Posts Tagged high cost
Emergency general surgery (EGS) is common in the United States. 11% of surgical admissions require emergency surgery. The statistics on EGS seem to create more questions than they answer:
- The 11% of surgerys classified as EGS are associated with 50% of all surgical deaths.
- Poor people who have EGS have a greater risk of death than average
- Rich people who have EGS have a lower risk of death than average
- Seven surgeries (removing part of the colon, removing part of the small-bowel, removing the gallbladder, operations related to peptic ulcer disease, removing abdominal adhesions, appendectomy and other operations to open the abdomen) accounted for 80% of the deaths and hospital costs related to EGS.
- The cost of ECS in the U.S. is about 7 billion dollars per year.
- EGS patients admitted by a surgeon have lower hospital costs than those admitted by a hospitalist.
- Specific quality guidelines for ECS do not exist.
One might be tempted to say the diagnosis is so complicated nothing could improve the situation for patients. However, this would be like the situation for pilots and passengers 30 years ago when major airliner accidents happened at least once a year. The quality movement swept over the airline industry which is now is rated as one of the safest of complex human endeavors. Those same measures need to be applied to EGS.
When an airplane has an emergency the crew pulls together and acts as a team. They follow a procedure practiced many times. They have simulators and tests. If an engine fails, if there is a fire, if a landing gear fails there’s a procedure to follow. Each pilot does not invent a procedure just because they are the pilot that day. Likewise, every surgeon should not invent a procedure just because they are the surgeon that day.
It would be easy to blame surgeons or the patients themselves for such dismal outcomes. But, as people in the quality improvement department say:
IT’S NOT THE PEOPLE, IT’S THE PROCESS.
The first step is to acknowledge EGS is a process. When a patient arrives in the emergency room with abdominal pain, low blood pressure, free air in the abdomen and a high white blood count there should be no barriers to evaluation an treatment.
- The goal is to have the patient in the operating room within 90 minutes from crossing the ER threshold (T).
- Blood tests and CT scan of the abdomen are done by T+ 20 minutes.
- Surgeon is in the ER to evaluate the patient by T + 30 minutes
- A decision for operation is made by T + 45 minutes.
- Pre-op antibiotics, fluids, and pressors are started as needed.
- Anesthesiologist begins care of the patient in the ER by T + 60 minutes.
- Central line is inserted, operating room is notified, ICU is notified, critical care team is notified by T+75 minutes.
- Patient is transported to the operating room. The opening incision is made by T + 90 minutes.
Such a process is obviously difficult. First, the ambulance crew can not transport a patient with an abdominal emergency to a facility unable to deal with the problem, like a small rural hospital or an urban community ER. This will require training of the ambulance crews and communication with a high level ER.
General surgeons and back-up general surgeons must be available within 30 minutes. It’s a difficult life to be immediately available — the hospital is responsible to either pay surgeons to be on-call or to hire surgeons to stay in the facility. Hospitalists are not an appropriate substitute to deal with an acute abdomen or even severe abdominal pain of uncertain cause. A helicopter ride to a higher level facility is the best solution for patients with severe abdominal pain entering a facility not capable of following the above protocol. The crazy practice of having a night-time hospitalist admit a critical surgical patient for a surgeon to see “in the morning” must come to an end.
Since the mortality rate of EGS patients is quite high the intensive care unit is the place they should go after surgery even if they seem stable in the operating room. Complications are very common so early recognition and treatment is essential. Returning to the operating room later may be needed and should not delayed. Critical care consultation should be strongly considered. Multidisciplinary rounding with critical care specialists, nurses, pharmacists, dietitians, and social workers is strongly advised. Rushing to get the patient out of the hospital to a secondary level of care is a mistake since re-admission is fairly common. The patient needs to be as stable as possible before discharge. Hospitalization for 1 – 2 weeks is not uncommon.
The difference in outcome of EGS between rich and poor is not uncommon for many things in medicine and surgery. Several factors are at play but probably the biggest is fear of big medical bills — if you can’t pay one would wait till the last moment. Second, medical literacy — always a bigger problem for lower socioeconomic groups — if you think Tums or Rolaids will fix anything you might wait too long to go for help. Finally, a negative bias toward Medicaid or “cash” patients — sometimes the finances determine whether a hospital will keep or transfer patients. At midnight many cases seem to be too “hard” and must be sent to a referral hospital which wastes valuable time.
Since prospective research is difficult and time consuming (taking years or decades) a local and national registry should be utilized. The diagnosis, the surgical approach and the outcome must be tracked to find the best combinations for the best outcome. As best practices are identified surgeons and hospitals must quickly change protocols and surgical techniques. U.S. healthcare can not stand the usual 15 years needed to implement new practices.
- Washington Post
- JAMA Surgery
- J Trauma Acute Care Surg.
- The Joint Commission
- J Trauma Acute Care Surgery
- J Trauma Acute Care Surgery
- J Am Coll Surgery
If any nurse out there has a standard order-set for EGS please share it.
Big Pharma blows the lid off the price for “specialty drugs”. Those drugs now cost more than an average American’s income. By 2020 the average specialty drug will cost $80,000 per year, just pray you don’t need two of them!
The data plotted above come from AARP. The raw data is concerning and three questions beg to be answered: WHY is this happening, IS THIS A PROBLEM and if it is a problem WHAT IS THE SOLUTION.
WHY? — because big pharma wants to make a lot of money. Somewhere, long ago and far away, some researcher wanted to help people with difficult medical problems. But, that altruistic thought was crushed as the drug was marketed.
PROBLEM? — absolutely, the US healthcare system can not afford the drugs and neither can average individuals. If a drug costs a trillion dollars it’s not a drug, it’s a joke. So where is big pharma going wrong? Here are some possible choices:
- Too much is spent on research
- Too much is spent on advertising
- Too much profit is paid to shareholders
Where is US healthcare going wrong?
- Too little regulation exists to require cost effectiveness research before marketing drugs
- Too little drug price control is being exerted by the government.
- Too little mirroring of price controls in other countries that shift profit taking to the US.
SOLUTIONS? — if the trend is allowed to continue “Bronze” health insurance will not cover specialty drugs but “Platinum” insurance will. Sadly, only the top 1% will be able to afford the “Platinum” plan. The US will have more of a two tier healthcare system with a huge gap between the 99% and the 1%.
- Impose cost controls on drugs — extremely high priced drugs should trigger rules to lower profits so such drugs will either cost less or not be produced.
- Demand cost benefit analysis on all drugs before marketing — if the benefit is not worth the cost then don’t add them to the formulary for Medicare or Medicaid.
- Wrap drug costs inside health plans. That way other factors get consideration, like preventive care, hip surgery, simple childhood vaccinations, and pregnancy. The big pharma bill should not be coming “off-the-top”.
One 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!
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!
- 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.
ER doctors never ask the question but often think: “Why did you call an ambulance for a sore throat?!” The trip costs at least $1000 and stands a chance of not being covered by insurance. The ambulance crew feels bad they don’t have a more appropriate option but if you call an ambulance — you get an ambulance.
Kaiser Health News reports the South Metro ambulance company in a suburb of Denver Colorado is trying a new service. An ambulance that is basically an ER in a box. Equipped with lab tests, bandages, sutures and a few medications they go to a home to treat a problem rather than transport a person to the ER. It costs about $500 — at this point, it is something insurance will not cover.
Here are two extremes:
- A single parent picks up their child from a family member after working 2 jobs at fast food restaurants. The parent just got the jobs after 3 months of being unemployed. The primary care doctor’s office is closed and the parent is expected at work in about 7 hours. But, the child has a fever and a sore throat. The bus they usually catch to go to the hospital does not run after 8 PM. The parent calls an ambulance.
- A woman drops a martini glass and cuts her finger. Her husband thinks she needs stitches but he has some after hours stock trading to do before bed. He tells the butler to call an ambulance and get the problem resolved.
The first case is common for Medicaid families. No resources, no car, and not much to lose by calling an ambulance. But, something to gain by not missing time at a new job and it helps the child on both counts. The ambulance and ER visit may cost Medicaid over $1000. But, during the day a visit to primary care might only cost $50.
The second case is crying for concierge care. The family has the cash to pay for someone to come to the house and put a few stitches in a finger. But, instead the problem clogs up the ER that should be dealing with heart attacks and car wrecks. Again, if the problem happened earlier in the day a primary care office or urgent care clinic could have solved the problem.
One could see Medicaid having a fleet of mobile treatment units just to limit the financial losses in the ER. Actually, a good idea. Both cases might have solved their problems by taking a taxi to an urgent care clinic — if one was open.
Will the “ER in a box” find a place? — at least a place where someone will pay them? The idea leans toward the concierge model. No insurance is going to pay for an ambulance when a taxi will work. No insurance company will pay extra just for the convenience of one patient.
Nice idea, but it’s not likely to fly financially.
Today’s medical futility is tomorrow’s routine care. A very hopeful thought. However, in the present consider a modern intensive care unit. A treatment area in most hospitals where a month of care could easily cost half a million dollars. That’s a big bill for any individual, hospital or insurance company and there is mounting pressure to use technology more wisely.
Cost is the most important factor to consider in a discussion of medical futility. Futility means doing something that will fail. Of course, our modern definition is doing something that will likely fail but might not if we spend enough money. If there is only one treatment for a horrible disease and it only costs a penny — we would spend it instantly, even if the treatment is futile. But, if it costs ten million pennies … we think about futility.
American medicine has been plagued with the problem of implementing treatments before they are affordable or even proven. Nobody asks a medical innovator “could you work on the invention a little more to make it less expensive”. Nobody asks a surgeon if a surgical procedure is proven — coronary bypass surgery is a good example, since the proof of effectiveness came 20 years later — turns out it’s not for every patient, just a select few.
The same question of effectiveness exists for intensive care. It’s clearly not for every patient, just a select few. But, how are doctors identifying those select few?
Critical illness is fraught with uncertainty. We have lots of expensive treatments but where do we draw the line. Deploy the technology or let nature take it’s course? Ethicists and theologians suggest they know the answers.
Yet, patients and families seek a pragmatic solution: grandpa was in great health but now his aneurysm has ruptured — he looks bad, should he have surgery?
Research shows critical care doctors actually predict outcome fairly well in this sea of uncertainty. They tend to favor using their skills to “give it a try” and make money doing so. But, if they say the chance of meaningful survival is less than 10% — absolutely do not go down that road. The road is often a dead end — the end may be after weeks in the ICU, or weeks in rehabilitation, or months in a nursing home.
Critical care is extremely stressful to the body. Research has shown that persons over 65 who survive an illness but who spend a week connected to a mechanical ventilator only have a 50% chance of living 6 months. So, even walking out of the hospital after critical illness is not a guaranteed success.
Back to the question of futility. Severe illness does not provide the luxury of time, time to check the internet, or time to go to the best doctor. This is when going to a hospital with a high quality score is important. There are always media splashes about miracle cures or soap opera dramas — the reality is patients and families do not want futile care. This is one time “ask your doctor” is exactly the right thing to do — listen carefully.
U.S. healthcare has gone crazy with testing for sleep apnea! No wonder: the standard test for the condition makes sleep specialists $1000 a pop. Talk about a “hammer”, anyone that snores or is overweight is a “nail”. People should be asking for 2 things before going down the testing road.
- A standard sleep apnea screening questionnaire.
- A night-time screening home oximetry test.
If the questionnaire and the oximetry are called “low probability” then stop the testing.
Sleep apnea is real and the people that suffer from the condition do need treatment. But, here’s the problem: mild sleep apnea does not need treatment. Yet, community sleep specialists have equated any sign of sleep apnea with the need for extensive testing and at least some type of treatment.
Well controlled scientific studies show that testing and treatment for sleep apnea are cost effective. Indeed, that may be true, but community sleep specialists are not following the guidelines as in the large studies. And, case-finding by community primary care is mostly based on the presence of snoring. Once the person is sent to a specialist it seems to be implied that an in-center sleep test (polysomnography) is warranted.
Here are some disturbing facts:
- 25% of the U.S. population snores
- 25% of people who start CPAP treatment stop treatment
- Pre-testing questionnaires are common but testing is done despite a low probability of the condition
- Sleep specialists only consider the expensive in-center sleep test as adequate for their purposes (other outpatient home tests work well for many patients)
- Surgery and dental prosthesis fail 50% of the time and are not recommended for first-line treatment. Yet, people are often sent to surgeons and dentists without trying CPAP (the gold standard) or APAP.