Archive for November, 2013

Freestanding ER — the microhospital

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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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Accountable Care — done the hard way

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Dr. Jeffrey C. Brenner, family doctor, is a 2013 fellow of the MacArthur Foundation.  He was awarded the distinguished position with a simple observation that medicine needs to be industrialized, meaning  standardized and protocolized.  He observed that physicians “try to do it all” when”they should be handing off less complex patients to clinical team members”.

His success was reported by Mary Ellen Schneider “Coalition Brings Health Care To N.J. City’s Neediest” in the October 15, 2013 edition of Internal Medicine News.  His accomplishments in Camden, N.J. are remarkable.

He managed to reduce repeat hospitalizations for patients with very difficult social situations.   Hospitals were loosing Medicare payments due to rehospitalizations so he convinced the hospitals, social services and outpatient doctors to be accountable for outpatients.  In essence, he built an accountable care organization the hard way.  No overarching organization, no mandated cooperation,  just the presence of an idea and protocols.

Could this happen elsewhere?  Probably not since Dr. Brenner does not have a twin brother.   But, he recognized the problem when 90% of hospital cost is due to 20% of patients.  He endeavored to treat that 20% more intently as outpatients with the benefit of hospital financial resources, nurses, social workers, physicians  and organizational know-how.  And, it worked.

Dr. Brenner attributes success to his organization (Camden Coalition of Healthcare Providers) making outpatient treatment more of a team effort guided by hospital data.  Past failure seems to be the lack of system thinking.  Primary care doctors  expect patients to seek outpatient help by walking through the office door.  Patients who do not walk through that door fail to receive medicines or social service help.  And, usually there is no money made by changing the approach.

Industrialization sounds mechanical and uncaring.  But, the approach in Camden was just the opposite.  Procedures, rules, data and delegated care lead to more caring and less illness.   Accountable care organizations have the same incentive and the same goals.  Hopefully, under the name ACO they can do as well as Dr. Brenner elsewhere in America.

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Concierge Medicine — spending your deductable

tank americaine 61k

 

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.

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The Insurance Exchange Worked!

PickACardI 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!

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