Monthly Archives: August 2013

Paying “Dozens of Dollars” for Salt (and water): Early Signs of Cost Shifting in the Affordable Care Act

The cost of medical care in the US is clearly well beyond what it has to be today.  The US leads all industrialized nations in the expenditures per capita for healthcare.  It has been common practice for many years for hospitals to charge a 200-300% markup for inexpensive medicines such as aspirin and tylenol when given to hospitalized patients.  The hospital administrators will tell you (if they actually agree to talk to you beyond “no comment”) that these charges are a way of making up deficits and compensating for costly uninsured patients who are not able to pay their bills.  Private insurers and more affluent individuals are often stuck with paying excessive prices for medicines and medical devices when hospitalized in order to help improve the hospital system’s profit margin and bolster its funds for routine operating expenses.  In addition, there is no standard–costs for identical products and services vary widely in the US from city to city and from institution to institution.  Much of these costs are determined by complex third party contract negotiations and are incredibly difficult to track down and deceifer.  Moreover, interpreting a patient bill for a hospitalization (or even an Emergency Room visit) sometimes requires a degree in forensics.

Today in the New York Times, columnist Nina Bernstein explores the inflated cost of a simple bag of intravenous saline–one of the most common therapies used in hospitals and Emergency Rooms–and how it varies from patient to patient and hospital to hospital.  As Ms Bernstein points out, the cost to manufacture, ship and deliver a bag of saline for medical use is approximately $1.  However, many patients are charged more than 1000 times that amount for the administration of a bag of salt water.  How does this happen?  More importantly why?

In the US today, the medical industry and those that supply medicines, devices and other healthcare products are first and foremost in existence for one reason–to make a profit.  The Affordable Care Act (ACA) is designed to save the US healthcare system money through prevention.  However, for-profit companies who supply medical devices and supplies are naturally still going to work hard to generate revenue.  As hospital systems merge and providers integrate into mega-groups, they have now begun to negotiate through several “middlemen” to procure medical supplies and devices.  These large (and powerful) purchasing and distributing organizations that negotiate pricing and contracts now are able to set pricing points in large accounts.  As competition in the marketplace begins to dwindle due to these complex and often difficult to interpret contracts, prices will ultimately go up (as dictated by the larger mega group contracts).  At each stage in the supply chain, middlemen will be “taking their cut” through further markups and ultimately further inflating costs.  Now that hospitals may be paid less for inpatient care and in turn may be paying less for expensive devices such as implantable defibrillators, companies (and hospitals) will now shift costs by inflating the price of a bag of salt water.

We must begin to place a true “value” on quality care as well as on medical supplies, devices and equipment.  Standards of cost for common items must be created and limits imposed–it should no longer be a market in which the hospital or hospital supplier dictates a 300% increase in cost of salt water in order to continue to generate profit for shareholders under the new ACA.  In addition, hospital charges and billing practices must be made more transparent to patients, government agencies and the individual consumer.  The services provided and medicines and supplies utilized should be clearly delineated and the charges easy to understand.

The Affordable Care Act was intended to protect the consumer and provide quality care.  Unfortunately, it appears that thus far, the ACA rollout has resulted in numerous delays and missed milestones–many of which were designed to protect the consumer from excess cost.  It is a certainty that the ACA will need to be modified in order to become functional–as modifications are made, we must ensure that we are able to control cost and keep the cost of salt water to less than a good bottle of bordeaux.


Underestimating The Impact of “Waiting for Godot” (and A Doctor’s Call)

In Samuel Beckett’s play, two vagrants pass the time of the day by waiting for another man named Godot–a person that they have never met.  The wait becomes intolerable at times and the men argue, philosophize and even go as far as to contemplate suicide in order to “pass the time.”  It is estimated that Americans spend roughly 37 billion hours waiting in lines each year.  Waiting in lines can have a negative emotional toll–just as in Beckett’s play–as we stand in line, many of us have a nagging sensation that our life is slipping away. Waiting can produce irritability, anger, anxiety, and boredom.

Unfortunately, healthcare is ubiquitous with waiting.  We wait for an appointment, we wait to be called to the exam room, we wait to hear the rattle in the door that signifies the arrival of the physician.  As patients, we all come to accept waiting as part of the ritual of medical care.  (and with the new Affordable Care Act I expect waiting will become even more commonplace).  However, some waits can be intolerable and can negatively affect our psyche–leading to sleeplessness, anxiety and even depression.  One of the biggest challenges facing healthcare providers is the ability to quickly and accurately disseminate tests results and information to patients.  Even in this era of electronic medical records, smartphones, twitter and facebook we still sometimes have to wait for an old fashioned phone call from our doctors.

This week in the New York Times, Dr. Mikkael Sekeres shares his own experience with waiting for news from a physician.   Dr Sekeres, an oncologist, often must return panicked phone calls from patients and families with serious diagnoses.  In his essay, Mikkael describes his emotions while waiting on his doctor to call him about an abnormal cardiac stress test.  As physicians, it is important that we read this piece and are able to understand the healing power of a simple phone call.  As with most things, the experience from the “other side” of the white coat is very different from what we may perceive about the patient experience.  Learning from our own experiences as patients will inevitably make us better caregivers in the end.

Today, physicians and other healthcare providers are asked to do more with less time.  With increasingly grueling inpatient and outpatient schedules, tasks such as returning phone calls often get delegated to others or pushed to the end of the day.  What may seem like a “low priority” activity to a busy physician may very well be a “game-changer” for the patient awaiting the buzz of his or her smartphone.  However, we must remember what is most important to a patient who is left waiting and worrying–information.  Information provides power and gives back control.  When we have information, we can start to make choices and begin to move forward.  Living in limbo is not a party–for many, limbo is purgatory.

Given the mandates for electronic records and e-prescribing, why can’t we come up with a HIPAA compliant way to allow patients immediate access to test results?  This is a very difficult question to ponder.  There is no easy answer.  Doctors are not reimbursed for this type of work and yet physicians must justify every minute of their existence to the “bean counters” that follow them around electronically.  Assistants often answer patient calls for healthcare providers and are often ill-equipped to handle the questions that may arise when providing results or other medical information.  Many patients and practices have systems in place that allow a patient to log on to a secure website and look up results–however, how does the average patient interpret these results?  Will this create even more anxiety and worry?  There is no replacement for the doctor’s call–some situations must be handled by either a face to face visit or a personal phone call.  We must remember to imagine what waiting in purgatory must be like for our patients and make it a priority to provide timely results and information in order to ease their pain.  Even if Godot never shows his face…


Limiting Choices and Destroying Relationships: Early Consequences of the Affordable Care Act

Providing healthcare to all is a noble goal.  Providing choice, however, is an entirely separate issue.  Successful partnerships between doctor and patient are developed over time.  These partnerships do not happen easily and most, just like a long standing marriage, take a great deal of work.  As I have mentioned in previous blogs, when patients are engaged and participate in their care, outcomes are improved.  It is easy to see how costs can be lowered through improved outcomes–the focus is shifted to prevention rather than “salvage”.

Last week in the Wall Street Journal, author Anne Mathews discusses the issues surrounding “choices” in the healthcare marketplaces that begin functioning in October.  Many insurers are making “deals” with hospitals and physicians–they will be included in their plans as preferred providers if they are willing to settle for pre-negotiated lower reimbursement rates.  Many major healthcare systems such as UCLA in California, Rush and Northwestern in Chicago and Vanderbilt in Tennessee are being excluded as preferred providers in many plans due to the fact that they are unwilling to accept the terms dictated by the insurers.   These institutions,  and many others like them,  employ many of medicine’s leaders in patient care and research.  Many patients have developed long standing relationships with physicians at these institutions and are now forced to make a “choice”—either continue with their preferred provider at an increased out  of pocket cost or change physicians and start over in their new healthcare plan.

Starting over with a new physician is a lot like divorce.  Divorce is not easy–it is fraught with uncertainty and can be emotionally painful.  It is difficult to face change when so much time has been invested in building a productive doctor-patient relationship.  However, with the pending implementation of the Affordable Care Act (ACA), patients are now being forced to choose between a doctor they trust and lower insurance premiums.  Physicians and hospital systems are being forced to accept payments at whatever level the insurers choose to dictate–irrespective of the cost of the procedure or the staffing and overhead incurred.  Once again, the reform of healthcare in the US is doing little to assist the patients who need help the most.  Instead of working to build relationships, streamline care and focus on prevention, the ACA is forcing “divorce” proceedings on many doctors and their patients.  Moreover, the “choice” that is supposedly supplied by the pending healthcare exchange marketplaces will be severely limited when they open in October.  The government cites a lack of time to prepare for the healthcare law rollout–Others cite a poorly thought out, complicated and unworkable plan.  More than a dozen ACA “deadlines” have already been missed and there will certainly be more to come.

No one argues that the current healthcare system in the US is on life support and badly in need of reform.  However, the current ACA plan is not the answer.  Based on the basic tenet of coverage for all at affordable prices, the ACA is not living up to its billing.  Now, as the law begins its rollout process, many of the finest academic medical institutions in the country are not going to be accessible to many Americans due to contractual issues with the insurance industry.  Ultimately this will create more of a medical care divide in the US.  Academic teaching hospitals provide cutting edge care and access to new potentially life saving technologies before these are available in the mainstream.  Those with rare diseases or those with disease processes that have failed other treatments often turn to academic institutions such as Vanderbilt, UCLA and Rush for experimental therapies that may provide hope for a cure.  Now, as long as the healthcare exchange plans are able to dictate which physicians and institutions are included in their respective plan, only the wealthy and privately (non government exchange or marketplace) insured will be able to have an opportunity to participate in ground breaking and potentially life saving clinical trials.  Ultimately patients will suffer.  Ultimately human beings will be denied potential life saving therapy–all because of limited choice and the coverage “assigned” by insurance companies hoping to limit cost–but at what price?


Healthcare Law Rollout “Delays”: Primum Non Nocere

Recently, President Obama’s healthcare law has been met with more challenges and “delays” than when it was rapidly pushed through Congress during his first term.  Many critics of the legislation argued that the rush to produce a product (predictably in time for the re-election campaign) would result in poorly thought out, overly-complex law that would be nearly impossible to understand and implement.  Four years ago, there was insufficient infrastructure at both the Federal and State levels to roll out such a piece of legislation–not surprisingly, things are no different today.  Rather than focusing on preparing for the implementation of sweeping reform, court battles have been fought, billions of tax dollars spent and complex decisions have been rendered by the Supreme Court.

Now, we are beginning to see that many of these critic’s concerns were in fact quite valid.  A few weeks ago, it was announced that the Obama administration would “delay” until 2015 the mandate that business provide healthcare insurance or pay a fine.  As I recall, this was one of the cornerstones of the healthcare law–statements from the White House indicate that it was “delayed” because there was insufficient infrastructure to provide more than one choice of insurance in the October premier of the Healthcare marketplace–the law promised multiple choices for small businesses. (surprised? C’mon,not really)

Today, the New York Times reported that yet another provision in the healthcare law is going to be “delayed” due to the fact that those that must comply need “more time”.  Interestingly, this provision was another one of Obama’s cornerstone promises–there will be limits set for individual out of pocket expenses.  Today, buried deep within other unrelated legislation, it was discovered that this particular consumer protection provision has been “delayed” until 2015 due to the fact that the poor, over-burdened insurance companies need “more time” to work on readying their computer systems to handle these particular co-pay limits.  (yea, right).  In my experience, insurance companies seem to be able to deny claims and disapprove treatments, drugs and procedures for my patients at an alarmingly quick pace.  It’s all a matter of priorities I guess.

What’s my take on all of this?  It’s the patient (or potential patient) that ultimately suffers….

The government and the healthcare law is playing favorites.  The law was supposedly passed in order to protect the individual American from escalating healthcare costs.  The law was created to provide affordable, sustainable healthcare to every American citizen.  The law was created in order to ensure quality care and contain costs.  All of these goals are extremely important and certainly worthy of our nation’s leaders time, resources and focus.  However, as is often the case in politics, much of this law is about partisan politics, re-election aspirations, campaign support and legacy. Forgotten in the midst of all of the debate is the patient.  The patient is the reason healthcare exists in the first place.  The patient is the reason most physicians and other healthcare providers go to work early each day.  In the latest “delay” in the healthcare law, consumers (and hence, the patient) will now have no protection from insurance company charges and co-pays.  By allowing the out of pocket limits to go unenforced, the Obama administration and Congress are effectively providing the insurance companies with a license to charge as much as they can–make as much profit as they can–until the legislated limits are actually enforced.  Many potential patients may not seek care because of the burden of cost.  Many of these patients will suffer with devastating but curable disease.  Many will die.

That’s capitalism right?  But should it be allowed to function at the expense of human lives?

For too long, the debate over healthcare costs and reform has centered around physicians, physician payments and hospital costs.  Isn’t it time we considered holding insurers responsible for years of abuse?–charges to consumers for insurance are far in excess to claims paid.  Most insurance companies that I deal with on behalf of my patients have lots of people trained to “deny” requested medically indicated treatments and procedures.  It is time for government to step up and advocate for the patient.  We must hold all players accountable for healthcare reform–physicians, hospitals, lawyers as well as insurers.  Lets stop playing favorites.  Lets focus on the patient.  Primum non nocere should apply to government, insurance companies, lawyers as well as physicians.  Primum non nocere…Primum non nocere…


Home monitoring to improve health outcomes: Holy grail or Rabbit Hole?

Technology in medicine advances at a rapid pace.  In the US today most patients have access to mobile phones, smartphones and tablets.  Medical device makers continue to innovate and create ways in which these technologies can be used by patients and physicians to monitor complex biologic machinery such as implantable cardiac defibrillators (ICDs) and Pacemakers at home–without the need for routine office visits.  These technologies create large masses of DATA.  These home-generated data can be instrumental in managing chronic disease  but can also create logistical as well as legal issues for physicians and their staff.

For the longest time, physicians have relied on patients to bring in a log of their blood pressures or blood sugars from home (often scribbled on a notepad, and often not accurately recorded) in order to determine when medication adjustments are needed.  In patients with congestive heart failure, physicians rely on a log of daily weights in order to make changes in the patients daily diuretic regimen in an effort to prevent hospital admissions for decompensation.  Now, device makers have created insulin pumps and glucometers that can be downloaded to a laptop and the information emailed to the physician for analysis.  ICD makers such as Biotronik actually have created cell phones that interact with the implanted device and transmits regular data to the physician 24 hours a day.

The big question is:  Does home monitoring really make a difference in outcomes and does it impact cost of care?

This week in the Annals of Internal Medicine, an important meta analysis was published evaluating the effectiveness of home monitoring technology on outcomes in patients with high blood pressure.  In the study, 52 different comparative trials were analysed.  Each of these trials evaluated the effectiveness of home monitoring of blood pressure and compared outcomes to patients who received home monitoring plus additional online or in-person support.  The study showed that all patients who had remote home monitoring of blood pressure had lower readings at 6 months but only those with home monitoring plus additional infrastructure and support from their physician’s office had more long term benefits.  Moreover, those patients with the added support experienced a more substantial reduction in blood pressure when compared to standard care or to remote monitoring without additional support.

As reported in the Wall Street Journal this week, the economic impact of home monitoring and data management on physicians and physician practices may be significantly negative.  Currently, physicians are not reimbursed for much of the home monitoring data management (with the exception of ICDs and Pacemakers which are reimbursed by medicare).  Many practices are hiring complete departments of highly skilled nurses and staff to deal with the enormous amount of incoming patient data from remote sources.  The additional staffing required to process and react to home monitoring data creates additional overhead–all in a practice setting where reimbursement continues to decline.  At some point, something has to give.

Don’t get me wrong, I am a huge proponent of the ePatient and of mHealth.  Using technology to help patients manage chronic  illnesses at home is the way medicine will be practiced in the future–and this practice will ultimately improve outcomes.  However, as technology advances, we must also find a way to advance the way in which physicians and their staff are able to process and utilize data in a cost effective and meaningful way for the patient.  If the government intends to successfully overhaul healthcare and institute a fully electronic universal electronic medical record, then some consideration must be given to practice workflow, data management and the costs associated with the challenges that these new frontiers will present.

The Annals of Internal Medicine study is clear–home monitoring and data collection helps patients manage their chronic disease–BUT, the largest benefit is seen when home monitoring is combined with additional support from the patient’s healthcare team.