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Now With the Elections Over, We Can Focus on Health Care – A View from the Trenches

By Brian L. Grant, MD

Pundits are debating the meaning of the recent election results. I believe that to some degree the election is a mandate to continue to address our out-of-control health care system and an endorsement by the  electorate to continue to develop and deploy the Affordable Care Act – aka ObamaCare.

Coming at health care as a physician, patient, employer, taxpayer and medical director of a company whose business it is to review medical claims for appropriateness of treatment and utilization – I believe I have both skin in the game and a deep perspective on the problems we face.

Long ago during residency, during my medical rotation, I concluded that so much of care was of little value in providing quality or quantity of life to those whose days were numbered. Those providing the treatment were unable or unwilling to ask the tough questions that would limit care in hopeless situations. Governed by good intentions, physicians were and still are largely expected to treat with little moderation. This decision is supported by the economic rewards of treatment, encouragement by the hospitals they work in, and a fear that denying treatment or moderating the testing provided might expose them to litigation.

I wondered how many people would choose the care received if the system were somehow different, such as their paying directly for care of having the money available for some other use. I continue to ask this question today, while recognizing that many would abuse this choice, denying necessary preventive care to themselves or their children if given the option of diverting their health care spending to another cause.

But absent external controls on utilization and consumption – overuse and unnecessary care is common, and according to some, represents some 750 billion dollars annually, or about 25% of our health spend! This would suggest that we stand to gain far more from curbing spending and utilization than we do from discounting it.

And since patients and their families are largely shielded via insurance from the economic impact of treatment, they lack interest or incentive in invoking the economic self-interest that governs all of us in our non-medical personal spending behaviors, when we are not spending directly for our care.

Third party payments also mean that the costs of treatment are not responsive to competition, since everything is expected to be paid for at whatever price may be charged. Third party surrogates including insurance carriers, bill reviewers, and companies such as MCN whose work aims to control excessive and unnecessary costs are attacked by stakeholders including patients, providers, drug manufacturers, device manufacturers and hospitals when limits or denials are suggested or imposed.

As an employer, I have experienced annual increases well into the double digits in proposed premiums for our staff, only curbed by increasing co-payments, deductibles and some of the premium increases to the employees. This means less income for staff as their personal health spend increases – a trend common across the economy. The rate of increase has appeared to curb a bit over the past two years, perhaps in response to the reforms underway that improve the structure of the system by spreading risks to a wider population of insured individuals.

I grudgingly accept the need to provide coverage for employees, all the while wondering why this is the case. Staff do not receive company-paid housing, food or education; they get a paycheck to pay for some, and we all pay taxes to pay for other universal needs such as education. Why is healthcare a unique outlier by being tied to employment? How do we as a society rationally defend employer-based health-care given the outcome? The consequences are well-known.

They include most notably the lack of paid insurance for dependents and spouses under most employer plans,  total lack of coverage for many working people whose jobs don’t provide coverage, the unemployed, students, and those who are self-employed and either can’t afford care or choose to gamble by not buying coverage. Since hospitals do not turn away patients needing emergency care, those without coverage are either forced into economically dire straits if they have any money left over to pay, or the rest of us pay for their care via cost-shifting by these institutions to those who can and do pay. This results in higher premiums for those with insurance and the employers paying for them.

In a nation that extols the virtues of small business and entrepreneurs, how many men and women who might take the risk to strike out on their own are deterred from doing so because they can’t afford the high cost of individual health care, especially if they or a member of their family has preexisting risk that makes insurance unavailable or unaffordable. One would think that those who claim to champion a creative economy would insist upon health care being available and affordable to all. Yet by and large this was and is not the case.

As a patient and physician, I have had the opportunity to consume and provide care and see hospital bills that were extraordinary in their complexity and impenetrability, including excesses in line item charges, and inclusion of items that were not necessary in a particular case but dispensed to all patients admitted as standing orders. If you have the occasion to be hospitalized, call and ask for the multi-page actual bill submitted to your carrier rather than the several line summary they send you describing what was billed, what was paid, what was discounted and what you owe as a balance. It will be an eye-opener!

As a taxpayer I am aware of the massive multi-trillion dollar size of the US system, representing about 18% of our GDP or around a third more than those of other industrialized nations that have better public health metrics including infant mortality and life-spans. This excess spending decreases our national productivity and imposes burdens on all, and riches on a few.

Reasonable people can and should debate the details and the specifics; but like defense spending, entitlements and other massive expenses – health-care should be debated and addressed with data, not ideology! Those who believe that continuing the system with minor alterations are advocating the structural equivalent to putting lipstick on a pig. Concluding that this will somehow lead to meaningful change is either naive or willfully deceptive.

I struggle with the concept of personal freedom vs. personal responsibility, the role of government and who should pay for choices. Others do as well. Thus the debates on public health and safety, lifestyles, chronic illness and self-determined behaviors and how much the government should regulate what we do, how we consume and who should pay for these choices. Many entries in MCNTalk have addressed these topics that include obesity, tobacco, vaccinations, and those who question if and how these should be regulated and who should pay. Again one can debate the details and the ideology, but we can’t escape the expensive outcomes for individuals and society.

Democracy is a participatory sport in a game with real consequences for all. We wish our legislators well, thank them for their service and will be there loudly exercising our freedom along with them in the coming years.

Five Ways Hospitals Could Prevent Deadly Mistakes

By Vanessa Radatus

The article, “How to Stop Hospitals from Killing Us” in The Wall Street Journal  provides a shockingly honest perspective into the health care industry and business of saving lives.

The author of the article, Dr. Marty Makery, a surgeon at Johns Hopkins Hospital, explains that 1 in 4 patients are harmed by a medical mistake that are almost always preventable. He asks a key question: Shouldn’t our healthcare system be held to the same safety standards as any other industry?

The comparison Makery uses is perfect. When there is a plane crash, it makes national headlines. Without question, a thorough investigation is done to find out what error was made, how it could have been avoided, and ultimately who is held accountable. It seems harsh, but then again, lives were lost because of a preventable error and you can be certain the aviation industry learns from their mistake.

However, the number of patients killed annually by medical errors is equivalent to four planes crashing every week, yet their stories are all too often unnoticed and forgotten. In the article, Makery states:

“If medical errors were a disease, they would be the sixth leading cause of death in America—just behind accidents and ahead of Alzheimer’s. The human toll aside, medical errors cost the U.S. health-care system tens of billions a year. Some 20% to 30% of all medications, tests and procedures are unnecessary, according to research done by medical specialists, surveying their own fields. What other industry misses the mark this often?” Read more…

Makery makes an excellent argument and explains a career defining moment when he learned the truth about our broken health care system. Few hospitals are actually held accountable for poor performance rates and bad outcomes and therefore, best-practices are lost in everyday procedures.

After years of witnessing this lack of accountability throughout his career, Makery published the book “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care.”

His book sheds light on the issue of bad doctors, botched surgeries, and the key changes that could change how hospitals treat patients. His book advocates that all hospitals should have data and statistics that are publicly accessible for patients to make best choices when it comes to treatment. Without that, patients are walking in to hospitals blind. Read more…

He believes five simple changes to the industry could make hospitals a safer place:

  1. Online Dashboards: Providing the public with the hospitals rates for infection, readmission, surgical complications and errors that should never occur. The dashboard should also list the hospital’s annual volume for each type of surgery that it performs and patient satisfaction scores so that a patient can choose a hospital that specializes in the procedure needed.
  2. Safety Culture Scores: Creating an environment where teamwork is encouraged and anyone from an intern to a nurse feels confident to speak up about a potential issue.
  3. Cameras: Cameras are already being used in health care, but usually no video is made. Reviewing tapes of cardiac catheterizations, arthroscopic surgery and other procedures could be used for peer-based quality improvement. Video would also serve as a more substantive record for future doctors and make doctors more compliant to perform best practices in their field.
  4. Open Notes: Giving patients the ability to review their doctors notes gives them access to explain all their symptoms and help prevent issues in the future.
  5. No More Gagging: Patients are increasingly being asked to sign a gag order, promising never to say anything negative about their physician online or publicly. In addition, if you are the victim of a medical mistake, hospital lawyers ensure that you will never speak publicly about the error as part of the settlement.

It is apparent that there needs to be more transparency in hospitals and medical procedures in order to create a safer and more reliable health care system. If an industry puts a person’s life at risk, like the aviation, automobile or drug industry, they are held accountable when they have made an error. Why should health care be any different?

A Global Health Issue: America’s Health Workforce & Countries Without Doctors

By Vanessa Radatus

The New York Times issued an Op-ed article last week that brings both good and bad news about our current healthcare employment dilemma. While jobs in the health care sector have increased by more than 1.2 million this year, there seems to be an imbalance in our medical education model and the number of foreign physicians we import.

The article “America’s Health Worker Mismatch” addresses the fact that despite increased demand for their graduates, medical schools have done little to expand their output and therefore must turn away hundreds of thousands of qualified medical school applicants. What’s more, our medical school tuition costs have increased by 312 percent in the past 20 years and some health specialties have raised the bar for education credentials – meaning more years of school, higher attrition rates, higher debt, higher wage demands and fewer workers from low-income areas.

The author of the op-ed, Kate Tulenko, is the senior director of health system innovation at IntraHealth International and author of “Insourced: How Importing Jobs Impacts the Healthcare Crisis Here and Abroad.” She explains that the United States dependence on foreign-trained health-care workers is creating a mismatch in our health care work force.

“It’s no surprise, then, that the response to this self-made labor shortage has been to recruit inexpensive workers from abroad, including the 57 poor countries defined by the World Health Organization as having significant shortages of their own. Among them is India, America’s largest source of foreign-trained doctors. A special visa program has made hiring these workers even easier… Today about 12 percent of the health work force is foreign-born and trained, including a quarter of all physicians…That’s bad for American workers, but even worse for the foreign workers’ home countries, including some of the world’s poorest and sickest, which could use these professionals at home.” Read More…

This trend is worrisome as most foreign-trained physicians applying to U.S. residency programs come from countries that are suffering a severe health service shortage. It raises the question: Does recruiting an imported physician workforce create more problems than solutions?