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The Practice of Medicine

Health Care Costs and Credit Scores

Health care bills are now the largest source of business for collection companies, according to consumer protection agency officials.  The Consumer Financial Protection Bureau has been studying the impact of medical billing on credit scores since 2012.

The problem is accelerating for several reasons. Charges are rising. Insurance policies are requiring more patient outlays in the form of higher deductibles and co-payments. More important, perhaps, is that while doctors’ practices traditionally worked out deals for patients who had trouble paying, today many doctors work for large professionally managed groups and hospital systems whose bills are generated far away, by computer. Examples abound, as exemplified in this editorial, of the complex and confusing system.  Read more…

Chronic Pain: Back in Control

Brian L. Grant, MD
My friend and colleague David Hanscom MD recently appeared on Dr. Oz discussing his experience and research on chronic pain, and the tragedy of operating on basically normal backs, on people in pain. He has published a book that anyone considering back surgery might consider reading first.

Sadly, common sense and good care as represented by Dr. Hanscom does not pay. No expensive back implants are sold, no surgical fees generated and no hospital stays take place. And for those who were not truly injured but underwent the knife for symptoms and not true pathology, they decidedly have an injury afterwards. This is tragic.

Random Acts of Kindness, or Crossing Boundaries?

This interesting column by Abigail Zuger MD, addresses divergent views on patient/professional boundaries. She outlines a challenge but does not answer it: when if ever is it OK to engage in the outside lives of our patients? Perhaps a good way to frame the answer is to be able to ask one’s self as a physician whose interests are being served? If it is truly the patient’s, one may perhaps breathe a sigh of relief and proceed. But how many have the capacity of introspection and self-knowledge to know whose interests are truly being served? And how many physicians’ cloudy thinking about helping their patients by gratifying immediate wishes or needs, are actually mistreating patients by for example, prescribing narcotics inappropriately, thoughtlessly filling out forms endorsing disability or other entitlements upon request, and other actions that cheapen the profession and hurt patients.

Boundary breeches are fraught with hazards. Thus they are generally engaged in by the naive, the scoundrels, or the saints. Sadly, many a scoundrel thinks their actions are that of the saint.

Common Surgery May Not Actually Help

The most common orthopedic procedure in the United States appeared to be no more helpful for some patients than a completely simulated surgery, according to an unusual Finnish study.

The Finnish study does not indicate that surgery never helps; there is consensus that it should be performed in some circumstances, especially for younger patients and for tears from acute sports injuries. But about 80 percent of tears develop from wear and aging, and some researchers believe surgery in those cases should be significantly limited.

Arthroscopic surgery on the meniscus is the most common orthopedic procedure in the United States, performed, the study said, about 700,000 times a year at an estimated cost of $4 billion. Read more…

Spike in Harm to Liver Is Tied to Dietary Aids

This past November we blogged about herbal/dietary supplements and asked, “and is it a problem?” The answer to this question is clearly a resounding “yes.” According to this recent article in The New York Times, dietary supplements now account for nearly 20 percent of drug-related liver injuries that turn up in hospitals, up from just 7 percent a decade ago.

Americans spend an estimated $32 billion on dietary supplements every year, attracted by unproven claims that various pills and powders will help them lose weight, build muscle and fight off everything from colds to chronic illnesses. About half of Americans use dietary supplements, and most of them take more than one product at a time. Read more…

Is There a Doctor Shortage?

The authors of this article argue that technology and change in regulations will effectively address concerns about a looming doctor shortage. Underscoring their assumptions is the novel concept that medicine ought not be immune from innovation at the system and delivery level, in much the same way that other businesses have changed and adapted.

As interesting as the article is, the comments by readers are even more so, both in their content and in the defensive fears that underscore many, accompanied by a cry to preserve the basic status quo while raising reimbursement. The devil of Medicaid is raised by more than one, claiming that treating such patients is simply unaffordable, thus diverting doctors to lucrative concierge practices.

So called mid-level practitioners including PAs (physicians assistants) and nurse practitioners are alternately praised or criticized, based more upon feelings and anecdotes than data.

The basic theme of the naysayers is leave the system alone, increase reimbursement, continue with fee-for-service excesses and basically make an unviable system even worse as a result. The clear lack of consensus based largely upon one’s personal interests or politics underscores virtually every aspect of the health care debate.

Health care in the US is belatedly being thrust into the real world of economics, where those paying get say in what they are willing to buy and willing to spend. This concept is simple in most things, where we open our own wallets. But when it comes to the wallet of employers, fellow citizens and government – those who pay for our healthcare, we have a medical equivalent of  “the tragedy of the commons,” an economics theory by Garrett Hardin, according to which “the depletion of a shared resource by individuals, acting independently and rationally according to each one’s self-interest, despite their understanding that depleting the common resource is contrary to the group’s long-term best interests.”

In this case, we individuals are depleting the shared resource of the health care system by acting in our own self-interests to the detriment of all.

When rules get in the way of treating cancer patients, who is served?

That a professional society would consider expelling a member who treats men is disturbing. There is no suggestion that the doctors in this article are under threat of loss of licensure due to questions of competence or ethical issues. On the contrary, they appear to be exercising their skill and expertise in treating the men in question. Try as I might, I can’t figure out why an esteemed professional board would impose on the practice of medicine. I thought Boards are in place to certify competence in a given specialty, not to tell a trained physician that they may not treat patients and exercise their skills in the service of health?

We should all be concerned about such policies and can imagine all sorts of mischief. Might the psychiatric board see fit to drum out a psychiatrist who sews up a laceration, drawing upon their general medical training? Telling a specialist that they may not treat a man is nonsensical and offensive. Were there a specialty that primarily treats men, punishing members who chose to treat women, there would likely be cries of discrimination and much indignation. Nobody’s interests would appear to be served by this rule. Let’s hope it is changed quickly.

Adventures in Healthcare – a Short Chapter

I opened the mail to find a medical bill for some lab studies on a family member. Total billings from “Laboratory Corporation of America” for 8 line items of services was $568.50. The adjustments by our insurance carrier, United Healthcare, were a total of $495.56, leaving a remaining balance of $72.94 on which the carrier paid $58.35, leaving a balance payable by us of $14.49.

What does this mean to those who don’t spend much time thinking about this? It is quite simple. The lab, a large national company, billed $568.50, the retail price that they decided to charge, which had we lacked insurance, we would have been expected to pay. The discount was 87% of charges, which means that the carrier used some sort of fee schedule, which is acceptable to the lab as a member of their network, to determine what was likely “usual and customary.” I sampled one of the line items that was charged at $219.00, and while my carrier permitted $21.71, the maximum that Medicare would permit was $16.99. So my carrier is generous compared to Medicare, paying about 27% more.

Why does the lab charge so much relative to what they get from carriers? Because they can. They can make up any number they wish, but clearly are thriving and surviving on actual payments that are 15% or less of what they charge. The small number of uninsured or underinsured, those least able to pay, are getting billed six times or more what their insured neighbors or retired relatives on Medicare are expected to pay.

What if the person in the check-out line buying the same basket of groceries was asked to pay 6 times more than the person in the next aisle because of where they work, or because they are younger, older, or for any other reason? Would we stand for this? Why do we permit this?

That the real prices differ from billed is a given in health care. I am accustomed to seeing discounts of 40% or so. But 87% is a new one that reflects, to my view, flagrant behavior that must be called out and must be stopped.

Not What They Seem — But Is It A Problem?

That products (in this case herbal supplements, as discussed in this article) are not as they seem is only a problem if one takes seriously the value of and need for such products. Evidence supported by quality peer-reviewed science as to the value of such supplements is sorely lacking.

A decent balanced diet emphasizing variety of food and moderate quantities is more than sufficient to meet nutritional needs. To avoid adulterated supplements, it is most effective to avoid supplements, and be healthier and a bit wealthier in the process. The money saved can be put to much better use.

Transporting Drugs Across The Border

No, this is not a story about recreational drug use and the US-Mexican border. As this article in The New York Times highlights, moving pharmaceutical across the US-Canadian — and many other — border(s) is big business. The Canadian International Pharmacy Association, a 10-year-old group, said its members fill prescriptions for one million Americans each year.

Per the Centers for Disease Control, about 2%  of adults — about 5% of the uninsured —said they had bought prescription drugs from other countries. The Food and Drug Administration says on its Web site that “in most circumstances it is illegal to import drugs into the U.S. for personal use” because the agency cannot guarantee they are safe and effective. The government also prohibits “reimportation” of drugs made in the United States because it cannot guarantee the medications were not tampered with or stored improperly.

The agency said it does not track the volume of such imports. However, it “typically does not object” to people buying imported medicine for personal use “under certain circumstances,” the agency said. Often the medications are available in other countries at a fraction of the cost here in the United States, even for those with health care insurance.

Personally, I’ve purchased prescription medications — with no prescription — in Spain, France, and Hungary. (I drew the line at Niger though it would have been interesting to see what the pills actually were. In 1999 in Niamey it was not uncommon in public places to be approached by a man with a foot-tall spinning rack of colorful pills in home packaging balanced on his head that he was eager to sell. None was in any sort of original packaging or had any directions included, much less was the name of the drug stated anywhere. Given the 20% literacy rate and the fact that cheap pink toilet paper for foreigners imported from China was about the only paper available in the country, this was probably reasonable in its way. There were of course dispensairs where you could be treated by a nurse if necessary, and given the country’s 47-year life expectancy at the time finding humor in the system is hardly the point. In Hungary in 2003 I paid $20 cash for a house call and some quite effective anti-nausea pills that lasted me a couple of years; in France in 1985 it was $5 and a couple of jokes at my father’s expense for the blood pressure medication he had forgotten to packet. He was traveling around Europe before settling into Spain for an extended stay and we left the pharmacy with enough medication to last a year.) Aside from the quirky cultural interactions, the situation itself is again a reminder of the ineffectiveness of how health care availability and costs are managed in the United States. The Times article is full of examples of purchasing medications on a regular basis from overseas as the only affordable way for many, including the insured, to manage their health. The title sums it up well: “As Drug Costs Rise, Bending the Law Is One Remedy.”