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Health Policy

A profound article, and must read for all patients and physicians

By Brian L. Grant MD

This article on doing no-thing is the best medical article I have read in some time. Properly applied, this technique would do more to solve our health care crisis than all the PPO discounts, new drugs, payment reforms or other interventions and improvements to our system. Doing no-thing, properly applied would reduce prescriptions of unnecessary harmful drugs, surgery, diagnostics, and more. So much of health care is not necessary. Sometimes this can only be learned in hindsight, but often it is obvious from the start.

Doing nothing is perhaps a bit of a misnomer. The act of listening, empathizing and caring – when active interventions are not of benefit to the patient.

The comments on this article are well worth a read. Some are highly critical of the author and others are most supportive. Read more…

Kennedy, Vaccinations, Autism, and Junk Science

It’s been quite a while since MCNtalk has posted on the subject of childhood vaccines—since our February 12, 2012 post, “More Doctors ‘Fire’ Vaccine Refusers.” But the issue has not gone away. As this article in Slate points out, there are still those who argue publicly that there is a link between autism and childhood vaccinations, specifically that a vaccine preservative called thimerosal causes autism when injected into children.

It is important to understand that the original study in 1998 linking childhood vaccinations and autism has been thoroughly debunked multiple times using rigorous standards of scientific evidence. (Read “Vaccinations and Autism—Junk Science Is Not a Victimless Crime” for a summary.)

Robert F. Kennedy Jr. gave this year’s (May 24) keynote address at the Autism One/Generation Rescue Conference in which he strongly argued for a link between childhood vaccination and autism. The Slate article touches upon the speech and subsequent conversation between Slate and Kennedy as well as neatly summarizing pertinent facts on the issue. Why is this important? Because when people are not vaccinated, they needlessly put not just themselves at serious health risk, but their entire community as well.

We refer to people who say vaccines cause autism with the shorthand “anti-vaxxers” or say that they are part of the “anti-vaccine movement.” Kennedy said that he is “very much pro-vaccine” and that “vaccines have saved millions and millions of lives.” They will save even more lives if he and his colleagues stop spreading fear and misinformation about them. Kennedy is a passionate guy with practically unique name recognition, powerful connections, and the ability to command attention. He could reverse the course of the anti-vaccine movement today if he announced that his concern about vaccines had been well-intentioned, but that research has shown that vaccines don’t cause autism after all. It would be a proud legacy, one worthy of his name.

Read more…

HIPAA Compliance in the Cloud

This short article in Forbes on-line summarizes concerns with compliance to — and related costs — updates in HIPAA (Health Insurance Portability and Accountability Act). As noted, security and privacy are getting more serious with each iteration.

This is no small concern:

The Department of Health and Human Services estimates that the cost of compliance with the final rule will be somewhere between $114 and $225 million (first year) and about $14 million for each year thereafter… the rule qualifies as an “economically significant” one under Executive Order 12866.

The reason for this new level of security is pretty fundamental. Healthcare has had some serious deficiencies through the years and it’s a prime target for identity theft. Not so much for the actual healthcare information but for financial fraud – which is a companion problem in healthcare (to the tune of about $70 billion a year in Medicare fraud alone).

Read more…

Hospital Mergers and Restrictions on Health Care Offerings

This recent New York Times article focuses on the impact of hospital mergers in Washington State, where increasingly, Catholic systems are taking over hospitals both small and large. The Church has a venerable history of leadership in providing health to the region since pioneer days, and what started as small missions, have evolved into very large systems.

The responsiblity to serve all people with compassionate care underscores the Catholic health mission and in so many ways inspires all, regardless of background – especially those who decry the increasingly profit-driven nature of the system.

While the vast majority of the work done in these hospitals are unaffected by the ownership structure, positions on procedures including abortion and assisted suicide between the hospitals and many patients and practitioners are at odds. Concerns exist that a physician working at such institutions on the medical staff is specifically precluded from a full discussion of legal options, when such options run counter to Catholic teachings, regardless of the personal beliefs of the physician or the patient. As a source in the article notes:

“If you go to a Catholic medical institution, you’re going to get medical advice that is in keeping with the moral norms of that institution”…“We think Catholic medical advice is the best medical advice to give.”

When a Catholic institution takes over the only hospital in a rural region, physicians and patients have little choice but to adhere to the dictates and restrictions imposed by the institution, unless they choose to travel a long distance to another facility. In many cases, the institutions have been supported with public funds via bonding, tax treatment and other benefits. Expect this conflict to widen in the context of individual cases where a clash of values conflicts with care desired vs. care available.

How Budget Conscious Doctors Can Lower Health Care Costs

When shopping, people tend to search for the best deal with the greatest value. But when it comes to receiving health care services, why is the price tag never a clear part of the discussion?

After TIME Magazine featured the report “Bitter Pill: Why Medical Bills Are Killing us,”  Cleveland Clinic CEO Dr. Toby Cosgrove argues that one potential cause of  out-of-control healthcare costs may be that doctors often have no idea how much medical procedures actually cost. He argues that by informing doctors about the specific costs of health care procedures, doctors may try to find more cost-effective alternatives.

And in a new study by Johns Hopkins published in the journal, JAMA Internal Medicine,  researchers showed that informing doctors of the cost of tests, services, and supplies they use actually can lead to hefty medical savings.

The researcher split physicians into two groups over the six-month experiment to see if showing the tests prices would change a physician’s decision about services.  One group was given the tests with prices on them, while the other group’s tests did not have a price.

The researchers compared the buying behavior of the physicians and found that showing the pricing information resulted in a 9% cut in use of the tests overall and a savings of over $400,000 over the six months. By comparison, there was a 6% increase in the use of the tests without pricing information over the same time period. Read More…

The researchers say the savings can be largely credited to the simple principles behind comparison shopping.

To challenge this theory, CEO Dr. Toby Cosgrove decided to make it a point to deconstruct the costs of their top three procedures, record the price of sutures, the number of instruments uses and record how long patient’s spend in post-anesthesia care.

“Take, for example, nitric oxide, a drug commonly used in heart, lung and chest surgeries to keep tissues well-supplied with oxygen during the operation. When it’s effective, it’s very effective, but it doesn’t help all patients. When we realized we were spending $2 million a year on the drug, we drilled down to see who was using it and why.

We found that doctors and OR staff did not have a standard protocol to guide them on when and how much to rely on nitric oxide; we had to educate them that if the drug didn’t work within a half hour of being administered, it won’t work at all, so repeated doses were wasteful. The result: nitric oxide use dropped by half, saving $1 million without any adverse effect on patient care,” Dr. Cosgrove said.

Read More…

When his team saw where they could easily cut costs, they made a goal to save $100 million in a year by focusing on what and how they use equipment and supplies they purchase. Within a year, they topped their $100 million goal and after three years have saved $155 million.

And while it’s crucial that quality of health care services always comes before price, it is equally important to realize that even the smallest cost saving practices create a monumental difference in our costly health care system.

A New Kind of Care for Adults

New York City may be facing a predicament as the prevalence and popularity of social adult day care centers is on the rise, especially in the Brooklyn area.

With the largest Medicaid budget in the country at $54 billion, the city is trying to find a way to balance spending for institutional care with less expensive care methods that allow people to remain in their communities.

These spending concerns arise as the number of social adult day care centers has grown from eight programs to 192 centers across the city.

Why has the number grown so much so quickly? The answer lies within their aggressive marketing tactics. To entice people, a facility may offer $50 for a referral, money each week, free food to take out, a grocery coupon, or an unlimited MetroCard.

Medicaid indirectly pays for the cost of attendance. Managed care companies pay the adult day care centers to provide services to its clients. In return, the centers refer new clients to these companies.

“Centers collected $25 million for managed care plans in the first nine months of 2012.” The rate per month for each member is about $3,800 or $93 per session. Read More…

Furthermore, these care centers are fairly inexpensive to operate because they are minimally regulated, do not require a license and only require a staff of two people, one of whom can be a volunteer.

Those who receive treatment are supposed to be impaired enough to need at least 120 days of help with everyday tasks. However, the The New York Times article,“Day Centers Sprout Up, Luring Fit Elders and Costing Medicaid,” reports that healthy individuals may be reaping the benefits of a superfluous Medicaid budget.

“The idea that people are bicycling home from managed long-term care is a complete misnomer…The idea that they’re playing Ping-Pong — I guess they could be wheelchair-bound Ping-Pong players, but otherwise it’s fraud and they are not eligible,” said Jason Helgerson, the state’s Medicaid Chief.

Obamacare & Medicare Advantage Update

As the future of Obamacare falls into place, many health insurers are pleased with recent outcomes.

The government recently made decisions regarding Medicare Advantage rates, the future of Medicaid, and the Patient Protection and Affordable Care Act. 

Instead of Medicare Advantage rate cuts, participating insurers will receive a 3.3 percent i crease in payment reimbursements, which is more than what some had hoped for.  In addition, the Department of Health and Human Services is now fully responsible for Medicaid expansion costs.

“Expansion would broaden the coverage umbrella to include patients below age 65 who have income that’s 133% above the federal poverty level.” Read more…

Although many are able to rest easy after the conclusion of this decision, there are still numerous decisions to be made concerning state health insurance laws. 

To read more about details of these new decisions click here.

An Overview of a Sick Health Care System

By Brian L. Grant, MD

This very detailed, long, and comprehensive report from Time  states the obvious to many who have paid attention to the debacle of our health care system.

It is long, but the best summary I have seen making the case for a need to revamp and disrupt the U.S. health care system. The article, “Bitter Pill: Why Medical Bills Are Killing Us,” details how:

“In the U.S., people spend almost 20% of the gross domestic product on health care, compared with about half that in most developed countries. Yet in every measurable way, the results our health care system produces are no better and often worse than the outcomes in those countries.”

A response to the article in Slate criticizes the article on giving doctors and their pay a pass.

Obviously this hits close to home for this writer and many readers of MCNTalk. It actually hits home for every American.

It will enlighten and disturb most. Readers may even learn a new word: Chargemaster. Learn what this means and why it is important to you.

What is clear is that virtually every interest group invested in health care stands to lose a lot if the system truly rationalizes itself structurally and functionally in a way that addresses the major dysfunctions in the current U.S. system.

If the 18+ GDP being currently spent in the U.S. were to decrease to a level consistent with other industrialized countries, that means the spend will be less and the income of impacted stakeholders in our present system may decrease.

This article ought to make readers angry and concerned, enough to do their own analyses rather than accept the rhetoric designed to polarize. Simply put, our health care system is indefensively abusive to society.

Any system that charges those who can least afford to pay, the uninsured, many times that charged to Medicare patients and double that paid by private insurers, is wrong.

Any system that costs us as a society one out of five dollars – twice what other countries with systems equal in quality to ours – when it comes to major measures of health is wrong. Any system that abuses its nonprofit status, holds charity balls to cover the 1% or so that it may give away, while ending up with 12% or more of untaxed profits, paying its key executives in the many millions each – is wrong!

The article says little about the unnecessary nature of much of the care received by patients and the excesses in care with respect to labs, medications, therapies and other interventions. There are no health care bills when one does not receive care that is not needed or when one is healthy in the first place. And preventative care should be evidence based, not automatic.

This writer is in the medical business, as a physician, patient, employer, and in a role with a business that every day analyzes and reviews care received or proposed. I know a train wreck in process when I see it.

The political divisiveness and partisanship that surrounds the health care debacle is not accidental. It is carefully calculated and brilliantly executed by political operatives on behalf of those who stand to lose.

How fascinating that many of those who suffer the most in the current system, most revile the president and party who have proposed solutions that might mean a few less folks would need to declare bankruptcy from their medical bills.

At some point in the relatively near future, change will be forced by political will and those who have been tricked into opposing change will see the errors of their ways. Those businesses who are footing ever increasing bills for private insurance will also decide that they are fed up.

Changes will be fought hard, with desperate claims to maintain the status quo. It is in the interest of those most impacted to be part of solution rather than have it be imposed on them.

In the interim, pray that you, your friends, and loved ones never show up at a hospital with none or inadequate insurance. And welcome the day you are eligible for Medicare.

We invite readers’ responses to this article. We would especially like to hear counterpoints to the main points raised in the article.

 

Are Your Health Benefits Cutting Your Pay?

This thoughtful and depressing article from the New York Times describes the actual health care costs to individuals in graphic terms; how it impacts their salary and how the political process ensures that the high costs continue.

The author closes with a modest proposal on how the system might change by only insuring for unexpected, catastrophic illness – leaving the remainder to individuals to self-insure.

Clearly such a suggestion would be resisted by most everyone. We currently consume health care in the context that we expect routine and affordable treatments such as teeth cleaning, eyeglasses, and contraception be paid for by someone else.

Most of us will drive a mile to save a couple of  cents on gas. If our car insurance paid for gas,  which it would if health insurance behavior applied to cars, not only would we go to the closest station, but the price of the gas would not be posted. Read More…

Will Self-Insurance Plans Drive Up Costs for Others?

A New York Times article addresses the self-insurance trend as some companies with relatively young and healthy employees decide to opt out of the health insurance marketplace.

Though it is unclear whether employers  are deciding to self-insure as a response to the Affordable Care Act, companies have found they can avoid the laws’ minimum coverage standards and save money by doing so.

“The new health care law created powerful incentives for smaller employers to self-insure,” said Deborah J. Chollet, a senior fellow at Mathematica Policy Research who has been studying the insurance industry for more than 25 years. “This trend could destabilize small-group insurance markets and erode protections provided by the Affordable Care Act.”

However, this change could drive up costs for employees at other companies because commercial insurers and insurance exchanges will be left with disproportionate numbers of older and sicker people who are more expensive to insure. This could drive up premiums for uninsured people seeking coverage in the exchanges and since the federal government subsidizes that coverage, it could face higher costs as well.