Archive for category High Cost of Care

Insurance CEO Paid $66,000,000 — for what?

hatinringThe author of this blog is willing to be the CEO of United Healthcare for a mere $60,000,000 / year.  That would save the insurance company 6 million dollars a year — a real bargain.   So why does United Healthcare need a new CEO?

The Wall Street Journal reported today that United Healthcare (the nations largest healthcare insurer) can’t seem to make enough money with clients who get insurance on the government exchanges.  They feel other insurance companies should have those pesky patients, who cost more for a couple of years, because they did not have insurance before.

United Healthcare (NYSE:UNH) has been having a lackluster financial situation for the past few months, like almost all other stocks — perhaps a little worse.  Reports show the health insurer will lower its earnings-per-share outlook to $6 per share, down from its earlier forecast of $6.25 to $6.35 per share.

Could it be that the 25 cent drop in earnings is due to business on the exchanges? — surely it’s not the fault of the CEO?   But, why take a chance, get a new CEO.  The company could get a new CEO for half the price and even might be able to snag someone with a PhD in economics to help figure out what to do.   Duh — lower the operating costs!

Presidential candidate, Dr. Ben Carson*, says insurance companies should be low-cost non-profit operations simply to process claims.  It makes a lot of sense.  Why is so much profit being extracted from the US healthcare system by insurance companies?  It does not need to be that way.  The companies keep about 20% to 25% of premiums for CEO salary, expenses and profits.  In France, insurance companies are limited to 6%.  Yes, it can be done.

 


 

* This is not a political endorsement, just an observation.

 

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The Emergency Room — high cost of care

ER signPeople go the the ER but often do not get admitted to the hospital.  Why does this happen?  Do they think the problem is an emergency or do they just not have access to other health care?  The CDC presented the following data from 2011:
ER_1 ER_2 ER_3

(note respondents could answer yes to multiple items)

The bottom line:  people who go to the ER but do not get admitted do so because they think the problem is serious, but 80% also say they lack access to other providers.

Social factors often force the ER visit:

  • No primary care provider has been established
  • Primary care does not have enough walk-in capacity
  • In rural communities once the few primary care offices close there is no other alternative
  • Work hours force evening or night care for family members
  • ER is closer than other options
  • ER is more willing to see someone without insurance
  • Patients seek continuity of care once they have been seen at the ER — they return.

A not uncommon scenario is when a single parent picks up a child from day care only to find they are sick but doctor’s offices are closed.  And, the parent is expected back at work early in the morning.

Possible solutions:

  • Encourage urgent care or “community ER” clinics.  In many larger cities doctors or hospitals have opened urgent care clinics — they are not intended to provide continuity of care but just service when needed.  In the UK such clinics are often staffed by nurse practitioners.
  • Assign one provider in a primary care office to walk-in duty — thus increasing the capacity for unscheduled visits and allowing the other providers uninterrupted time to see scheduled patients.
  • Locate some primary care clinics with extended hours next to the ER.  The patients can see a primary care provider at a lower cost — but if the problem really is critical the ER is next door.
  • Use the phone more.  Also, use Skype since it is encrypted and should meet HIPPA guidelines.  Cost would be lower for everyone if health care providers made better use of technology.  Accountable care organizations (with less fee for service incentive) should find the lower cost aspect very attractive.
  • Provide more mobile care.  Some enterprising ambulance services provide service on location and don’t actually transport the patient to the ER.  Unfortunately, the overhead cost is rather high — but the same can be said for the ER in general.  It’s like the guy who comes to your driveway to replace a car windshield.  Instead, you might get a laceration sutured in your kitchen!  Or your child with a sore throat could be checked with a strep-screen.

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Warning: Price could cause ulcers — CMS drug data

purplepillThe purple pill tops the list of the most expensive drugs for government health programs in 2013.  No, your first reaction to blame the government is wrong — the drug is prescribed by health care providers — and, the government is prevented by law from negotiating drug prices.  Why is this a problem? –there was a perfectly fine OTC generic substitute available in 2013 at only 6% of the cost.

WHAT???  Prescribers wrote prescriptions for a drug that could have been substituted by an equivalent drug and saved 94%.  OK, at the margins of the argument, at the fringes of reality, at the level it makes no clinical difference, big pharma says it might not be a perfect substitute.  A good example where the “perfect”  is the enemy of the very good.

But, how could prescribers and patients have the wool pulled over their eyes? — fantastic marketing.  And, by the way, if you take this drug, send me your name, address, social security number, and bank account number,  I have a nice bridge to sell you.brooklinbridge

The magnitude of the problem became crystal clear when CMS published prescription data.  The following data is widely reported from CMS as the spending on drugs through Medicare’s Part D prescription-drug program in 2013:

Rank Brand Name Generic Name Number of Claims Cost in Billions
1 NEXIUM ESOMEPRAZOLE 8,192,362 $2.53
28 OMEPRAZOLE OMEPRAZOLE 32,250,368 $0.64

Omeprazole is a very good substitute for Nexium for heartburn and reflux.  Despite the cloud of industry generated studies many pharmacists say the two drugs have equal effects.  As the table above shows omeprazole was prescribed 4 times as often as Nexium but the providers who chose Nexium created a vastly larger and unnecessary cost.  Why Nexium is even be on the Medicare Part-D formulary is a mystery.  Who pays the bill? — taxpayers, of course, and the patients who paid a co-pay higher than the full cost of an equivalent.

In 2015 Nexium became an over the counter drug (OTC) and just as you might suspect it now costs about the same as OTC omeprazole — about $32 for 56 pills (at Costco) rather than $300.

Where is the oversight?  Where is the cost control?  Why is US healthcare so expensive?  Need more examples? Just look at the other medications on the list.

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Urinary Retention — 1 in 10 men over 70

urologybillboardOne ER visit is a red flag — more ER visits for the same problem become an example of  poor quality health care.

Urinary difficulty is something older men don’t like to talk about.  But, 1 in 10 men over the age of 70 will end up in the emergency room with urinary retention — an uncomfortable situation where they can not pass urine.  Urologists are aware of this frequent problem — see the billboard story.  It is a serious problem;  in third world countries it may be fatal.

The usual cause is enlargement of the prostate preceded by symptoms of slow and frequent urination.   Sometimes there are few symptoms until a painful inability to pass urine forces a rush to the emergency room.

The usual medical approach is to insert a tube (a catheter) into the bladder to relieve the pressure, start a medication to help urination, and 3 days later to remove the catheter.  50% of men can then pass urine adequately (for a while).  The quality issue is that 50% have a recurrence within a week — so is another ER visit the answer?

A friend of this blogger landed in the ER a total of 4 times with urinary retention.  Why is the ER the center of after-hours treatment for this problem — once identified as an issue why is the health care system making it a recurring emergency?

The solution is Urologists need to own the problem and provide adequate patient care 24 hours a day once a catheter is removed.  Yes, own the problem, not turn off the phone and let the ER solve it.  Does that mean the urologist must be at the clinic 24 hours a day?  No, but there must be an arrangement for immediate care — no waiting in the ER, no ER charges, no secondary consultations.  An arrangement with a 24 hour urgent care center may be enough but some back-up plan and patient education are essential.

The majority of men with urinary retention end up having a surgery to ream-out the prostate (TURP).  According to healthcare-salaries.com a suburban US urologist makes $500k to $1M each year.  This is another example of the decoupling of cost and quality caused by involving multiple providers with no common financial risk.

A proactive patient who has a catheter removed should ask the urologist “what is the plan if this does not work?”  and “is there some alternative to the ER since you have already evaluated me?”.  At least find out how to get in touch with the on-call urologist!

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High Medical Cost in Winter Havens — unnecessary testing

mctestswithlegend

Snowbirds:  watch out for high medical costs in Florida, Texas, Arizona and California.  According to Elisabeth Rosenthal in the New York Times 2/1/15 “Patients Find Winter Havens Push Costs Up”.  She points out providers in Florida are the worst offenders — the same place notorious for Medicare fraud!

Ms. Rosenthal highlights one patient from New York wintering in Florida who had a checkup for his pacemaker but did not have any new symptoms.  Many in-office tests were ordered by the substitute cardiologist — tests the patient’s regular cardiologist said were unnecessary.

To be very blunt:  cardiologists, and other providers, who order in-office tests make a lot of money from those tests.  Many studies show providers who profit from tests do more tests than providers who don’t profit from tests.  A medical license is not a license to take advantage of patients or Medicare — profit motivation seems to blind some providers to this distinction.

The lure of profit is made greater by a patient not having any new symptoms, not having any record of previous tests, and not having plans for follow-up visits.  It is like the patient has a sticker pinned on their back:  “TEST ME”.   The choice for the cardiologist is simple: either pay the nurse to spend time getting out-of-town records OR make money by repeating tests.  Make money, right!

Suggestions:

  • If you are on vacation and have a sudden health problem your best bet is an urgent care center.  They can send you to a specialist, if needed.
  • If you have health problems and will be spending several weeks or months away from home:
    • Talk to you primary care provider:  they may want you to call in and give a report on the phone (diabetes is a good example).  If so, no office visit may be needed while away.
    • Get enough medication to last the trip.  Or, get prescriptions with refills at WalMart or Target and have the prescription transferred to a store near your winter location.
  • Identify a doctor to see in your vacation area before you leave.  Ask friends or other people who winter in the area for a recommendation.  Call the distant provider office and get a FAX number so records can be sent.
  • If your primary care provider thinks you need a health care visit while you are away then make an appointment and have your records sent before you leave home — also take a paper copy!
  • If tests or surgery are recommended then call your regular doctor’s office to see if they agree.
  • Give any provider you see your regular provider’s name, address, phone number and FAX number (a business card is good).  Request that results of visits, tests or hospitalizations be faxed or sent to them — and make sure it happens.  Fill out a release of information form while you are at the office or other facility.

Bon Voyage!

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Fee for Counseling Service — another CPT code

cptwowWow, you could have had a CPT code and $60.  While fee-for-service is widely excoriated for excessive cost what is CMS doing?  They want primary care providers or someone to have another fee-for-service.  The fee is for “counseling” about lung cancer CT screening and “counseling” about weight loss.  Both things that are currently part of an office visit with no additional CPT code — just good patient care.

Both topics could easily be covered on YouTube in several languages but NO — lets do this the old fashioned way and spend a zillion dollars for each provider to reinvent the discussion each time.   CMS:  don’t be so lazy — make the patient education video and tell primary care providers the URL!  And, update the video every 6 months.

The bottom line:

  • Lung Cancer CT Screening:
    • Don’t do it if the patient can’t have surgery
    • Don’t do it until the patient has 30 pk yrs accumulated (number of packs per day times number of years)
    • Don’t do it if the patient is less than 55 or over 80 years old.
    • Don’t do it if the patient quit smoking more than 15 years ago.
  • Weight-loss counseling:
    • Say in a loud voice “you weigh too much” then say “eat less”.  (that was not so hard!)
    • Doctors have been doing this for decades without sustained  results.
    • There are 20,000 books about diets to loose weight without sustained results.
    • This is not going to work — at least be honest.

Follow the money:  

Counseling fees for CT scans is an incentive to do the CT scans.   The primary care provider makes money, the x-ray office makes money and the radiologist makes money.  A better idea is to have the radiology office pay the primary care provider for the counseling out of CT revenue so this is a no-sum-gain.  Better yet — make it a provided service under an ACO plan!

Counseling fees for intensive weight-loss is an incentive for lots of repeat visits or a referral.  The Primary care provider makes money (and changes from a primary care provider to a specialty provider).  The incentive reduces the pool of available visits for primary care with little if any benefit to the vast majority of obese people.  A better idea is not to add another CPT code.  If the patient needs more time — make another appointment!

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Hippocrates — the missing duty

hippocratesHippocrates missed something big — a doctor’s responsibility to improve the care of other doctors.  OK he did get some things right — here are his points from the 5th century BC:

  • use good judgement — nice
  • revere your teachers — nice if you are a teacher
  • order a good diet — still a matter of question
  • don’t hurt or damage people — really or just statistically?
  • don’t poison people — makes sense to me
  • comport oneself in a Godly manner — doctors have no problem here
  • don’t do surgery if you don’t know how — duh
  • doctor visits should be for the advantage of the patient — patient centered care is nothing new
  • keep medical information private — HIPPA before its time

Doctors often take some revised or modernized version of the Hippocratic Oath.  Sadly, the idea that doctors have some responsibility for the care provided by other doctors is missing.  The idea is front-and-center in most work on quality improvement — where the idea is indeed to improve everybody’s care.  Doctors should have 2 responsibilities:  1) care for the patient and 2) improve the quality of care for all.

Most doctors don’t accept item #2, instead the list is:  1) care for the patient and 2) care for personal finances.  In essence, doctors shun quality improvement because “I’m not paid to do that”.

How many doctors participate in quality improvement activities?  Meaning, find a problem, make a plan,  do something, study the result, then act to improve the plan and repeat the cycle.  This is not rocket science.  A physician is not expected to do molecular biology research in the office but there is an expectation they will improve waiting time and reduce prescribing errors — things easily within their grasp.  How many physicians have a quality improvement meeting each morning or at least once a week — I dare say less than 1%.

Systems of care are very important.  But, the lack of physician involvement in quality improvement is a serious deficiency in many health care systems.  In some respects this is a structural issue for health care — it’s not a process, and it’s not an outcome.  It’s like a foundation for a house — no foundation means the house will not last.

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