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Health Policy

Discrepancies on Medical Bills Can Leave a Credit Stain

From a distressing but not unexpected article in The New York Times:

  • According to the American Medical Association’s 2011 National Health Insurer Report Card, commercial health insurers processed 19.3 percent of claims erroneously in 2011, up from 17.3 percent in 2010.
  • In 2010, an estimated 9.2 million people aged 19 to 64 were contacted by a collection agency because of a billing mistake according to the Commonwealth Fund, a nonprofit research group, while 30 million were contacted by a collection agency because of an unpaid medical bill.
  • Medical providers collected no more than 8 percent of their revenue from patients about 10 years ago. Now it is closer to 20 percent, or even 30 percent, in some markets.

Rodney Anderson, a mortgage banker in Plano, Tex., said he started to notice in 2008 that more of his customers were being hurt by these medical delinquencies. So he kept notes on 5,100 loan applicants over 10 months. He found that 2,200 had at least one medical debt that lowered their credit score, and many of them were unaware of the damage.

“It’s the same thing over and over,” said Mr. Anderson, executive director of Supreme Lending. “You just don’t let $100 go to collections to ruin your credit.”

That prompted him to take the issue to Congress. He said he had spent $1.5 million of his own money on consultants and on lobbying to change the rules. And his efforts, along with those of consumer groups and others, have gotten lawmakers’ attention.

A version of the Medical Debt Responsibility Act, which would erase medical debts from credit reports within 45 days of being settled or paid, was approved by the House with bipartisan support in 2010. The bill was reintroduced in the Senate by Jeff Merkley, Democrat of Oregon, in March. Read more…

Tightening the Lid on Pain Prescriptions

An article that ends with “I think we are dealing with a lost generation of patients”  sounds maybe just too depressing to read. But this article in Sunday’s New York Times, “Tightening the Lid on Pain Prescriptions,” which focuses on the effects of a Washington State law passed last year, provides a good summary of the opioid crisis nationwide and is well worth the read.

Opioid over-prescription is a subject MCNtalk has written about multiple times in the past year, and with good reason: High-strength painkillers known as opioids represent the most widely prescribed class of medications in the United States, and data suggests that hundreds of thousands of patients nationwide may be on potentially dangerous dosages.  Washington State has imposed new requirements on doctors to refer patients taking high dosages for evaluation by a pain specialist if their underlying condition is not improving. 

The clues were buried in the dullest of places: thousands of workers’ compensation claims.

A pain expert here in Seattle, Dr. Jane C. Ballantyne, said she now finds herself in the role of former believer turned crusading reformer.

“We started on this whole thing because we were on a mission to help people in pain,” she said of the medical profession’s embrace of opioids. “But the long-term outcomes for many of these patients are appalling, and it is ending up destroying their lives.”

The system is now examining how those changes have affected patients. Studies elsewhere suggest the benefits of lower opioid use may be significant for many patients. For example, Danish researchers have published a study indicating that chronic pain patients getting non-drug treatments recover at a rate four times as high as those on opioids.

So where does the “lost generation” fit into all this? Sadly, if the patients were taken off the medications, many would experience severe withdrawal or have to take addiction treatment drugs for years. Even avid believers in the new direction, like Dr. Ballantyne, suggest that it might be necessary to keep those patients on the opioids and to focus instead on preventing new pain patients from getting caught in the cycle. Read more…

“You can’t enjoy a meal when you know your mother is hungry”

Sadly, the title quote could apply to any number of situations related to life in sub-Saharan Africa, but in this case is taken from a physician in this article in the New York Times Magazine, “America Is Stealing the World’s Doctors.”

The premise of the article: In a globalized economy, the countries that pay the most and offer the greatest chance for advancement tend to get the top talent. South America’s best soccer players generally migrate to Europe, where the salaries are high and the tournaments are glitzier than those in Brazil or Argentina. Many top high-tech workers from India and China move to the United States to work for American companies. And the United States, with its high salaries and technological innovation, is also the world’s most powerful magnet for doctors, attracting more every year than Britain, Canada and Australia — the next most popular destinations for migrating doctors — combined.

Just how extreme is the situation? In Zambia, there are slightly more than 600 doctors working in the public sector, which is where most Zambians get their health care. That is 1 doctor for every 23,000 people, compared with about 1 for every 416 in the United States.

There are some hints at plans to address the problem:

  • There are 13 sub-Saharan medical schools receiving support from a United States-financed $130 million program; 
  • The Global Fund to Fight AIDS, Tuberculosis and Malaria provided money to Zambia’s ministry of health (Zambia is featured prominently in the article) to recruit and retain doctors;
  • Western aid agencies, many financed by donors like Bill and Melinda Gates, have also hired local doctors at higher salaries.

But apparent solutions can create further problems; many of the doctors hired by aid agencies are doing research. They don’t see patients. Frustrated public health officials in Zambia and other developing countries call this the “internal brain drain.”

And there are other circumstances: a friend of mine was in the Peace Corps in Niger about a decade ago. a Nigerien friend of hers wanted to go to nursing school, so we agreed to spend the $300 to cover all his expenses in the program. But he decided to go to mechanics school instead to become a bush taxi driver. Why? He’d have a more secure income; in Niger nurses are hired by the government which clearly had no funds – and no history – of paying public workers (when I visited in 1999 the school systems were closed as the teachers had been on strike for months, not having been paid for at least the prior 6 months). In the scheme of things it was a minor situation to be sure, but nonetheless strikes an important chord: medical providers, like everyone else, are part of an economic system, though unlike many others their presence has immediate has life or death consequences for the community. There are no easy solutions, either in the article or in real life, though the answers probably lie somewhere in the simple phrase that is the title of Nobel Prize for Economics recipient Amartya Sen’s major work, Development as Freedom.

It’s a well written article and a situation worth contemplating. Read more…

More Doctors “Fire” Vaccine Refusers

When this MCNTalk blogger was pregnant and interviewing a pediatrician, she told me that she couldn’t take our child on if we didn’t have our child vaccinated on the routine schedule. Though I didn’t necessarily disagree with her, this took me by surprise; I had thought we were doing the interviewing, after all. As it turns out, my pediatrician’s standard is not so unusual. Per this Wall Street Journal article, more and more pediatricians are choosing not to treat children whose parents don’t allow them to receive standard immunizations on a standard schedule.

Some interesting points:

  • In a study of Connecticut pediatricians published last year, some 30% of 133 doctors said they had asked a family to leave their practice for vaccine refusal, and a recent survey of 909 Midwestern pediatricians found that 21% reported discharging families for the same reason.
  • For Allan LaReau of Kalamazoo, Mich., and his 11 colleagues at Bronson Rambling Road Pediatrics, who chose in 2010 to stop working with vaccine-refusing families, a major factor was the concern that unimmunized children could pose a danger in the waiting room to infants or sick children who haven’t yet been fully vaccinated.
  • Pediatricians disagree about what their duty is to these families. “The bottom line is you should try to do whatever you can to maintain the family in the best care,” said Michael Brady, chair of the pediatrics department at Nationwide Children’s Hospital in Columbus, Ohio, and a member of the AAP’s immunization committee. “If they leave your practice, they’re probably going to gravitate toward another practice with unhealthy practices.”
  • Other physicians say they rarely have had luck persuading vaccine opponents to change their minds.

Read more…

The Money Traps in U.S. Health Care

I am continuously baffled when I experience the disconnect between the data and facts presented in this article, and the hue and cry by those many who defend our current health care system. Case in point: the data cited in this New York Times article. Make sure you click on the graphics and absorb the data. And if there are salient points missing that would reveal flaws in the article or this comment, please add a comment.

As a consumer, provider and employer – it is obvious that the return on investment in our health care system pales relative to our friends in Canada, France, Germany and Britain. Only the latter of these four to my knowledge has a system of government-employed physicians. The others have systems of government pricing controls for the private sector providers.

The annual inflation that we experience in health care is unsustainable and puts the US at a competitive disadvantage internationally. It is a major drag on employment as many employers focus in part on rising benefits cost as a reason to not hire more positions. And it is obvious that money that might go in the pockets of employees in the form of raises, or consumers in the form of lower costs, are going into the rising costs of health care premiums for employers.

That many who defend the current system are one pink slip away from no employer coverage, and that few could afford to pay the cost of a private policy, seems to escape the minds or vision of many.

So merrily we march forward, with persistent demonization of those who would dare point out that this problem is not going away.

There are many fine examples of systems that fundamentally work in terms of care delivery, quality of care, health outcomes, and cost of care. Adopting any will entail trade-offs in terms of quantity and access, but on balance would be a marked improvement over our very sick system. Read more…

MCN Promotes Industry-Wide Examination Standards

by Brian L. Grant, MD

We at MCN speak about quality in examination and review services and hear similar speech from others including competitors. The term “quality” is but a homily or empty rhetoric unless it is defined and clarified. We also believe that some may have been led astray when they allow quality to be defined along standards that lose sight of the inherent values of the medical profession. We believe that adherence to quality standards is neither negotiable nor fluid or subject to market forces. From time to time we observe within our company or learn from other quarters certain practices that we can’t endorse and ought not be endorsed or practiced by others. By raising the matter publicly we call attention to standards that should be expected by clients who order review services, by doctors who perform them, and by companies that facilitate them.

The below memo was sent to MCN consultants. We share them with you and invite you to pass them on. Or if readers have additional standards or take issue with any we have raised, we would enjoy hearing from you:

December 6, 2011

To: MCN Consultants

From: Mark Doyne MD and Brian Grant MD, Medical Directors

Regarding: Examination conduct, standards and physician demeanor

As medical directors for MCN, we review complaints that periodically arrive from claimants regarding their examinations. Every one of these is reviewed individually and each physician is given the opportunity to respond. We are passionate about the integrity of MCN examinations and expect that all MCN consultants share our values and practice accordingly. Given the nature of our work, a complaint should be reviewed in the context of the nature of the issues raised, including the possibility of there being other motivations for a given complaint among other factors. We do not take complaints at face value at all times. We review the specifics and may conclude that a complaint may lack merit. Sometimes we may choose to investigate with a call to the claimant and review the consultant’s response to the complaint. Other times we have chosen to briefly survey other claimants who have been evaluated by the consultant via phone calls to them and an audit of the corresponding reports.

Certain types of problems, when representing a pattern, will and have resulted in termination of a consulting relationship with the company for specific consultants. We believe that adherence to appropriate standards should be inherent in the profession and are obvious requirements to perform quality reports. As such, they may be beyond the scope of MCN or others to teach, and when basic standards are not adhered to, this is a serious matter.

We expect consultants performing medical reviews, whether for MCN or others, clients requesting such examinations, and competing companies to adhere to basic standards of conduct and practice.

Some of the points below have been conveyed in past memos. We are restating them as a reminder, and for the benefit of new consultants. We call upon the industry, including clients, physician consultants and MCN’s competitors, to enforce adherence to these standards, embracing them in intent and practice. We also welcome your comments and additional ideas.

Our standards (as expected of all who perform medical reviews) include but are not limited to the following:

Sufficient Time Must Be Spent with Claimants. We expect that the consultant devote sufficient time for a thorough review of records, history and physical or mental status assessment of the claimant. It is NOT appropriate to book exams in increments of less than thirty minutes. We have heard stories of companies in certain regions of the country where four to six or more exams scheduled per hour are not uncommon. Some consultants find it of benefit to review the records in the presence of the claimant. If time has been spent away from the claimant reviewing the records, however, it might be a good idea to share this fact and show those records to the claimant. Actual face time with claimants should be sufficient to perform an appropriate history and examination without creating a perception by the claimant of being rushed. It is impossible to perform a thorough history and physical of a typical injury claim in less than thirty minutes and often more time is required.

Reports Must Be of Sufficient Length. A report should be several pages or more in length, have sufficient depth to answer the questions of the client, and reflect a thoughtful, individual review of the specific case. There should be documentation of what has been reviewed. We remind you that it is not necessary to extensively quote records that have been reviewed. Some consultants issue reviews that are unnecessarily long. It should generally suffice to state the nature of the record, date, person who generated it, and a brief reference to the conclusions. The goal is to be certain that you have reviewed the document and considered it in your conclusions. If need be, one can refer to the original document at a later date.

Each Case Must Be Evaluated on Its Individual Merit with Every Examination a Unique Event. Other than a preliminary disclosure paragraph used at times, MCN does not employ any standard language in reports. We expect that consultants likewise will individualize each report in their own words. Held to the light, no two reports should ever appear the same or close to the same. Clinical boilerplate is not permitted for MCN examinations. Normal findings, if conveyed numerically, should reflect normal range and not a standard value.

Report Findings Must Be Objective and Evidence-Based. Our clients want quality, objective reports, regardless of claim impact. They want reports that are based upon data, not merely a claimant’s self-report. They use IMEs and medical reviews because they want incisive and critical medical thinking. If they wanted a report to repeat the claims of the claimant in the absence of data, they would have no need to spend the time and resources to ask for an IME and would merely accept what the claimant says. The reader of the report (more often than not a non-clinical individual) should be able to understand the reasoning behind the conclusions.

 Consultants Must “Stay in the Box.”  This means answering each question you are asked, not answering questions you are not asked, and staying within your area of clinical expertise. These are simple concepts, but too often not honored.

Reports Must Be Issued in a Timely Manner. A good examination ceases to be good if the consultant is late on initial report submission, signatures, clarifications, and other actions that delay report issuance. Our clients are often working under time constraints. Delays rarely add value and quality may be diminished with the passage of time as specific details can fade. We rely upon consultants being timely to meet our mutual commitments.

Claimants Must Be Shown Respect During all Interactions. Remember that some claimants are nervous, apprehensive, and often unsophisticated when they report for an examination. They deserve a response to questions and an explanation of procedures as well as appropriate respect for modesty and personal boundaries. Curtness, over-familiarity, and criticism of the claimant or their treating physicians are all to be avoided. Demonstrate respect for claimants as you would want your own friends or family members to be shown respect if they were to be sent for an examination. And write a report that you would respect if issued by a colleague.

Treatment Is Never Offered During an Independent Medical Evaluation. Never offer treatment or comment on current or past treating doctors: Please remember that your credibility depends on being regarded as neutral, objective, and not vested clinically. From time to time a claimant may request that a reviewing doctor assume treatment, and there have been situations when a reviewing doctor has offered his/her own services or even issued a prescription. Offering any sort of treatment, however, should never occur. If there is an urgent medical matter observed during an evaluation, stabilization and referral to an appropriate physician or emergency facility should be undertaken.

Testing Should Only Be Performed as Necessary. Additional diagnostic testing should be only performed when necessary to answer questions posed to the examiner.  In many cases testing must be authorized by MCN or the client. In our experience the need for additional testing is relatively infrequent because numerous diagnostic tests have typically been performed prior to the IME, with the results readily available in the medical records.

We are proud of our work at MCN. We have been in the business of performing medical judgment services for almost twenty-seven years and strongly believe in the value of our services to society and the integrity of the company and our consultants. We call upon all involved in requesting and providing such services to adapt and enforce standards that reflect the best of medicine and respect for the dignity of claimants.

Thank you for your support and quality consultations. If you have any questions or comments, feel free to contact Brian Grant at bgrant@mcn.com or 206.447.3449. Mark Doyne may be reached at mdoyne@mcn.com or by phone at 214.762.0784.

OxyContin: the strange saga of Purdue and its $3 billion drug

“Their chemical composition is such that the U.S. is just a few carbon molecules from being a nation of heroin addicts.”

That’s a pretty harsh quote from this recent article from CNN. And it’s just the start in this latest entry about the U. S. and our dependence on prescription pain killers. Some facts to back up this assertion:

  • 254 million prescriptions for opioids were filled in the U.S. in 2010, according to Wall Street analysts Cowen & Co.
  • Enough painkillers were prescribed in 2010 to “medicate every American adult around the clock for a month,” the federal Centers for Disease Control reported on Nov. 1.
  • It estimated that “non-medical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct health care costs.”
  • Opioids generated $11 billion in revenues for pharmaceutical companies, says market research firm Frost & Sullivan.
  • 15,000 Americans died of opioid overdoses in 2008
  • Two decades ago opioid sales were a small fraction of today’s figures, as such drugs were reserved for the worst cancer pain.

Why this recent spate of attention on Purdue Pharma, the makers of OxyContin? Last year they began selling a reformulated version that should help reduce the worst form of abuse. The original drug had a time-release mechanism that could be defeated by crushing the pill and snorting it, smoking it, or adding water to the powder and injecting it for a heroin-like high. By contrast, the new version breaks into chunks rather than a powder; if water is added, the result is a gelatinous goop. But at the same time, taking that step lifts a stigma from the drug and may make doctors more comfortable prescribing it, an outcome Purdue is hoping for. The result could be an even greater number of invisible addicts. Read more…

Apple juice can pose a health risk — from calories

This article on the dangers of apple juice should pose no surprise to anyone who understands the nature of weight gain. But it flies in the face of “common wisdom” that holds that if it is natural, it is good. Many schools have substituted fruit juices for carbonated sodas in vending machines. If the calories are the same or higher, the only change is that those who now put in their money are believing that they are engaging in healthful behavior by drinking juice. At least before they may have known that they were buying a high caloric sugary indulgence.

Once again, this article underscores the laws of thermodynamics as they pertain to weight: If you take in more calories from food, regardless of the kind of food, regardless of it being natural, organic, or highly processed, the person ingesting it gains weight. If one consumes fewer calories than one expends, again regardless of the source of such calories, one loses weight. Making a virtue out of the nature of food consumed does far less to address obesity related health issues than addressing quantity. Read more…