Archive for category Medical Statistics

Classification of Diseases — ICD-10

ICD10_diagram

The International Classification of Diseases version 10 is called ICD-10.  Here is an example:  S06.5X9A    You can look this up on the CMS web site (ICD-10 Lookup) to find “Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter (that’s bleeding around the brain due to a blow to the head which the provider evaluated for the first time).

So, why is this important to you as a health care consumer?  Because the bills sent to insurance companies use these codes — if the code is wrong then insurance will reject the claim.  By looking up the code you will actually know the technical diagnosis made by your provider — something to add to your DIY medical record especially if it is a critical diagnosis in your situation.

The diagnosis codes are intended to force providers to be very specific about the conditions they treat.  The people who connect diagnosis to outcome find the codes very valuable — which in turn helps consumers know how providers perform.

The codes are not always seen by the consumer — they are transmitted on insurance claim forms.  In fact, insurance companies will refuse to tell you what diagnosis was used to bill services.  But, the codes often find their way into the medical record — as they should.

The ICD-10 code tells the diagnosis.  A companion code called Current Procedural Terminology (CPT code) tells what service was provided (like an office visit, or perhaps a brain surgery).  ICD codes are in the public domain but the CPT codes are produced by the American Medical Association and are copyrighted.

From a purely economic standpoint the CPT codes serve primarily to fractionate the health care market to maximize profit for providers.  It is helpful to know what service is provided but the CPT codes are blighted by meaningless detail.  And, they are hard for the consumer to decode because of the proprietary nature of the codes.  Many feel the CPT codes are part of the cause of high health care cost in the US.  They should be scrapped and replaced with some international standard.

Another site to look up ICD-10 codes:  click here.
The AMA site to look up CPT codes:  click here.

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States with Poor Health Care — the bottom 13

2014overallbystatePoor healthcare exists in the United States and there are 13 states to prove it (*).  The map at the left is from the Commonwealth Fund and it is an aggregate of many measures of healthcare quality.  Mississippi is the worst — perhaps the State should be listed as a 3rd world country!

So just to make the point a little sharper here is the list of States in the bottom quartile and the Governors.

State Governor Party
Alabama Robert Bentley R
Arkansas Asa Hutchinson ** R
Illinois Bruce Rauner** R
Indiana Mike Pence R
Kentucky Steve Beshear D
Louisianna Bobby Jindal R
Mississippi Phil Bryant R
Missouri Jay Nixon D
Ohio John Kasich R
Oklahoma Mary Fallin R
S. Carolina Nikki Haley R
Tennessee Bill Haslam R
W. Virginia Earl Tomblin D

So, how to look at the data?  Do the above States just have a lot of health problems or just ineffective State government.   Sadly, the answer is both.

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*D.C. Radley, D. McCarthy, J.A. Lippa, S.L. Hayes, and C. Schoen, Results from a Scorecard on State Health System Performance, 2014, The Commonwealth Fund, April 2014.

** New Governors just elected for 2015

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5% of Patients, 50% of Cost — where to focus

EmergencySocialThe U.S. spends more than other countries for health care but the outcome is not as good as other countries.  Why?  Many feel it is a failure to respond to the statistic that 5% of patients consume 50% of health care spending.  And, those 5% are often at the bottom of the socioeconomic ladder — either they started at the bottom or drifted to the bottom because of health problems.  See the recent article in Manage Care Magazine.

The health care solutions for the top 95% don’t work for the bottom 5% — because the 5% are not well educated, have unreliable transportation, no phone, smoke cigarettes, and only have part-time jobs.  No matter how much research is done on new drugs and surgical robots if a patient does not have transportation to a health care provider it is money down the drain.

Face the facts:  Sweden spends more money on social services than health care.  The result:  infant mortality rate in Sweden is 1/6 th of the rate in the U.S.   Overall, Sweden spends less on health care and delivers much better results.

Here are the 2009 statistics from the Organization for Economic Cooperation and Development (OECD):

socservice

costperperson

Countries with much higher health care quality (like the UK and France) spend at least twice the amount per person for social service as in the U.S.  The fragmented U.S. healthcare system fails to FOCUS on obvious problems — social service seems to be a lens to sharpen that focus.  It’s easy to see the return on investment for the system when social service provides transportation, navigation through difficult medical situations, health education, home vaccinations, and frequent contacts with pregnant women when needed.  Health care without social service is like building a house without one of the walls — looks great from one side only!

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Choice of Doctors — what is choice worth?

multiple choice

How much extra are you willing to pay to continue to see your current primary care provider?  $100 per visit? $20 per visit, or $2 per visit?  That’s an individual decision.  But, insurance industry  studies show an average person in a health plan would change primary care providers if they had to pay more than $2 extra.

correct answer

This is one of those dichotomies where people rate choice of providers very highly but in practice are not willing to pay more than about $2 to pick one provider over another.  Doctors uniformly place a much higher value on the doctor-patient relationship than patients themselves.

However, to paint the picture with a large brush leaves out details.  Patients who have primary care providers that manage chronic illness like diabetes, asthma or migraine headaches are much more willing to pay higher co-pays to maintain that relationship.  Sometimes the relationship with a specialist is worth more to patients, but not always, because of a prevailing notion specialists are more alike than primary care providers.

The $2 statistic also includes the huge number of people who do not see a health care provider regularly — they just go to a clinic when a problem arises.  In fact, they just want to be seen quickly, the name of the provider is not important.

Over the past 10 years employers have changed insurance carriers on average every 3 years.  A change in insurance often forces people to change providers in order to stay “in-panel” and avoid high out of pocket costs.  Anna Wilde Mathews’ article “Health Plans Limit Choice of Doctors” appeared in the Wall Street Journal today (8/15/13).   She suggests the Affordable Care Act causes patients to change health care providers, an assertion that has no relevance, since that’s how our current system works!   Not to say this is good — in fact, forcing patients with chronic illnesses to change providers borders on unethical business behavior.

Conclusion:  rather than whine about the Affordable Care Act we need reasonable legislation to improve US healthcare, NOT legislation to return to something worse.   Businesses should not have to change health plans so frequently.  We need more large high functioning health plans (like Kaiser Permanente and a few others)  so businesses don’t feel the need to change insurance carriers so patients can keep the health care providers they like.

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U.S. Health Care Report Card — failing grade

age lt 50 cause of death

The above graph is from a recent publication of the Institute of Medicine entitled  “U.S. Health in International Perspective: Shorter Lives, Poorer Health (2013)”.  The graph depicts the causes of death for males less than 50 years old.    Compared to other wealthy countries the U.S. life-expectancy ranks 17th for men and 16th for women  According to the report “The tragedy is not that the U.S. is losing a contest with other countries, but that Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.”  Several causes were cited  including lack of insurance, lack of access to primary care, high poverty rate, poor diet, lack of exercise and use of firearms in acts of violence.

Although the report is blunt enough the bottom line is we have good doctors, good nurses, good medications, good equipment, good hospitals, and good clinics but we have poor management of our health care system.   The equation is:

Good Providers + Bad Management = Bad Health Care

You may ask:  what is health care management?  In a word a “PLAN” or simply coordination of action — we truly do not have a health care system.  We have a variety of types of insurance, government programs and fee for service (i.e. no money no service).  Even the very wealthy get poor health care because of a lack of quality management.   Some States do much better than others.  If Minnesota was a country it would rank near the top.  If Louisiana was a country it would be a third world country ranked near the bottom.

One of the big political concerns is cost.  We pay more for health care than any other country.  One third of our cost is attributed to waste (i.e. paperwork).  When a system is poorly coordinated the cost is high.  So, why would any country spend more money on such a system?

The above report is just another in a long series of bad reports on U.S. health care.  Although the Affordable Care Act (Obama Care) is helpful it will never move life expectancy to the top of the list.

There are lots of solutions.  But, they all require planning and system thinking.  Trying to solve one problem at a time to evolve a better system will take about as long as human evolution.  Perhaps in a million years we will have evolved beyond illness — yes, that’s the plan.

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False Positive — what’s not there can kill you.

An x-ray, biopsy or other medical test can have a number of possible results.  The uninformed patient or the unwary doctor can be fooled by some of the possibilities.  How could a little test hurt you — it’s just a harmless x-ray or small biopsy or just a few drops of blood?  There is some underlying truth about a condition we want to know.  Do we have a problem or not, yes or no, cancer or no cancer, pregnant or not pregnant, AIDS or no AIDS and many other questions.

Most people understand if the weatherman predicts rain tomorrow, but no rain comes, we laugh because we know prediction of weather is not always accurate.  Yet we don’t apply the same common sense to medical tests.  If a test predicts a person has cancer we believe it — the sad fact is medical tests are not always accurate.  A test can predict a condition when none is present which is called a false positive.  A test can predict a condition is absent when it really is present which is called a false negative.  A test can predict a condition which turns out to be correct which is a true positive.

So how can a little test hurt?  If the test is a false positive which leads to surgery which has a complication then a person could die.  This is not just theoretical, it happens.  The problem is made worse by a tendency of health care professionals to over-diagnose disease.  For example, if a pathologist is not certain if a biopsy shows cancer the safe thing to say is “possibly cancer” rather than “I don’t know”.  The surgeon says if it is “possibly cancer” the best thing is to “take it out”.  Later, when the patient is missing some body part and no cancer is found the surgeon says “you were lucky”.  Really?  Perhaps the patient should not have had the test in the first place.

In certain circumstances the chance of getting a false positive is higher than the chance of a true positive.  A good example is finding a small spot on a chest x-ray.  Most spots on chest x-rays are not cancers.  Because of the unreliable nature of the chest  x-ray for cancer screening, routine chest x-rays are not advised.

People who study the statistics of medical testing can figure out which tests have the best chances of true results.  This is important information for patients and doctors.  Recently, the PSA test has come under criticism.  It seems the test has a high rate of false positive results and to make it worse, positive results may lead to unnecessary surgery.  In view of the statistics, experts now do not recommend PSA tests for routine screening for prostate cancer.  Hopefully, this will lead to better tests while the old PSA test heads to the history books.

Another important question is whether the result of a test will change treatment.  If not, then don’t do the test.  For example, surgery in the very elderly is dangerous.  So if no surgery would be recommended for a 100 year old person then don’t do a CT scan of the brain.  Is that mean and uncaring?  No, it is taking care not to do tests that lead to harmful procedures.

So, more information is not always better.  It is smart to avoid tests with a high false positive rate.  National guidelines do exist for many tests so search for them on the Internet and as they say “ask your doctor”.

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