Posts Tagged medical care
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.
Delinquent, delayed and diverted the electronic health records in the US are missing. According to the Washington Post two Presidents set 2014 as the target for all medical records to be electronic — so has American medicine hit the target?
According to a study by the Robert Woods Johnson Foundation US healthcare has been very slow to adopt the technology. RWJF reports 50% of office practices have a “basic” system and 59% of hospitals have at least a “basic” system (25% of hospitals have a comprehensive system). To give perspective, a “basic” system contains medical reports and medication lists but no physician notes.
Barriers stand in the way of progress:
- Medical data is a very valuable business asset. EHR companies are threatened if such data could be easily transferred to a competitor.
- Fear of losing control. Doctors and hospitals don’t want their data to be too available to insurance companies or regulators. Quality problems could be easily exposed.
- Self-determination. Health care entities want to make their own systems — the CEO would rather manage than cooperate.
- Lack of governmental action. Doctors and hospitals are licensed by States — just putting the license at risk is all that is needed to make EHRs mandatory.
- High cost of building an EHR. Every office practice and hospital needs a financial system. But, really, only one EHR is needed in a State or perhaps only one in the entire US. Hundreds of EHRs across the country is a waste of money — they all do the same thing, and they can’t “talk” to each other.
- Failure to embrace a “cloud” computing solution for a large scale EHR.
Ask your doctor:
- Please show me my chest x-ray on the computer screen in the office exam room.
- Please electronically send all my records to a specialist across town.
- Please show me a record of all the prescriptions I had filled this past year and which pharmacies filled them and how much they cost. (surely you can trust your doctor with that small bit of financial information).
- Can I send you a secure email and expect a response?
- Can you securely send me the results of my tests?
- Can you easily look up the discharge instructions from my recent hospitalization on your office computer?
- Do all the doctors and hospitals and pharmacies in town share the same medical record system — why not? It would be very good from a patient standpoint.
NO answers exemplify the current data problem. The US has a far better tax system than a medical record system and a far better post office than a medical record system. Contrary to the story in the Washington Post this is NOT OK.
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.
Patients like a choice of healthcare providers but never are willing to pay much for that opportunity. Recently, insurance companies have taken advantage of shrinking the available panel of physicians to select those that are both less expensive and provide higher quality. The higher quality part is obviously secondary.
Electa Draper of the Denver Post reported 7/27/14 “Coloradans could lose medical choices, but save money”. The essence of the article was a report on the United Healthcare (UHC) plan to “narrow the panel” of available physicians. $100 per month is reported as the possible savings for subscribers to the plan.
UHC is the largest insurance carrier in the US. This national strategy to “narrow the panel” will save someone some money; but, the amount of leverage this gives to quality is nebulous. This huge insurance company could raise US healthcare quality to number 25 from number 26 in the world — sadly they don’t have much ambition for international competition.
The lack of transparency is striking:
- will all the cost savings be passed on to the consumer?
- will CEO Stephen Hemsley’s salary go higher than $106 milllion?
- physicians seem easy to squeeze for money; what about drug companies, device makers and hospitals?
- what quality measures cause physicians to be excluded?
- forcing patients to change doctors as employers change insurance plans is common practice — when will this stop?
- will UHC or any insurance company saying they intend to improve quality also reduce errors? Will they stand shoulder to shoulder with physicians who are named in medical error suits?
- will UHC reduce patient waiting times?
- will UHC drop Medicare patients and stick with younger healthier patients?
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.