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The Practice of Medicine

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.

Hospital Billing Varies Wildly, Government Data Shows

As this New York Times article details, data being released for the first time by the government on Wednesday shows that hospitals charge Medicare wildly differing amounts — sometimes 10 to 20 times what Medicare typically reimburses — for the same procedure, raising questions about how hospitals determine prices and why they differ so widely.

The data for 3,300 hospitals, released by the federal Center for Medicare and Medicaid Services, shows wide variations not only regionally but among hospitals in the same area or city. For instance, in Saint Augustine, Fla., one hospital typically billed nearly $40,000 to remove a gallbladder using minimally invasive surgery, while one in Orange Park, Fla., charged $91,000. A hospital in Livingston, N.J., charged $70,712 on average to implant a pacemaker, while a hospital in nearby Rahway, N.J., charged $101,945.

Hospitals submitted bills to Medicare that were, on average, about three to five times what the agency typically pays to treat a condition, an analysis of the data by The New York Times indicates. And variations between what hospitals charge may be even greater.

The data covers bills submitted from virtually every hospital in the country in 2011 for the 100 most common treatments and procedures performed in hospitals. Medicare does not actually pay the amount a hospital charges but instead uses a system of standardized payments to reimburse hospitals for treating specific conditions.

Private insurers do not pay the full charge either, but negotiate payments with hospitals for specific treatments. Since many patients are covered by Medicare or have private insurance, they are not directly affected by what hospitals charge.

Experts say it is likely that the people who can afford it least — those with little or no insurance — are getting hit with extremely high hospitals bills that may bear little connection to the cost of treatment.

Read more…

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 Compassionate Surgeon & Friend

David Hanscom, MD, is a long-time friend, colleague, and neighbor in Seattle. He is also a noted orthopaedic spine surgeon.

David has a personal story about his own experience with chronic pain and recovering from it. He has dedicated his professional life to understanding chronic pain in a holistic fashion.

He is a surgeon who is judicious and very conservative, especially when it comes to addressing pain.

His personal website outlines his own methodology and is highly recommended.

We invite our readers to visit his website and read his book:

www.drdavidhanscom.com

Back in Control: A Spin Surgeon’s Roadmap Out of Chronic Pain

Job Prospects for Radiology Graduates in Decline

A recent MCNTalk article describes changing perceptions and beliefs by U.S. doctors.

This New York Times posting “Job Prospects are Dimming for Radiology Trainees,” describes major disruption in the field of radiology – once one of the most coveted specialties from a compensation and lifestyle standpoint.

Recent radiology graduates with huge medical school debts are having trouble finding work, let alone the $400,000-and-up dream jobs that beckoned as they signed on for five to seven years of relatively low-paid labor as trainees….

“The times of graduating from medical school and driving a Porsche are done,’ said Dr. Dana Lowenthal, a first-year radiology resident and fourth-generation doctor. “It was never easy, but there was light at the end of the tunnel. This is new territory.” Read More…

A reader may feel a certain disconnect when noting that the 10% decline in average radiologist income still places them in the top echelons of the nation and are double that of primary care doctors. But it would appear, as we are seeing a similar trend with new law school graduates, that the prospects for new radiology trainees are far less promising. And that technology and payer behaviors, especially Medicare, are having a very disruptive impact on the profession.

Many U.S. Doctors Appear Alienated From Their Profession

By Brian L. Grant MD

The AMA News reports that many physicians are reducing their hours treating patients and in some cases, leaving or considering leaving the profession altogether.

Some decreased productivity is a result of being employed rather than independent. Morale in many physicians is said to be suffering. The causes can be debated, but the phenomenon is real.

When I entered the profession in the early ’80s, physicians prided themselves on autonomy and enjoyed a great deal of respect. Little did my colleagues and I know that U.S. healthcare was in the twilight of an era of professional control.

We have shifted to a world where the “system” is under challenge by many factors: runaway costs, massive engagement by market driven businesses in the technology, device, and pharmaceutical industries, consolidation of hospital groups, buying of physician practices and many other forces.

Physicians no longer enjoy, by and large, the sense of control and respect that once was their domain. To a degree we may have brought in on ourselves and there have been some decent trade-offs made by some. For example, work-life balance for many has become more important than professional power and pride.

The large number of women who have entered the profession (48% of current medical school graduates) have encouraged new models for women and men in balancing work and family. But to the degree this means fewer hours worked, it is equivalent to less care being provided per doctor working. (For more information on women in medicine, see http://www.catalyst.org/knowledge/women-medicine.)
In order to address the growing physician shortage, many solutions are being considered. This includes leveraging the talents of other professionals, altered delivery models, encouraging more medical immigration (to the detriment of the countries who have trained professionals only to see them leave), and striving towards new delivery models using technology and innovation.

In the end, medicine as we knew it may be history.

Read more…

The practice changes physicians are planning in 2012

Practice plan Physicians agree
Continue as I am 49.8%
Cut back on hours 22.0%
Retire 13.4%
Relocate to another practice or community 10.9%
Seek nonclinical job in health care 9.9%
Cut back on patients seen 9.6%
Switch to cash/concierge practice 6.8%
Work part time 6.5%
Work locum tenens 6.4%
Seek job outside health care 6.4%
Seek hospital employment 5.6%
Close practice to new patients 4.0%
Other 5.5%

 

Could IBM’s “Watson” Be a Healthcare Game Changer?

When we think of breakthroughs in our healthcare system, we often place our hopes in miracle drugs, cutting-edge research, or new legislation.  But IBM has something entirely different in mind to change the medical playing field.

Using the same supercomputer that competed and beat two Jeopardy champions in 2011, IBM is developing Watson to digest complex information and make medical recommendations more efficiently than humans.

The Atlantic article, “The Robot Will See you Now,” presents a detailed look into the revolutionary machine and how it could be an effective tool in the health care industry.

In order to help train Watson for medical purposes, researchers at the Memorial Sloan-Kettering Cancer Center in New York have been developing fictional cases to demonstrate Watson’s ability to absorb complex cases and “natural language” and make intelligent medical diagnosis.

Unlike any other machine, Watson is able to process up to 60 million pages of text per second, whether the information is in the form of unstructured physician notes or complex medical jargon.  Researchers have also found that the longer Watson is exposed to real cases,  it gets better at figuring out medical problems and ways of treating them. The article states, “Watson even has the ability to convey doubt. When it makes diagnoses and recommends treatments, it usually issues a series of possibilities, each with its own level of confidence attached.”

“Watson fills in for some human limitations,” Kohn told me in an interview. “Studies show that humans are good at taking a relatively limited list of possibilities and using that list, but are far less adept at using huge volumes of information. That’s where Watson shines: taking a huge list of information and winnowing it down.” Read more…

But the notion of having a robot make serious medical recommendations and decisions poses many questions. Just how much can we rely on artificial intelligence and could it replace human doctors?

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.

 

The Challenge with Accountable Care

Noted business professor Clayton Christensen and colleagues discuss the challenge that new health regulations face in the context of physician and patient behaviors that may remain unchanged.

The article, “Christensen, Flier and Vijayaraghavan: The Coming Failure of Accountable Care,”  hints at the major challenge in engaging stakeholders in meaningful change, when custom, economic drivers, and human nature do not reinforce the changes enacted. Perhaps we will end up with a two-tier system, not based upon economics, but based upon compliance and attitude.

The Everett Clinic, as described in the article, has told Medicare patients that they must change to Medicare Advantage – which promotes preventive care and disease management – or seek care elsewhere, in the old fee-for-service model.

The article states that Accountable Care Organizations (ACO’s) are on the hook for patients who don’t comply with recommended treatment or lifestyle changes. In other words, there is a misalignment of interests.

In the old fee-for-service model, hospitals and physicians are paid more for caring for the sick, including those whose problems are of their own making based on lifestyle decisions and avoidance of preventative measures. A system that has one-sided economic sanctions against physicians based upon patient outcomes may induce doctors and even hospitals to deny non-emergent access to certain patients in favor of those who engage in healthier behaviors. The ethics of such care denial have been challenged in this article. Ultimately, the development of ACO’s may limit care access to those who need it the most.

The Rising Need and Cost of Dialysis

The Seattle Times article, “The Dialysis Dilemma: Urgent Need vs. Overtaxed System,” gives an excellent historical account of the development, impact, and moral hazards involved in treatment of kidney failure.

In the early 1960s, dialysis became a long-term treatment option for select few. At $20,000 per patient, the three machines could treat nine patients. But money wasn’t the only issue.

Because of the limited number of machines available, a committee dubbed “The God Committee” or “The Life or Death Committee” was formed to decide who would be treated.

The committee members — a surgeon, a pastor, a lawyer, a banker, a state government official, a labor leader and a “housewife,” plus two physician advisers — were white. All but one were male.

Most patients they picked were well-off, white and male. Patients had to be able to pay for the treatment — $30,000 for three years, about $229,000 in today’s dollars. The committee also considered net worth, number of dependents, education and ‘future potential.’

Patients less than 25 or older than 45 generally weren’t eligible, nor were those with other illnesses.

Though our nation has seen significant progress in treating end-stage kidney disease since the “The Life or Death Committee, ” roughly 600,000 U.S. patients are affected by the disease and the costs are high.

In 2010, for each patient with end-stage renal disease on hemodialysis — the most common dialysis method — Medicare paid $87,561 on average, counting medications and other medical expenses. For those who dialyze at home, it was $66,751 per year, and for those who received a transplant, $32,914. Read more…

This once fatal disease has become survivable with dialysis and transplants. But the costs are high for society and the human lives involved very real.