Improve ACA — so says USA Today

peopletowerKelly Kennedy of USA Today published the story “Finding Consensus on How to Improve the ACA” 2/28/14.

Here is the list:

  1. Pay doctors more
  2. Let the government pay subsidies to families not covered by the employee’s health insurance.
  3. Get rid of fee-for-service payments
  4. Smooth the transition from Medicaid to subsidized health insurance
  5. Transparent pricing

There are obviously some problems with this “consensus”.  To begin with, who is part of the consensus?  And who benefits from the 5 suggestions?  On the face the ideas seem OK but where is overall cost reduction — the real crux of our health care problem?

So, to address each point:

  1. Pay doctors more — if the payment is not tied to reducing health care costs and increasing quality then it is money down the drain.
  2. Covering families — seems simple enough but why should business be exempt from doing what they have traditionally done?  Employer insurance needs to cover the whole family — that’s simple.
  3. Get rid of fee-for-service.  Yes that payment method  is a problem but there must be an incentive for health care providers to provide a high volume of work and an incentive to do quality work.  The simple solution is to pay a health care system (an accountable care organization) to provide care for a large group of people for a yearly fee.  The organization must meet quality and budget constraints as opposed to our current “the sky is the limit” fee model.
  4. Smooth the the transition away from Medicaid.  At this point Medicaid is less expensive than standard indemnity plans — why think about a change?  If the person enters the workforce the employer just pays the cost — simple.  Changing providers is not easy but if quality is uniformly better there would not be such concern.
  5. Transparent pricing.  This is presented to suggest people could decide on what tests and treatments to buy if only they knew the prices — patients have never had the knowledge to make that decision and never will.  The transparency of pricing should be the price for ALL the healthcare a person needs per year.  Market forces may be helpful on the macro level (like for a healthcare system) but there is no free market for healthcare on the micro level — imagine a person being asked  to choose between various methods of treating diabetes or the best way to remove an appendix (the decision is either random or biased by what the very person asking the question tells them).

The U.S. is experiencing something its citizens have not witnessed before:  the transition away from population healthcare decisions being made behind closed doors at insurance companies to those decisions being made in the political arena.  Other countries experience this all the time — just look at newspaper headlines in the UK or France over the past 20 years!

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Choosing a Nursing Home — hard on many levels


If you are choosing a nursing home it means a parent or close relative is not doing well.  It is a time of anxiety and concern.  You think about the fact the average stay in a nursing home is 2 years — bluntly meaning 50% of people who go into a nursing home (ICF) are dead within 2 years.   But, a big question is “which is the right one”?

In years past there were just “nursing homes”.  But, just like a growing tree there are now many branches.   So what are the branches of care in 2014?

  • Family care in the home
  • Family care supplemented with visiting aids and nurses
  • Full time home care (very expensive)
  • Independent living with services (senior apartments)
  • Assisted living — apartment  but with lots of services and meals
  • Residential care facility (RCF) (like assisted living but care includes medical oversight, like with a few nurses)
  • Intermediate care facility (ICF) for people who can not care for themselves.  People who are demented or severely disabled who need 24 hour per day supervision and medical oversight.  There are some reasons for short term stays like severe injuries that take a long time to heal.  But, generally, patients stay there until they die.  The next level is skilled nursing which leads to the concern that ICF is “unskilled” nursing which is not correct.
  • Skilled nursing facility (SNF).  High level of care, nearly like a hospital.  A strong component of therapy with the expectation of improvement and a switch to a lower level of care within a few weeks or few months.  If a patient is a hospital inpatient for at least 3 days they may qualify for 100 days of Medicare payment.
  • In recent years many ICF facilities have chosen to upgraded services to qualify as SNF facilities (at least for some beds) — they still provide long term care but have the option of billing Medicare for those patients who come out of the hospital.  It’s now hard to tell the difference between ICF and SNF in many locations.
  • Rehabilitation Facilities.  Not for long term care and usually paid for by insurance or Medicare.  Qualified patients might need rehab (intensive physical  and occupational therapy) following  joint surgery or following a stroke.  Some long term care facilities are connected to rehab facilities and only offer the long term care if the patient fails to go home after rehab.

Hospice is not a level of care or even home care.  It is medical supervision oriented solely toward comfort and death with dignity.  It is  mainly staffed by nurses plus a supervising physician.  The services are for dying patients.  The average time a person spends under hospice supervision is 2 weeks.  A doctor must certify a life expectancy of less than 6 months to qualify.  Hospice can supervise care in many locations (but not SNF).  Service at home and in the ICF are very common.

In many respects ICF is the last step and often the hardest.  Patients have usually been through several other levels of care and are failing.  Cost is always an issue.  ICF is expensive ($200 -$300 per day) and it is not uncommon to exhaust personal funds and end up requiring State financial assistance (Medicaid).  Because of the expense, patients and families usually see ICF as a last resort.  It is such a difficult step  patients are sometimes hospitalized before the decision to go to ICF is finally made (not good).

OK you need to select an ICF facility.  There are often several choices.  How do you pick one?  What are the main deciding factors:

  • Medicare rating — the higher the better (top is 5 stars)
  • Cost and whether the care center will keep the patient if they do not have money or will run out of money
  • Recommendations from families with relatives in the facility
  • The general appearance of the facility and the smell (smell of urine is a bad sign).
  • The care the facility delivers is vastly more important than the age of the facility or the size of the rooms.   One very highly rated care facility is 40 years old and has rooms holding 3 people each!

The facility needs to answer questions before choosing that facility.  Some questions are intended to set expectations.  Some questions are intended to find issues that might make the facility unacceptable.

  • What is the Medicare quality rating? (avoid less than 3 stars)
  • What is the price per day and what are the options?
  • What expenses are not covered by the room rate?
  • How is pharmacy involved with medications?
  • Can mail-order medications be used in the facility?
  • What are the findings from State inspections for the past 3 years?
  • What is the process to be admitted?  What is required?
  • What is the ratio of care givers (RN, LPN and CNA) per patient — during the day, at night and on weekends.  1 RN + 1LPN + 1 CNA per every 10 patients is good.
  • What is the waiting time for a bed?
  • Is there a house doctor, nurse practitioner or physician assistant that rounds regularly?  (under contract with the facility to make rounds — very nice service)
  • Can an outside primary care doctor also write orders?
  • How does the facility deal with a “do not resuscitate” order?
  • How often can a family call and obtain up to date information?
  • If a doctor or assistant rounds will the care center nurse inform the family of the recommendations?
  • What is the general daily schedule?
  • Is exercise & mental stimulation included every day?
  • What is the menu and how is it rotated
  • Are the rooms treated as just bedrooms or as the place where patients spend the day (the former is better)
  • What is the expectation for frequency of nursing checks at night (in order to prevent falls a check every 15 to 30 minutes is good)
  • How does the facility prevent loss of glasses or hearing aids?
  • Can special meals be served.  Is there a way to limit salt in the diet?
  • What is the average length of employment for staff (5 years is good)
  • Are SNF beds available in case of a short-term problem (like recovery from hospitalization)
  • What is the ratio of private pay to Medicaid pay patients.  (a ratio of 3 to 1 is OK but a care facility with all Medicaid operates with less money and less staff.
  • Does the staff have special training for dementia care?
  • What is the expense for oxygen therapy?
  • Can family bring food for the patient?
  • What are the statistics for falls in the facility for the past few years?  (falls are often a reflection of infrequent patient checks — checks that lead to helping the patient go to the bathroom)
  • Is there a psychiatrist that can assist the other doctors with adjustment of medications for agitation and depression?
  • What sort of alarm systems are present should a patient walk out a door?  (important for demented patients).

It is interesting to note that older care facilities often have better quality ratings than new facilities.   Older facilities can’t suddenly be new so they may opt to  meet strict quality measures.  It differentiates the facilities that otherwise might be squeezed out of the market.  But, any facility that has failed to make renovations over time suggests poor management or excessive profit taking.

Many people have selected nursing homes for loved ones.  Your comments would be appreciated.   Any other questions you think are important?

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Dermatology — prices that get under your skin


Elisabeth Rosenthal reported “Patients’ Costs Skyrocket; Specialists’ Incomes Soar” in the New York Times today 1/19/19.  She particularly targets one of the most popular specialties for US trained physicians, dermatology.  Good hours, great pay, and compared to other specialties, easy to learn.

A highly trained thoracic surgeon can only do 2 bypass surgeries per day but a dermatologist can to 20 lesion removals per day and make almost as much money.   Patients choose to go to a dermatologist when most primary care doctors can just as easily solve the problem at a fraction of the cost (like benign skin lesions, sun related pre-cancers, and acne).  And, when infection sets in on the weekend the dermatologist’s answering machine says to  go to the emergency room ($300 co-pay).

She describes a situation where a woman had a facial skin cancer removed at a cost of $26,014.   The astounding cost was the result of a dermatologist removing a lesion and then being unable or unwilling to close the wound — but still billing for the procedure.  And, the patient also received bills from the doctors that actually fixed the problem (perhaps they should have billed the dermatologist).  Sadly, a bad system is more profitable than a good system.

It is easy to see why the patient and Ms. Rosenthal believe there is a problem with US healthcare.   Because, THERE IS A PROBLEM!

Rather than complain about the problem, what is the solution?  It is not rocket science.  The dermatologist, surgeon, operating room personnel and anesthesologist all need to be employed by an accountable care organization (ACO)– that way there is just one predetermined fee for taking care of the whole patient for a year.  If the system does the work correctly they make some money, if they goof-it-up (as in this case) they lose money.   The incentive should be to do good and efficient work.  Not to make money by making mistakes.

This solution is extremely easy yet extremely unpopular with hospitals, surgeons, anesthesiologists, pathologists, radiologists, ophthalmologists and dermatologists.  The reasons are obvious — they make less money and must follow quality guidelines.  Given the low quality and extreme  high cost of US healthcare is that really a problem?  A few more articles by Ms. Rosenthal and a few thousand letters to congress might help.  Sadly, one industry lobbyist equals one journalist in this battle.

By the way, the lesion at the top is a benign seborrheic keratosis — harmless, but gladly removed by dermatologists ($250).

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Generic Medications — where to get them

genericpillGeneric medications are supposed to be inexpensive!  But, not if you are facing price gouging.  Your favorite chain pharmacy may rip your wallet out and empty it.

The PBS NewsHour reported on 12/23/13 an astounding survey   — they found a generic medication for breast cancer (letrozole) ranged in price from $9 to $400 dollars for a 30 day supply.  Even more surprising the company that charged $400 dollars agreed to match the $9 price at a competitor.

Not only do pharmacies price gouge so do insurance companies.  Almost uniformly insurance drug plans add $20 to every generic prescription.  So a typical $10 generic prescription without insurance involvement will cost you a copay of $30 with insurance.  And, do you think the pharmacist will suggest you avoid using insurance — not usually, since the $20 copay is for them!

What should you do?

  • Shop around — check prices at several pharmacies
  • ASK if there is any program the pharmacy has to lower that price (sometimes if you get a shoppers card you get better prices)
  • You don’t need a membership to get prescriptions from Costco.  Consumer Reports rated them as having the best generic prices.
  • Here is a great place to check prices:  (and they will print coupons for free!)
  • You can get mail order generics here with free shipping.  Usually their prices are good:
  • Don’t involve your insurance plan if it costs you more out of pocket than just outright paying for the prescription.
  • Insurance plans often limit the prescription to 30 days (with a copay every time).  Getting your prescription in 90 day amounts saves trips to the pharmacy and often improves the discount.
  • Pharmaceutical companies often make a long-acting medication just before the patent runs out on the short-acting form.  Ask your doctor if the long-acting medication is absolutely needed.  Sometimes taking a medication twice a day at a generic price is much less expensive than once a day at a brand name price.

The price gouging is astounding.  Patients often think a pharmacy just adds a small amount to the wholesale price.  Not so.  They often set the price at some percentage less that the brand name — hugely more profitable for them and devastating for consumers.

The price gouging makes you understand better why the UK and other countries have legislated a solution — they negotiate a country-wide price for each generic medication and allow only a few dollars to be charged as a dispensing fee.  The US has a long way to go to protect consumers and reduce health care costs.

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Dangers for Removing Fibroids – the morcelator

morcelatorJennifer Levits reported in the Wall Street Journal 12/18/13 “Doctors Eye Cancer Risk in Uterine Procedure“.  She recounted the story of Dr. Amy Reed who had a hysterectomy.  The uterus contained fibroids and the fibroids contained cancer.  The procedure was done with an instrument, the morcelator.  In kitchen terms it is a combination blender and vacuum cleaner.  It is used during laproscopic surgery to chop up things (like a uterus with fibroids) and remove them through a small incision in the abdomen.

The problem is the morcelator does not remove all the tissue.  A few cells escape the vacuum and they are left behind in the abdomen.  If those cells contain cancer the cancer is then planted in the abdomen later to grow and likely kill the patient.  Dr. Reed developed the seeding of cancer and claims other procedures would be better.  Traditional surgery removes the uterus and fibroids intact with less chance of spreading any unsuspected cancer.

Here is what the package insert that comes with the morcelator says:

CAUTION: … use of the …  Morcellator may lead to dissemination of malignant tissue.

So what are the statistics?

  • 20% – 40% of women will develop fibroids
  • 1 in 1000 cases of fibroids contain cancer
  • intact removal of fibroids with malignancy failed to stop the malignancy 19% of the time
  • morcelator removal of fibroids with malignancy failed to stop the malignancy 44% of the time

The big question is:  should a morcelator be used if a woman has fibroids because it may double the risk of spreading an unsuspected cancer?

The simple answer is NO, because there are other surgical options.  But, will women accept that answer?  The laprosocopic procedure has less pain and quicker recovery, so the answer turns out not to be so simple.  There are many forces at work on the decision to continue to use the morcelator.   The analysis of these forces is called force-field analysis which was originally described by social scientist Kurt Lewin in the 1940′s.     The following is such an analysis (the rating of force vectors is by the author of this blog):

Morcelator Analysis

So, what will happen?  It seems at this point the morcelator will continue to be used.  But, the risk remains.  Law suits will continue.  Perhaps a safer device will be developed.  Perhaps a high risk of litigation will be perceived by gynecologists and the malpractice insurance companies as  being too great.  Such risk will lower the forces from doctors and perhaps tip the balance.  Time will tell.

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Legal Loopholes — patient bankruptcy



Again, Steven Brill of Time Magazine twists the knife in the hospital chargemaster with his article “Bungling the Easy Stuff” published 12/16/13.   Uninsured patients continue to suffer hospital price gouging and personal bankruptcy  even though legislative relief was passed years ago when the Affordable Care Act was enacted.

Mr. Brill explains that the ACA prevents hospitals from collecting fees based on the chargemaster (the discredited fee schedule of astronomic charges).  But, because no rules were published in the Federal Register no legal help is available to victims of the practice.

How could this happen?  Because the work to implement the rules to prevent overcharging did not seem worth the effort, after all, in 2014 everybody will have insurance!  Sadly, during the 4 years up to the time when everybody supposedly will have insurance legal enforcement was sidelined.

Although Mr. Brill piles blame on the Obama administration one must also blame those in congress who pass bill after bill to try to stop the ACA — this is unbelievable — one side not implementing the law and the other side trying to kill the law both without regard to the finances of the vulnerable uninsured while hospitals ignore the will of congress and continue an unethical practice.

Mr. Brill has been hammering on the problems of the chargemaster.  It’s time to listen and help your fellow citizens — hospital boards need to stop the practice immediately.  Citizens need to ask hospital board members why they stand for such a cruel and unethical practice?  Perhaps they should give the money back.  However, the current plan is to use the money to buy ads to extol the caring nature of hospitals — that will make us all feel better.

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Freestanding ER — the microhospital


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.

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