What is a freestanding emergency center? And, is it something good for patients or not? Michael Booth reported on the spread of this concept in Colorado in his article in the Denver Post ”The parent of metro Denver’s Exempla to open four micro-hospitals” (4/14/13). The feature that separates a simple urgent care clinic and a microhospital is the presence of a few patient rooms intended for short term “observation”.
These microhospitals exist to make money. They are not charity operations or an improvement on hospital care or low cost options. Patients with a high deductible insurance plans do think of the cost. And such facilities may be less expensive than a hospital emergency room but more expensive than an urgent care center and much more expensive than a primary care office.
Urgent care clinics are much less expensive than a hospital sponsored emergency room because they are not allowed to charge the “facility fee” — the fee allowed by Medicare and insurance companies to compensate hospitals for special equipment and staff for very sick patients. Any facility that must own expensive diagnostic equipment does shift the cost to all that visit even if they don’t use the equipment. Also, there is the tendency to over-utilize high tech equipment (because it makes money for the clinic).
What about those observation rooms? They are very expensive and usually billed by the hour ($50-$100 per hour) plus a cost for medications that may be astronomical. An observation room is helpful to provide time (at the patients expense) to wait for test results or to see if treatment is working (like for nausea). Generally, if a patient does not have a condition that warrants full hospitalization they should be able to manage at home. There are some social situations that prevent a patient from going home in which case outpatient observation may have a place — but not one that insurance will always cover.
Insurance companies vary in what they will pay for outpatient observation — often they exclude medication costs. If a patient has to take an ambulance ride it is best not to go to a freestanding ER because a second ambulance ride to an actual hospital may be needed. Ambulance transport usually costs between $600 and $2000 — not something to be duplicated.
The notion that microhospitals have providers present 24/7 is of course true. But those providers are ER doctors who have work to do in the emergency area, they work in shifts, and ER doctors are not accustomed to hospital type care — they are not hospitalists or surgeons or specialists as might be found at a true hospital.
People need to have primary care providers. A primary care doctor may see someone with acute illness fairly soon (like the same day). Often that is soon enough and certainly at much lower cost than any outside microhospital. But, if the provider is busy or not available urgent care or microhospital care are substitutes.
Are microhospitals good or bad for patients? They probably have little place in outpatient care. If a patient has a condition that medically requires intravenous medications or oxygen then hospital care is probably better and safer. A lower cost option for some people is care at an urgent care center that does not have all the overhead cost of a hospital facility.
Jen Wieczner published her article “The Pros and Cons of Concierge Medicine” in the Wall Street Journal on November 11, 2013. Concierge medicine doctors are “on retainer” much like some lawyers. They made a certain reputation as doctors for the rich and famous charging $500 dollars a visit on top of a $30,000 per month retainer. The above Cartier watch ($61,000) was just what they needed to take the patient’s pulse.
Ms. Wieczner now informs us the conciergierie has found a new way to tap into wealth, a patient’s insurance deductible. As it turns out, there are a lot more people trying to be frugal with their health care costs than trying to be extravagant. Those frugal masses are trying to avoid the high out-of-pocket costs for medical exams and tests . In essence, the profitable concierge doctor finds a way to provide less expensive, but very personal care for cash (not insurance) in the environment below the deductible level found in that silver insurance plan. And, as P.T. Barnum said, “there’s a sucker born every minute“.
If it were true concierge medicine has some medical skill not provided by most primary care doctors it would be a wonderful development. But, according the article the wonderful services include PSA testing (not needed), routine blood tests (not advised), testosterone tests (leading to unnecessary and dangerous treatment), x-rays (never an advised screening), PAP smears (really only needed every 3 years), CAT scans (lots of false positives that require more testing), and MRI scans of the brain (for no known reason except the irrational fear of dementia). The claim they can do a colonoscopy for $400 dollars is probably true, the same price as in Europe — perhaps mainstream medicine should take note.
The Wall Street Journal is a forum for capitalist ideas. The notion there is profit to be made in this high deductible world is likely true. Competition to provide low cost care is clearly needed. But, that low cost must be coupled with reasonable, evidence based, coordinated, and quality care. The Timex watch might be a better model for US healthcare than the Cartier watch.
I waited a month before before using Connect for Health Colorado because I heard about the insurance exchange website problems. The exchanges started in October. It’s November now so I did it — I purchased health insurance with the exchange. There were a few minor website issues which I will discuss later but, overall it was a vast improvement over what I went through just a year ago. As expected, the price was higher than last year (it’s higher every year, nothing new).
Over the past few years I have had insurance problems. I left my previous employer and their group insurance plan but purchased individual insurance from the same carrier according to COBRA rules — other individual insurance choices were very expensive. After 18 months COBRA came to an end and so did my insurance. Along the way I moved to a different state. So, I had to get new insurance in a new state. I quickly learned insurance companies require payment of the first month premium before they would would consider an application (or tell you a firm price), a definite deterrent to applying for too many alternatives.
I applied to 2 insurance companies and dutifully filled out the 15 page health questionnaire for each. One company, the affiliate of my original insurance company, immediately rejected my application, no questions asked. I suddenly realized I had been designated persona non grata within that national carrier without even knowing it — the possibility of insurance with them had been cancelled. Too old, too many claims, who knows? They advised I contact a state program for people in my situation (increased risk so let the state take the case!)
The other company requested a letter from my doctor and after some anxious weeks they approved my insurance (for which I will always be grateful).
Now, a year later, my new insurance company sent me a letter stating that all their policies were being revised to comply with the new insurance rules. They promised to let me continue as a customer with a new policy but, the current policy was cancelled. Not again!
I fired up my computer and logged on to the insurance exchange. There were four insurance company choices. Each insurance company had a quality rating 1 to 5 stars and a list of prices and benefits. Thankfully, my current insurance company had 5 quality stars and was also the lowest priced. I noticed the original insurance company that gave me the lightning rejection last year now wants my business — sorry big buddy, your application is rejected by me!
The information I had to enter was minimal. The only intrusive information required was whether I smoked (heaven forbid) and my race. But, compared to the questions last year this was a piece of cake. Last year it took me 6 hours to get through all the questions, now the whole process took only an hour. Last year I felt like every question was intended to disqualify me or find some evidence of a preexisting condition. This year the pressure was off.
I added the insurance to my “CART” and checked out. I must pay the first month premium, but not right now. Finally, there was the “DONE” button which was a nice touch.
As I mentioned initially, there are a few website issues. On several pages the prompt to enter information overlaps with the actual information field. One page opens at the bottom not showing missing information at the top — when submit is clicked the site says information is missing — I scroll up and fill in the blanks. Finally, the system has difficulty finding my current provider’s name — only by using “ADVANCED SEARCH” is it successful.
Overall, I am very satisfied with the experience. I suppose people who have not applied for insurance in the past few years will fail to realize what a huge mess we had. Health insurance cost needs to come down — fodder for more blogs!
Elisabeth Rosenthal wrote the lead story for The New York Times today (10/13/13) “The Soaring Cost of a Simple Breath“. This is another blockbuster exposé of drug costs that are crippling US health care. Sadly, not a story about what is being done to correct the problem.
Here are some of her key points:
- The average brand name prescription has risen from 1995 at $40 to 2013 at $170
- The average generic prescription has risen from 1995 at $20 to 2013 at $45.
- A common asthma medication Pulmicort costs $175 in the US but only $20 in the UK and $25 in France.
- Drugs account for 10% of the $2.7 trillion annual health bill.
- Americans take more generic medications than people in other countries (they just can’t afford branded or new medications)
- Other countries set the wholesale price of drugs to make drugs affordable.
- US pharmaceutical companies have used the FDA to restrict manufacturing rules to favor large companies and have used the judicial system to bankrupt competitors.
- US pharmaceutical companies have paid generic companies not to sell their products in the US.
- Medicaid, paid for by taxes, pays millions of dollars to drug companies for high priced medications.
- Asthma medications have been the target of profiteering drug companies. Not a single inhaler is available as a generic. Despite the fact that inhaled medications have been available for over 30 years. The effect on people with this condition is a tremendous burden.
- Drug companies spend about 50% of funds on marketing and only about 20% on drug research. Other advanced countries prohibit marketing prescription medications directly to consumers.
- Medicare is prohibited from negotiating prices.
- Drug prescribing guidelines published by the government are prohibited from considering cost.
Rather than just be angry about the sorry state of drug costs, what can be done? Just take a lesson from other countries, this is not rocket science:
- The US government should set the prices for all drugs
- The FDA needs to loosen the rules for generic manufacturing — for goodness sake, an inhaler is an inhaler, not the space shuttle.
- Comparative effectiveness research should be required, and the results published for doctors as in the UK. Drug cost is important to all US citizens, so restricting the government from considering cost borders on insanity (perhaps giving psychiatric medications to Congress is currently too expensive).
- Finally, there is no excuse for the current drug cost problem — other countries have solved the problem, the US needs to do the same.
The above prescription example comes from Medical School Headquarters intended as an example of what doctors should NOT do — that is to issue handwritten prescriptions. There are just so many possibilities for error mostly coming from illegibility. Also, errors from inadequate information provided to the pharmacist and the patient.
Electronic prescribing is unquestionably the best solution. Patients should choose prescribers who use computer software to send prescriptions to the pharmacy. In fact, prescribers who don’t use computers to do this are dinosaurs soon to be extinct — perhaps it would be a good time to leave that office practice and find something more modern.
You might think electronic prescribing solves all the problems, NOT SO. Just ask any patient taking a few medications on a regular basis! Here is what they say:
- My office appointments never match when prescriptions expire –so I either have to change appointment times or hope the office will renew the prescription early — always involves a phone call and wastes my time.
- I had no idea the doctor prescribed a brand name drug instead of a generic and I got hit with an unnecessary huge bill.
- The doctor has no idea how much medications cost.
- I need 90 day prescriptions for some things and 30 day prescriptions for other things but they can’t get it straight.
- My doctor’s computer system can’t send things to my mail order pharmacy
- I have to send prescriptions to my mail order pharmacy myself — usually they are the handwritten type and sometimes the pharmacy can’t read them.
- If my doctor issues a duplicate prescription so it will last until my next visit sometimes I get more medication (and cost) than I need.
- Often generic medications are less expensive if I purchase them without involving insurance — the pharmacist sure does not tell me that!
Here are some prescription suggestions for PATIENTS:
- ALWAYS take a list of prescriptions with you to health care appointments (or just take the bottles, but there is a risk of loosing expensive medications in the process).
- Your record should include the name of the medication (brand name if appropriate) and generic name
- Dose — that means the size (mg) of the pills and number taken, or amount of liquid (ml) or strength (%) of a cream or ointment
- How often taken and whether scheduled or as needed
- Why the medication is taken
- Number of doses of medication prescribed AND exactly how many days that covers (like 30 day supply)
- When that medication will expire and need refill
- The pharmacy phone number and FAX number (the latter is very important for mail order pharmacies)
- ASK if a new medication is generic and if not if a suitable generic is available. Or, if a suitable generic in the same drug family is available.
- ASK if the medication is short term or long term. If it is long term usually ask for 90 day supply with 3 refills (if insurance will approve). And, use mail order services advised by the insurance company since they are usually less expensive.
- BEFORE leaving the prescribers presence ask if the number of refills on a new prescription will last until next appointment? And, ask for an extension of refills for older prescriptions that will expire before the next scheduled visit (otherwise you get the fun of calling the nurse for refills)
- If a specialist prescribes a medication ASK if the specialist plans on long term follow-up and providing refills — if not what communication with primary care will convey the needed prescription information. But, if the specialist plans on managing the medication expect a full review of all medications to avoid duplicate prescribing and adverse drug interactions.
Here are some prescription suggestions for PRESCRIBERS:
- Consider the cost of medications — you can’t do that if you don’t find out how much they cost, especially the brand name drugs
- Prescribe the lowest cost alternative. Before prescribing a brand name drug ask if you are sure there is a real cost benefit over an older generic. If you don’t know, find out.
- Don’t prescribe antibiotics for viral infections
- Think about refills, don’t just write some arbitrary number. Make sure the patient has enough refills and will not have to call your nurse to get them. Contrary to popular belief patients do not like to go the the pharmacy — give 90 day prescriptions where possible.
- Have a patient Internet portal to deal with medication refill issues.
- Although it’s nice to compute the number of pills a patient will need it is sometimes better for insurance reasons to say the number of days of medication is needed ( 7 days, 90 days etc.)
- To avoid duplicate prescriptions when the patients prescription will not last until the next scheduled visit the following statement is helpful “extend existing active prescription so refills last until ____ ”(e.g. a year from today). Sometimes: “stop refills on current active prescription. This is a replacement so note the changes.”
- Most mail-order pharmacies will take either electronic prescriptions or faxed prescriptions — it is not rocket science to get those numbers into the electronic prescribing system — make it happen.
Finally, sloppy prescribing causes patient injuries, provider law suits, extra time, and extra costs for both the patient and the prescriber. Electronic prescriptions are a step in the right direction but they are now mostly geared for pharmacists and not the real-world problems of patients. The integration of pharmacies within care delivery systems (e.g. an ACO) is an urgent need.
President Obama vs. Republican Congress. Another grudge match, the sweaty pugilists in the corners, puffs of smoke from the cigars in the front row, the referee holding the mike, saying it’s the 8th round, the clang of the bell, the jabs, the left hook, bam – a hard right to the teeth, finally the round ends with a flurry of punches under the belt. We now interrupt the show for an important announcement.
HEALTH CARE IS NOT A CONTEST. We are not in a reality show, this is real life. The consequences are life and death. Why is there an argument or a fight?
The sky-box view. Look down at the basic arguments of the two sides:
- Obama — health care is a right
- Republican congress — health care is not a right
- Both agree — health care costs too much
The punches and counter punches.
Punch: The southern US has poor health care
Counter: Not our problem, don’t fix it with our money
Punch: Insurance companies are unethical
Counter: They are just businesses trying to make a profit
Punch: Primary care is better and more efficient
Counter: The market determines what is better or more efficient
Punch: Everybody should have access to health care
Counter: Only those who have money should have access
Punch: If everybody has insurance the system would be more fair
Counter: Don’t tell me to buy insurance, I will do what I want.
Punch: Raise taxes to pay for the uninsured
Counter: We can’t afford higher taxes
Punch: We already pay enough to provide good health care for everybody
Counter: We don’t want regulations. Some of us get great health care already
Punch: U.S. health care only ranks 30th in the world
Counter: Poverty and old age are the fault of individuals, don’t count them
Punch: We need government oversight of health care quality
Counter: That’s what lawyers are for
Punch: Women need care for female health problems
Counter: What is good enough for men is good enough for women
Punch: The constitution gives the right to life, liberty and the pursuit of happiness. You can’t have any of those things without being healthy.
Counter: The Constitution says nothing about a right to health care.
Punch: All this fighting makes me forget about poor health care quality and high cost
Counter: Me too.