increase the number of patients classified as “observation” status.

On one hand, hospitals get paid more for admitting Medicare patients.
On the other hand, hospitals could be accused of false claims and penalized for admitting Medicare patients who don’t meet Medicare’s strict admission criteria. Medicare’s RAC mercenaries will be combing through charts because they have a financial incentive to find patients who have been “inappropriately” classified as “admissions.”

So hospitals play it safe and classify more and more Medicare patients as “observation” status.

Who gets stuck in the middle?

The patients … many of whom worked their lives and paid into a system so that they would have medical care when they reached age 65.

Now they’re finding that they only have “insurance.”

Free Market Transparency on the Horizon?

Saturday, May 29th, 2010

Now THIS is what I’m talking about!

From an article in ModernPhysician.com (registration required)…

Pricing transparency gaining renewed interest
Led by a physician lawmaker, members of Congress on both sides of the aisle have shown renewed interest in mandating a boost in healthcare pricing transparency, including charges for physician services.

More on pricing transparency from an article in The Hill.

Rep. Steve Kagen, M.D., (D-Wis.) sponsored one bill (H.R. 4700) that would require all medical providers to openly disclose prices or face a financial penalty.”The “Transparency in All Health Care Pricing Act of 2010” would finally allow patients to see the price of a pill before they swallow it.”

Rep. Joe Barton (R-Tex.) sponsored H.R. 4803 which is a little more vague, but which still requires that all hospitals in each state report “the charges for inpatient and outpatient services typically performed by such hospital.” This bill has 11 co-sponsors.

Sources in the ModernPhysician.com article discussed whether the pricing scheme would be “too complex” and suggested that if competitors knew each others’ prices, they would raise prices in a given market. If hospitals have to list every little thing, I suppose it could be too complex. I don’t go along with the price fixing argument.

A few simple solutions:
1. If we’re worried about the complexity of pricing all hospital services, require that providers report pricing based upon CPT codes. That way, consumers can compare apples to apples (or codes to codes).
2. Any charges that do not correspond to a CPT code must be explicitly stated in simple English. No charges of $129 for a “mucous recovery device” when all they’re giving you is a box of tissues.
3. Require that any procedure or test or other charge whose price is not published must be provided free of charge to the patient. Patients have the option of accepting or rejecting items once they know the charges involved. You want to charge $129 for a box of tissues, you better tell me about it first. Then your charges will be out there for people like me to comment upon.

This whole pricing transparency thing is catching on. Just read a blog post about transparency from Paul Levy – the CEO of Beth Israel Deaconess Medical Center in Boston. In Massachusetts. You know, that state where they have insurance for everyone, but access for … well … not everyone.

“we should measure parties’ commitment to change by the degree to which they advocate and adopt the kind of transparency that exists in virtually every other segment of the economy”

Bingo.

Dr. WhiteCoat Goes to Washington

Thursday, May 20th, 2010

Sorry about the sparse posting lately – have been away in Washington at an ACEP conference

Just so Matt and others don’t think that all I’m all talk and no action, I’ll let you in on some things that I did at the conference.

I attended some excellent lectures about leadership.

  • Colonel Thomas Kolditz gave a great talk about leadership in extreme circumstances. He described his interviews with many soldiers, Iraqi prisoners, sports team captains and their teammates, and various other people in leadership positions to determine what makes a good leader. Why do people follow some leaders and not others? Commitment is important. If a leader doesn’t believe in a mission, neither will the rest of the team. Effective leaders work with the team – they get down in the trenches and don’t sit on the sidelines barking orders and cheerleading. Trust is also important. If team members are worried about whether their leader might throw them under the bus, they will second-guess the leader’s intentions. The biggest factor in being an effective leader is competence. Col. Kolditz described his interview with a group of soldiers in an elite army unit. Almost all of them hated their commander. They thought he was a jerk. But every one of them said that when the rubber met the road he knew what he was doing and that there was no one else they would rather have leading them in their missions.
  • I listened to Dr. Melissa Givens, a Lieutenant Colonel in the US Army, describe how difficult it was to manage the shootings at Fort Hood and all of the unexpected difficulties they had in trying to save the wounded soldiers. Ever wonder what it’s like to watch one of your co-workers die right in front of you? She told us how she was in the same room where the shootings took place only two days prior to when the shootings occurred. Very informative and very emotional.
  • I watched a room full of physicians throw up their hands in frustration when a California physician showed how his group and other groups in the state are having difficulty staying solvent because California does not allow medical groups to bill patients fair prices for the care that they provide. Insurers lowball payment to the physicians and the California government made it illegal for the physicians to bill the patients for the remainder of the payments. Many physicians are considering whether or not to leave the state. California patients may soon be getting what they – or their insurers – pay for.

There were other lectures about how health care reform fell short and some possible options for the future.
One of the most informative lectures I attended was given by a former Congressional aide and current consultant who described his impressions about how legislators come to decisions and what does and does not influence a legislator’s decision-making. Personalized letters to legislators really do make a difference.

And I went to legislators’ offices.
The legislators weren’t in town when I went to visit, so I was lucky enough to get appointments with some of their staff.
I discussed ideas for health reform and medical malpractice reform with one legislator’s assistant. He took my name and said that he was going to have another assistant get in touch with me to get some more ideas and input.

I spent 45 minutes talking with one legislator’s assistant who is the go-to person for health care policy. I didn’t try to sell anything to him, I asked him if he had any questions that I could answer for him. We sat there for 45 minutes talking. Below are some of the things we discussed.

“What do you think about the SGR?” He asked.

  • Honestly, I don’t think they should fix it. Nobody cares about it right now. All they know is that they can keep kicking it down the road until it becomes a big enough problem that someone is forced to fix it. The only way to deal with the issue right now is not to fix it. Cut payments to physicians. Let most of them drop out of the system. Let the patients who depend on Medicare be stuck without medical care. Almost immediately, the AARP will pay for a bunch of buses for all the grandmas and grandpas with their pink hair and canes with the tennis balls on them (probably my own mother included) to go to Washington and demand a fix. Only then will legislators realize that the current system is unsustainable and unfixable. We can’t patch this system and expect that it will continue to work. We must focus on starting over and creating an entirely new system that will be sustainable in the future. And a side note – if you try to create another system without extensive input from physicians, it will fail in the same manner that the current system is failing.

“Do you think that the AMA represents the views of physicians across the country?”

  • Not really. I believe there is a lot of attrition from the AMA and know of many physicians who have dropped their membership. At the same time, membership in specialty societies is growing. ACEP is a perfect example. ACEP’s membership is going up, not down.

“How would you make the health care system better?”

  • Patients must have more skin in the game. Right now many people think that the value of the health care they receive is their $20 copay. You can’t get work done on your car for that much. A plumber would laugh at you if you told him that was all you would pay him. But, in practical terms, all a physician visit is worth is $20. That mindset has to change. $20 per visit won’t even keep the lights on.
    There is a tremendous demand for high technology and for extensive testing that is often low yield. That is because a majority of patients have no direct responsibility for paying the cost of the testing. There is no incentive for patients not to want a test and there is no incentive for a physician not to order the test. In fact, with the push toward “patient satisfaction” as a basis for reimbursement, the incentive for physicians to order extensive testing will only increase. If patients don’t have skin in the game, costs will continue to rise no matter what regulations are put in place. I guarantee it.
  • The only instance in which patients and physicians work together to decrease costs is when patients have to pay out of pocket for their medical care. If a patient’s medication goes off formulary for their health plan, the patient goes to the physician to find an alternative or to get the physician to request an exception from the insurance company. If a physician would like an MRI on an patient’s back after the patient was injured at work, the patient will not get the exam done until worker’s compensation agrees to pay for the test. This is what we need – patients need to be responsible for the costs and physicians need to help them determine what they really need and don’t really need. If patients want a low yield test, no problem – but they have to pay for it out of their pocket. Let them have ten low yield tests if they want. The only one who bears the cost of the testing is the patient.
    Homeowner’s insurance doesn’t cover the cost of someone mowing your lawn and it doesn’t cover the cost of your kid breaking a window.
    Auto insurance doesn’t cover the cost of oil changes or fixing your tire.
    Why should health insurance cover routine medications and routine medical care? It shouldn’t.
  • Health savings accounts have to become an integral part of our culture. Use the money in those accounts to pay for routine health care costs. Make money in the accounts tax-free to encourage people to use them. Allow patients to carry some of the money in the accounts over to future years, but require that they spend at least some of the money in the account each year to encourage people to engage in preventative health care practices. Family practitioners could drop all their insurance plans and could all go “cash only.” No insurance hassles. Money at time of services. They’re happier and more productive. More people go into family medicine. Patients get seen quicker. What a concept.
  • Mandatory insurance isn’t fair and it probably isn’t Constitutional. You want everyone to pay into the system, increase taxes in an amount proportionate to the amount you’ll need to provide for medical care and provide the care at government-run hospitals for free. You don’t have to pay for an insurance policy, you have to pay 5% more in taxes. In return, you have access to health care at any VA hospital. Include county hospitals if you need more access. Will the care be the best available? Probably not. Will everyone get a same-day appointment? Not likely. Will everyone have access? Absolutely. Do this and you could eliminate much of the costs that are currently wasted on insurance companies.

“What do you think still needs to be included in the health care bill?”

  • Malpractice reform. The AAJ has talking points stating how direct medical malpractice costs are an infinitesimal amount of total medical expenditures in this country. The statistics are true, but are only half of the story. The AAJ states that instilling fear in medical practitioners is good for medical quality of care. That fear drives defensive medicine. Defensive medicine accounts for hundreds of billions of dollars in indirect medical costs – at little gain to the system. If lawsuits improve quality of care, then the trial lawyers have failed. They’ve been suing doctors for decades and mistakes are still being made. The only thing that seems to go up is the size of the judgments. We can’t sue our way to better health care. Yes, I said that and yes the assistant laughed. I think he even wrote it down on his pad.
  • Damage caps are a tricky subject. Capping a patient’s damages at $250,000 isn’t fair to the patient, but neither is making a doctor liable for a $60 million judgment. There has to be some reasonable limit to damages, but even those limits won’t decrease the physician fear of being sued. [I actually agree with Matt on this point - in almost all cases, caps don't save physicians money, they save insurance companies money - but if insurance companies go out of business, hike rates, or stop offering coverage because of a $60 million judgment, physicians will have a more difficult time finding coverage and won't be able to practice. There has to be a happy medium].
  • Like it or not, we will likely need to provide some type of limited liability protection to certain providers if we want to increase the numbers of those providers. Few physicians like being on call at hospitals because they know that they probably won’t be paid for the care and that they are highly likely to be sued if anything goes wrong. We have to ask ourselves whether we value the ability to find a physician to care for us in an emergency more than we value the right to sue that physician if anything goes wrong. Which is more important to us: Perfect care or available care?

We had other discussions, but this post is already getting too long.

You naysayers want my ideas? Here they are.

Now try to show me how they won’t work and come up with some better ideas.

Free Market Medicine

Tuesday, April 13th, 2010

If you read this blog regularly, you know that I am an advocate of free market medicine. Force medical providers to advertise their prices like all the other businesses, let insurance cover catastrophic costs instead of everyday costs, and let market forces go to work.

In order for the free market concept to work, though, we have to get rid of the third party obfuscation, though. Right now, not many people care about the cost of a product because they aren’t paying for it. Third party “middlemen” are paying for the product.

I read a post on Kevin MD’s blog that puts free market principles into play.

Take all of those who are suffering from low back pain. You want to know if something might be wrong. Do you need an MRI? That depends. Is the pain acute or chronic? Are you having any “red flag” symptoms? Will you be willing to undergo surgery if something is wrong? You may need to see a primary care physician to see whether an MRI is warranted.

That’s another thing I would change with the system, by the way. Do away with the concept of requiring a physician’s order to obtain testing. You want an x-ray? Go to the radiology department, plop down your credit card, and get your x-ray. We can buy pregnancy tests, HIV tests, and glucose testing supplies over the counter, why can’t be buy urinalysis test strips or tests for strep throat? Why do we need a doctor’s order to have blood testing done? Don’t give me the song and dance about the dangers of x-rays, either. We allow tobacco companies sell lung rockets to any patient with a nicotine addiction as long as the packets have a label stating that the surgeon general has determined that cigarette smoking is bad for your health. Everybody is hereby warned that the surgeon general has determined that excess radiation is bad for your health. Done.

It would make the practice of medicine a lot easier and a lot less expensive if we didn’t erect so many barriers for patients to get testing done. Sorry about the tangent. Off the soapbox and back on topic.

Let’s say you get the prescription for an MRI of your low back. You lost your job and lost your COBRA coverage. You have to pay for everything out of pocket and you know how expensive MRIs can be. Where do you go to have your back MRI done? According to LesliesList.org, you can have your MRI done at Northwestern Memorial Hospital in Chicago for$3800 plus the cost for the radiologist to interpret the films.

Or, if you want to have the exact same test done at the Lincoln Imaging Center in Chicago, according to LesliesList.org the test and reading fee together would cost you $325. That’s more than a twelvefold difference in price … in the same city … for the same exam.

Now maybe you want the university radiologists to read your scan and you’re willing to pay extra. Or maybe the Lincoln Imaging Center sees that the prices it is charging are too low and increases them to reflect the market pricing. The whole point is that prices will take care of themselves once customers begin voting with their feet and their wallets.

Hopefully LesliesList.org will be one of many resources that patients can use to decrease the costs of medical care.

Thumbs Up. We need more sites like this.

Healthcare Update — 04-01-2010

Thursday, April 1st, 2010

Tort reform lessens the risk of medical malpractice, “but it doesn’t change the capriciousness of the legal system … and it hasn’t changed the nature of the risk.” “If there is ANY DELAY AT ALL in the diagnosis of a condition, then they label it as ‘malpractice.'” This Newsweek article explains very succinctly why defensive medicine is real – despite what the American Association for Justice’s mouthpieces would tell you. Ooops. One lawyer in the comment section says defensive medicine is a myth. Oh well. There goes my theory.

It’s not really patient “dumping” — I helped her get out of the car. Florida surgeon cuts wrong duct during gallbladder surgery, then brings patient to another hospital in his own car and drops her off at the emergency department, telling her to inform the staff that she was discharged from the first hospital two days prior. Funny … his hospital notes showed that the patient was feeling better and that he was discharging the patient home. Moron.

Michael Jackson’s heart was still beating when he got to the emergency department. Joe Jackson, Michael Jackson’s father alleges a “cover up” in Jacko’s death. Yeah. The agonal heart rhythm must prove it. Sorry, but I just could never write about celebrities for a living.

The Wisconsin State medical malpractice fund was running a surplus. Then Governor Jim Doyle raided the fund for $200 million to cover some of the state deficits. Now, payments to patients have the fund running at a net negative for the past two years. This year it is $109 million in the hole. Governor’s response: The fund could afford to give up the money – it had a surplus. Next source of state revenues: Children’s piggybanks and the spaces between old ladies’ couch cushions.

Total emergency department visits dropped by 1.3% in 2009. Meanwhile, emergency department visits by Medicaid recipients increased by 6%. When few physicians accept your insurance, where are you supposed to go for treatment of your medical problems?

Should psychotherapists Google their clients? What about Facebook friending? Personally, I think the whole Facebook thing between physicians and patients really crosses the line for a professional relationship. Will patients start disclosing their protected health information on your Facebook wall? Will physicians be hesitant to deny inappropriate requests for prescriptions or requests for medical care out of the office because they don’t want to offend their Facebook “friends”? I stay off of Facebook for just this reason.

Don’t have your heart attack in Nova Scotia on Sunday night or during Monday afternoon. This Nova Scotia emergency department will be closed — due to physician shortages.

Now that health care is all shored up, we can start fixing this country’s legal system. Enter SinglePayerLegal.org. According to the site … half of poor Americans suffer from at least one serious legal problem each year, but 75% of those people have no access to legal care … thousands of innocent working Americans are wrongfully convicted of crimes every year – in part due to negligent or poorly trained lawyers … and the average profit per partner at the most successful law firms was more than $750,000 per year.
I really think we should pass a law about this whole legal mess.
Hat tip to Throckmorton.

Philippine physicians take a mass leave of absence from Philippine General Hospital to “to strongly protest the lack of a democratic process” in selecting hospital director. Hospital staff elected one person for the hospital director and the hospital chose someone else. Now administrators can do the appendectomies.

Houston’s mayor may have priced some retired city employees out of the healthcare market by increasing insurance premium payments by 50%. The city is required to pay for 79% of active employee health care costs, but there is no minimum payment for retirees. Why did the mayor cut retiree benefits? All about the Benjamins – that demographic used the plan far more than active employees or retirees over age 65. The article states that many other cities and states around the country are looking at making similar cuts.

Ten thousand emergency department visits for dental problems in one city in one year. Checkups at a dental office cost $24 per visit. Emergency departments cost $600 per visit (although I’m sure the state actually pays much less than that amount). What does Minnesota’s governor do to help improve the state’s budget crisis? Cut non-emergency dental health services for the state’s Medicaid recipients. No, their cavities won’t miraculously disappear. They’ll just end up in pain in the emergency department with no access to proper dental care. And the state will pay out more money in emergency care than it would have saved by just providing preventative care to begin with.

AT&T, Caterpillar, 3M and other companies are expected to have non-cash earnings that are $14 billion less due to non-cash expenses from the health care bill. Health care benefits paid to retirees are also no longer deductible. How will these changes affect tax revenues and retiree health care?

Mt. Vernon, Illinois hospital implements policy to discourage drug-seeking patients. Allergic to NSAIDS? Looks like you’re getting Extra Strength Tylenol, a pat on the back, and some good wishes for your chronic pain. No narcotics will be given to chronic pain patients. Lost or expired prescriptions for any pain medications will not be refilled.
Why is it that patients never lose prescriptions for their blood pressure medications, anyway?

Given the title of the article, I thought they were talking about me. Nope. The “new dummy” in the emergency department was just a training mannequin.

What are some experts recommending that doctors do after Medicare cuts?
“Doctors may need to think of changing the amount of time they allocate to Medicare patient encounters or limiting the hours per day they can accept Medicare patient appointments. And even with that, you want to handle those times as efficiently as possible … You might decide to see 6 patients an hour instead of 4 and to get the exam rooms turned over more quickly. Or, while it may sound unfair or insensitive, a practice could allocate only a day a week for Medicare patients and move those patients through much faster.”
In other words, “decrease access to Medicare patients.”
Have Medicare? Sorry, only one complaint per appointment. Here’s a referral. Have a nice day.

Focus On The Cost

Tuesday, March 2nd, 2010

Yeah, I agree with Howard Fineman. You got a problem with that?

Read his Newsweek article about his experiences being admitted to an Argentinian hospital and how he believes we should be focused on the costs of health care in this country.

His bill for a hospital stay with dehydration in Argentina: About $1500. Similar hospitalization in the US: $10,000 to $15,000 – if he was lucky. Money quote: “Most Americans have no idea how much their health care really costs, nor do they know how well it really works ….”

We desperately need price transparency in our health care system.

Look at the four systems in Pennsylvania that I reviewed in a previous post. If one hospital cost 4 times as much as another hospital for treating the same medical problem, would that affect anyone’s decision on where to go for medical care?

One commenter to the article noted that “Health services are often urgently needed and the consumer doesn’t have the time or inclination to shop around.” If people shop around for weeks to find the best deal on a car and spend all Sunday morning going through newspaper ads to find the cheapest head of broccoli at the grocery store, I have no sympathy for those who “don’t have the time or inclination” to research where they would want to go if their life was on the line or if they needed specialized surgery.

Regardless of what health care reform measures are taken, we still need to be educated consumers with our most important assets – our lives.

Brinksmanship

Friday, February 26th, 2010

colonel_sandersI may end up eating my words about this. We’ll see.

James Rohack, the current AMA President, made a post at Kevin MD about why patients should care about fixing the pending Medicare payment cuts. Basically his take on the matter was that if the cuts go through, many physicians will stop seeing Medicare patients and that some seniors on Medicare will have difficulty finding medical care. I tend to agree with him.

I commented that we should let Congress cut Medicare payments. Stop fighting it. I won’t rehash everything, but suffice it to say that I think we need a crisis in medicine to get things straightened out right now.

A Medicare pay cut of 21.2% has been looming over physicians’ heads for several months now. The same pay cut has come up in the past, but, through some last minute “miracle” (otherwise known as brinksmanship), the pay cuts are averted, the deadlines are extended, and the medial societies pat themselves on the back for all of their hard work in averting disaster.

Now the stakes just went up.

The Senate blocked the latest legislation to extend the deadlines for the pay cut. Pay cuts will take effect on Monday.

Physicians now will have to make an important decision. March 17 is the deadline for physicians to decide whether they will continue to participate in the Medicare program. Things are a little more complicated than this, but the basic consequences of the decision are the following: If physicians decide to participate, then they’re stuck with the 21% pay cut. If physicians decide not to participate, then Medicare patients have to pay the physicians’ fees out of pocket — or find another doctor who accepts Medicare. Why don’t all physicians just drop Medicare and then sign back up when the rate cuts go away? Another arcane rule crafted by Medicare – once you decide not to participate, you can’t participate again for a minimum of two years.

So do physicians drop low payments and gamble that payments won’t go up in the future? Or do they bite the bullet and continue providing services at even more of a pittance? Our physician organizations need to collectively tell Medicare to go pound sand.

Maybe this is what the government wants. Notice how the payroll deductions for Medicare and Medicaid aren’t getting any smaller. But with less people working, the amount of money collected is becoming less and less while the numbers of people needing the services continues to increase. By significantly reducing the number of available providers, perhaps the government wonks believe that they can reduce the amount of money they spend on care.

Initially, that may be true. Then what happens?

First, a good percentage of about 40 million AARP members, and a significant portion of the rest of the Medicare population, are going to become extremely upset when they can’t find a doctor to take care of them.

Then, just based on sheer percentages, every single member of Congress is going to get at least a few phone calls from angry constituents who are no longer able to find medical care. The legislators will go into damage control mode, but it will be too late – because even if Congress raises the pay a week after the opt-out decision deadline, those doctors that opted out still won’t be able to participate in Medicare for another two years. There will be a lot of turnover in Congress in November and that’s something else we need.

If a lot of physicians opt out of Medicare, the health care system will turn chaotic. Maybe a few of the well-to-do elderly patients will pay out of pocket to continue seeing their current physician. However, most will start calling around to find other physicians who still accept Medicare. The wait lists with those physicians will grow from weeks to months.

In the meantime, elderly patients will go to emergency departments for their health care needs because we emergency physicians will always be there to help them when their doctors aren’t available (I’m already starting to see this happen in my ED) and because the hospitals won’t dare to opt out of Medicare.

Hospitals accept Medicare … Medicare pays for care rendered to seniors … seniors go to hospitals. Seniors who come to the emergency department tend to get BMWs (but remember, folks, defensive medicine doesn’t exist), therefore costs to Medicare go up, not down. Medicare goes bankrupt sooner than anticipated.

A crisis like this is what we need to get legislators back to the table to create a better health care plan. It needs to happen. Even the status quo is unacceptable.

I doubt it will happen, though. CMS has announced that it will not process claims for Medicare payments for the first two weeks of March, so my prediction is that Congress will eliminate the pay cuts next week and that all the physicians will get their “full” payments after March 14. We’ll continue in the same dysfunctional system until the next crisis occurs about 10 months from now.

Unfortunately.

Gutsy move by Congress letting things get this far, though. No matter what happens, this is turning into one helluva game of chicken.

UPDATE FEBRUARY 28, 2010
See Throckmorton’s blog for another good point – with the cuts to reimbursements also come a cut to reimbursements for medical care to all of our soldiers. What happens to Congress?
There are already reports that a bill will be introduced this week to delay the effective dates of the cuts for another 30 days. And the AMA is actually showing doctors how to drop Medicare, if they so choose, including samples of documents to file (.pdf file – also contains excellent explanation of options physicians have regarding participation versus non-participation)
The merry-go-round continues.

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