Healthcare Costs and Deductibles

Despite all the changes from the HITECH act and the healthcare reform there remains a continuing problem of healthcare costs and the deductible. This was brought home to me listening to NPR on health and the podcast: Sleep My Little Couch Potato – Sleep“.
You can listen here at around minute 13:00).

The title hides a segment on the to the “Fancy Diagnosis of House

Where All Things Considered dissected the cost of procedures ordered up on “House” that is featured in a book by Andrew Holtz (The Medical Science of House MD). What was shocking was the numbers featured in the example.

• Liver biopsy: $ 8,000 – 11,000
• MRI: $ 200 – 1,000
• Splenectomy: $ 140,000 (8 days in hospital)

As Andrew said anytime you get into understanding healthcare costs

“we just don’t know (how much things cost), it depends on what variety of the procedure, in which institution (!!!), if the moon is in retrograde…it seems as with anything else in healthcare trying to nail down what seems like a simple question turns into an episode of bizzaroland”

This is  continuing problem and compounded by co pays and deductibles that are rising for many people as companies try to reduce the impact of rising health care costs. In fact most polices, even ones that people would consider “good” insurance includes shared costs that might read “you pay 30%, plan pays 70%”. There are some caps on this but even for relatively simple treatments you can rapidly find yourself with big unexpected bills even with “full” medical insurance. And many of these plans have lifetime limits that may seem large (1 – 2 million dollars) but treatment of any significant condition (cardiac, cancer these being the top two killers) and you can see that maximum reached very quickly

The latest changes are trying to move the system in the right direction but the problem of medical of medical bankruptcy is likely to explode in the coming years as the population ages, coverage decreases and gets more expensive and healthcare costs continue to rise unabated.

I suggest you read the fine print now on your policy and start planning for these costs since we can typically expect to be accessing and needing more and more healthcare as we age.

Telemedicine Coming of Age

HIMSS10 in Atlanta was heavily focused on Meaningful Use. Indirectly related and certainly a technology coming of age was the demonstration of “HealthPresence” from Cisco systems. Their solution designed for installation in doctors offices, clinics and urgent care locations includes a range of additional technology to enable a remote consultation.

I had an opportunity to talk with Frances Dare, Director IBSG Healthcare Practice:

As you can see exciting technology that includes additional features to enable an effective remote consultation. It will certainly take some getting used to on the part of patients and clinicians alike but in terms of spreading and improving access Telemedicine technology really is coming of age.

Right now limited to office based settings in part due to the high end technology requirements but like technology in general this will filter down to individual use, and probably quickly. It may seem far removed from most people’s reality that they connect with their clinician over an internet connection and video conference but think about the success of Skype and a range of other video conferences facilities. In a connected world there will be increasing availability of remote access to satisfy increasing demand, increasing specialization and eventually customer demand.

Have you seen or used this technology a facility near you. Would you use it if it was available. If not what would stop you and what would help you accept this as a good clinical consultation

Healthcare Insurance – Its CostCo membership for Health

It is now being referred to the as the third rail in healthcareNo one wants to touch it for fear of electrocuting themselves but it remains one of the greatest challenges facing healthcare and rising costs. The fact that healthcare insurance companies stock prices have reacted positively to the news of the loss of the 60 seat majority in the senate. The insurers have bitterly fought any notion of a public insurance plan because this would cut into their profits.

Taking a look at some recent profits: Wellpoint owner of Anthem Blue Cross – $ 2,700,000,000 which was followed by an announcement they would be raising premiums by as much as 39%……..! That’s even more than the university and education sectors astounding rate increases.  Kathleen Sebelius the Health and Human Services Secretary weighed in asking them to “justify” this. Seriously – “justify”!

All this was discussed in the “GetBetterHealth” Blog by DrStanleyFeld in a piece titled: “Are Health Insurers Killing the Goose that Laid the Golden Egg“. Pointing out the usual techniques in play to deflect criticism in an attempt to justify this behavior

using a well worn public relations technique by pointing a finger at the other stakeholders. All its administrative costs, additional reserves, and investment costs are included in the “85 cents out of every premium dollar figure.”

In fact you have to wonder which group of middlemen the Health Insurance industry falls into

You don’t need to be an economist to understand that any middleman interposed between seller and buyer raises the price of a given service or product. Some intermediaries justify this by providing benefits, such as salesmanship, advertising or transport. Others offer physical facilities, such as warehouses. A third group, organized crime, utilizes fear and intimidation to muscle its way into the provider-consumer chain, raking in hefty profits and bloating cost, without providing any benefit at all.”

and this characterization

“The health insurance model is closest to the parasitic relationship imposed by the Mafia. Insurance companies provide nothing other than an ambiguous, shifty notion of “protection.“

So what do individual personal experiences tell us about dealing with the insurance industry. Recent experince suggests that the insurance industry is misnamed. Insurance is designed to pay out for legitimate claims. Health Insurance does no such thing and is much closer to buying membership to CostCo but not as good. The CostCo model has customers paying a membership for exclusive access to lower priced of goods. If you are not a member you have to pay the higher rate.

Examination of a recent claim form showed that membership to the Healthcare Insurance club provided a discount to the billable amount of 87%. But unlike CostCo if any of the items you selected or used the insurer deems to be uncovered then you get to pay 100%. So this would be like showing up at the CostCo check out and being told that in your case the meat you purchased is not part of you membership perhaps because they think you are a vegetarian and therefor instead of paying $5 per pound you must pay $9.35 per pound

In the healthcare example a legitimate set of routine laboratory tests on blood and urine as part of an annual physical.  It is impossible for me to imagine a reason to deny basic routing screening but the system is geared to do precisely that every time a claim is submitted. SO where is all the money going… aside from posting profits and investor returns there is a big chunk in the case of Wellpoint allocated to $1.8 to $8.4 Million dollars per year for its CEO and Divisional Presidents. And UnitedHealthcare was even worse:

In a March 2007 post I stated that “ UnitedHealthcare claims that costs are out of control. Why? Who paid their CEO $1.8 billion dollars over 8 years? The amount equals $300 million dollars a year or $821,917 a day in salary and benefits to one person. What are the other top executives at UnitedHealthcare receiving in salary and benefits? Do you think these salaries affect the cost of insurance?”

I agree with the notion that we the consumer need to take greater control and management of our healthcare dollars and remove these excess additive costs. Will someone have the courage to take this on….?

What have your experiences been with insurance. Do you think you get value for money and that health insurance is part of your health solution as opposed to being part of your health problem?

Multivitamins Do No Harm but Limited Benefits

The Washington post published an article “Evidence is thin that multivitamins are beneficial, but they seem benign“. Relevant in today’s struggling economy when you consider that there is an estimated $25 Billion spent in vitamins, minerals and supplements;

over 50% of Americans take a daily multivitamin

In the interests of full disclosure I take a multivitamin and have done for many years. As is often the case – emotions, perception and marketing rule our decision-making but

some older studies have linked multivitamin use to the prevention of conditions such as breast and colon cancer and heart disease

But in fact we should be basing our views on science and

the latest research has shown absolutely no impact on health and disease prevention, over time

As described the most rigorous widely regarded study in the Archives of Internal Medicine: Multivitamin Use and Risk of Cancer and Cardiovascular Disease in the Women’s Health Initiative Cohorts (Arch Intern Med. 2009;169(3):294-304.)

The study included 161 808 participants from the Women’s Health Initiative clinical trials in 3 overlapping trials of hormone therapy, dietary modification, and calcium and vitamin D supplements…between 1993 and 1998…disease end points were collected through 2005. documenting cancers of the breast (invasive), colon/rectum, endometrium, kidney, bladder, stomach, ovary, and lung; CVD (myocardial infarction, stroke, and venous thromboembolism); and total mortality.

This is an extended large cohort (combined) study and represents and excellent block of data to help establish a link between taking these supplements and preventative health benefits….the results here:

After a median follow-up of 8.0 and 7.9 years in the clinical trial and observational study cohorts, respectively, the Women’s Health Initiative study provided convincing evidence that multivitamin use has little or no influence on the risk of common cancers, CVD, or total mortality in postmenopausal women.

So the summary – no detectable benefit in the conditions study. It does not do harm

“The big takeaway message is that if someone takes a multivitamin, it doesn’t make them any healthier, but it doesn’t really harm them, either,” says lead author Marian Neuhouser, a cancer prevention researcher at the Fred Hutchinson Cancer Research Center in Seattle. “So then consumers have to ask themselves: What is really the benefit of spending money on these products, if they are not going to decrease the risk of common diseases that affect women or benefit health? It’s a waste.”

So will you stop buying vitamins – I’m moving toward that direction and may save my money for more proven ways of improving my health. What’s your experience? Do you have any other studies or data – leave your comments below

NHS IT Project (NPfIT) Could be cancelled

A recent article in the Times reports that the NHS gargantuan IT project is at risk of being cancelled:

http://business.timesonline.co.uk/tol/business/economics/pbr/article6946336.ece#cid=OTC-RSS&attr=2015164

>>>>The multibillion-pound national progamme to overhaul NHS computer systems could be cancelled in this week’s Pre-Budget Report, Alistair Darling has said.<<<

There are those who rejoice, those that commiserate and many who will probably say “I told you so” this is a sad result after so much money and effort. The project has been watched by many. The results have been less than stellar with 400 Million GBP spent and fewer than 20 hospitals trusts that have installed despite an initial deadline for the whole country by 2010.

But there is a generally accepted principle that the delivery of healthcare is broken not just in the United Kingdom but many other countries including here in the US. As such the project in the UK provided a vision of some of the challenges and solutions. Recognizing the differences between countries and healthcare systems the concepts and ideas learned may not all be suitable in every circumstance but loosing the project totally would be a very poor outcome for everyone.

Posted via email from nvt’s posterous

Abuse of Resources – Its Everyone’s Responsibility

I spent the last weekend up to my neck in organizing a local soccer tournament with 280 teams, hundreds of games and thousands of participants. Weather challenged our scheduling with severe thunderstorms and rain but we managed to pull off most of the tournament and get everyone to play their games.

We had some injuries including at least one fracture to an arm, some cuts bruises and even some concussions. Local services provide excellent coverage and I have experienced the great response and work when I refereed a game when one of the players fractured their leg in a hard tackle. The local ambulance crew arrived quickly, drove onto the field to collect the player and took them to a nearby facility and where they received excellent care.

Since I am part of the tournament staff and easily identified I get included in much of what is going on. In once such instance one of the facility organizers stopped me to tell me that the medical crew were pulling in to the back to deal with the bee sting. I was immediately concerned thinking about anaphylactic shock and followed her outside to meet the ambulance crew and the police escort to get them across grass fields. The local facility staff meets the crew and says:

She’s inside

Wait a second I just walked out from there and I did not see anyone lying comatose on the floor? Did I miss something? We proceeded inside and I look at the patient. An middle aged lady sitting on a chair with one foot partially obscured with a bag of ice……..!

My initial thought is there’s some mistake the patient must be in a room nearby. But no – this is the bee sting patient. The detail was correct – it was a patient with a bee sting. A bee sting on her foot.

This is an abuse of the system. Its inexcusable. I challenge anyone to provide me with any reason that could possibly justify calling an ambulance for a bee sting to the foot. There is no anaphylactic shock problem. There is no transport issue here – for anyone to have arrived at the facility they had to drive or be driven.

This is inexcusable and there seems no other way to curb this wasteful selfish behavior that by imposing financial penalties. That individual should be required to pay for the cost of the ambulance, the crew, the park escort and any subsequent treatment she received in the Emergency room – at the full rate. No insurance coverage or subsidies.

Unfortunately that position is a slippery slope and will quickly lead to the requirement to justify every call for an ambulance and visit to the ER. Fine in such cases of flagrant abuse but what happens when its not so clear cut or the patient believes with the best intentions it was the right call. We want to err on the side of best choice and care without inhibiting those people that genuinely need these services but are afraid to call for fear of punitive charges.

The only solution I can see is have an independent body determine justifiable use. A body that is not linked to the payors, service providers or patients. Clear guidelines and a quick independent process for review and arbitration of cases that are not clear cut.

Maybe this is already in place. No doubt it can and will be abused – but if we cannot take our own persona responsibility then we can hardly expect the insurance companies to accept this level of abuse of coverage and to pay up for in appropriate use of expensive emergency services.

Litigation in Healthcare – The Two Sides to the Pond

I like Dr Crippen’s blog and enjoy reading his posts and commentary. He typifies the long suffering British doctor in many respects. He rails into waste as in this post on the ridiculous expenditure by Essex health commissars (!!) insisting on spending who knows how much on educating the population that they should eat more fruit and nuts. As Dr Crippen says:

..most of all, it is a waste of money. The hospital is on fire, burning to the ground. Why is no one doing anything? Where are the fire-fighters? They are in the local school lecturing children on the dangers of matches

But in this recent post: Paranoid Doctors he is distraught that in the US attorney’s advertise their services and offer a “No recovery, No Fee” option. As he puts it

So I can stop my medication. And thank God we don’t live in America

Yes and no…… as one of the comments on his post put it:

How would you respond to a patient whose GP had been giving him Steroid eye drops on repeat prescription for 11 years without reviewing him and who was not under the care of an Ophthalmologist, who now has bilateral steroid induced glaucoma and steroid induced cataracts?

I bet you dollars to donuts that this is a real case not just a hypothetical and therein lies the challenge. While there is abuse (as there is in any system) the idea that making it so costly and difficult provides good protection for the patient is wrong. A very good friend of mine was treated for a complex fracture of radius and ulna at some local hospital. The gung ho orthopedic surgeon decided he was up the task of treating this set of fractures and left him with permanent disability and finished his tennis career. No amount of money will ever make up for that but without accountability that surgeon would continue his treatment of other patient instead of referring them to a specialist. This all the more worrying since it occurred in the NHS a system that does not reward by number of patients/procedures carried out

For a more detailed look at the state of medical litigation this piece by Atul Gawande in the New Yorker – The Malpractice Mess provides more detail and an interesting slant on the topic. The case under review was for medical malpractice from nine years ago but what makes this more interesting is the lawyer for the patient Barry Lang was an orthopedic surgeon for 23 years. He had even been an expert witness on behalf of other surgeons defending their treatment in court. He certainly did not do it for the money and ended up in his new career because as he described:

because he thought he’d be good at it, because he thought he could help people, and because, after twenty-three years in medicine, he was burning out

Part of his original intent was to be a defensive lawyer for his colleagues but nobody would hire him as he had no experience. But as he advertised his expertise as the “Law Doctor” he managed to carve out a business working on behalf of patients. He does not take every case and in fact takes only a small percentage of the cases that comes his way. For him there are two basic requirements

1. You need the doctor to be negligent
2. You need the doctor to have caused damage

Most fail on both but when they don’t he spends time investigating and applying his years of clinical practice and experience to understanding the case to determine if there is malpractice. Many factors contribute but he takes the risk on a case since his payment is dependent on a successful outcome. There is much to dislike about a system of accountability that can reward inappropriately but accountability and review is an essential part of any high quality system.

Somewhere in this mess there has to be a better balance and approach. Malpractice is not bad – it is the abuse of Malpractice that is bad. Consider the MGH physician Bill Franklin who’s son’s developed a lung tumor that had been identified on a Chest X-Ray 4 years previously but never followed up and acted upon. His attempt to understand the reason for the failure to prevent the occurrence happening again to some other patient were met with

The (hospital) director told him that he couldn’t talk to him about the matter. He should get a lawyer, he said. Was there no other way, Franklin wanted to know. There wasn’t.

He was left with no other course than to open a malpractice suit which was won. It left an indelible mark on the son and the father and changed the way both practice medicine. But the method is still unsatisfactory

litigation has proved to be a singularly unsatisfactory solution. It is expensive, drawn-out, and painfully adversarial. It also helps very few people. Ninety-eight per cent of families that are hurt by medical errors don’t sue. They are unable to find lawyers who think they would make good plaintiffs, or they are simply too daunted. Of those who do sue, most will lose. In the end, fewer than one in a hundred deserving families receive any money. The rest get nothing: no help, not even an apology

There have been many attempts and much like the healthcare debate the special interests weigh in quickly when they feel their turf and income stream might be threatened. One such system started for vaccines where a surcharge is made to the cost of the vaccine that is placed in a fund set aside for the purpose of compensating the small percentage of people harmed by side effects. Some countries have tried to instigate systems along similar lines – New Zealand which has a set of limits, clear defined liability and importantly quick payouts (within 9 months). There are better models and solutions. The answer lies in a fair timely system that helps those that have been hurt, identifies fault in an effort to prevent future errors without over burdening the system and the clinicians.

Malpractice or some variant of oversight is an essential part of our healthcare system and needs to be included in any debate of reform but as with all things balance and informed debate is the way to go

Self Care and Management

In a great post by Don Kempler (CEO of Healthwise) on the Healthcare Blog titled “Patient Heal Thyself” the challenge of health management and the over usage was very clearly addressed by comparing two families – the Jones’ and the Smiths

The Smith family represents the vast majority of healthcare usage in the US – Doctor knows best and is typified in my experience with the frequent visits for every ailment that crops up. The Joneses are at the other end of the spectrum and much more conservative using the information they find and more importantly applying it as part of their interaction with their physician

For the same condition of back pain they represent the cost both financially and also from a health perspective
The Smiths (Doctor knows best):

When Sam Smith’s back pain flared at age 45, he was quick to accept his doctor’s recommendation for an MRI and a visit to an orthopedic specialist to make sure it wasn’t serious. The MRI showed a possible cause of the pain and (just to be sure) Sam had surgery the following week, marveling at the efficiency of the system. The cost: about $40,000 for surgery, hospital, physician care and rehab.

For the Joneses with the same condition:

When Jay Jones, also age 45, had an identical bout of back pain he reviewed a back surgery decision aid on the Web—even before his first visit. He learned that back surgery is not usually needed or always successful. For him the case for surgery was not very strong.

When his doctor recommended an MRI, Jay pointed out that a decision aid helped him learn that 50 percent of back pain cases go away in four weeks, 90 percent in six months, and only 10 percent of back pain cases need surgery. Jay also learned that MRI reports often find things that can lead to surgery even though they were not the cause of the pain. With that information he asked if he might put off the MRI and the surgery while he determined if his back would get better on its own—it did. The cost: $150 for the office call and $12 for the over-the-counter medications. Back surgery is among the most over prescribed treatments.

Now not everyone is comfortable with the self diagnosis and I blogged about that some time back in this piece on online symptom checkers but that the point is not to defer the whole diagnostic process to technology but to use the technology to help support decision making.

I know where our family is (sometimes to the chagrin of my own children who feel I am less than sympathetic) – we use the services when we feel we need them and are very conservative. Intervention and investigation is not always good as we discovered in the hospital I commissioned a number of years ago. To check the equipment the staff were asked for volunteers to test the MRI machine – it was a very short run as no soon as we put people into the MRI but we discovered “abnormalities”. In this case abnormalities that were not abnormal but normal variations but the cost in time and investigation was high on the institution and on the individuals and the tests ere stopped.

Using good judgment and being a Jones family is better for your health and better for your wallet.

Which family is closest to your style. Had good or bad experiences with either style – let me know

We the Patient Want to be Included in Meaningful Use

There is a great post on THCB “Bringing Patients into the Health IT COnversation About ‘Meanaingful Use‘” by David Kibbe. We are looking at $34 billion of our money being used over the next several years to improve our health

After all, we, the taxpayers, will pay for all this hardware, software, and associated
training. There are many more consumers of health care than doctors or health care professionals. Shouldn’t we have a say in what matters – in what is meaningful – to us?

As is often the case the end user is forgotten. Clinicians often complain they are forgotten in the design and build of EMR’s. The same is true of the HITECH and ARRA investments for patients. Their voice is hard to hear if not completely absent. But as the article clearly points out we are already using technology and find much of what we need online without recourse or even the desire to contact our local healthcare provider. When we do the process is archaic at best and fails miserably to provide the necessary information in a form we can use. In a recent discussion in a medical office I asked the question what clinical system the office used…..they had no idea. So it was not a great surprise when I asked for my records in digital form that they looked at me with blank stares akin to the deer in headlights! I have yet to have a reasonable response to this simple request.
The suggested included elements to cater to patients for meaningful use were:

• Prevention and screening reminders. As appropriate, these should be shared along with a personal health plan and full access to one’s records.
• Patient decision aids for major surgery and procedures. This might include messaging pre-and post-surgery to help avoid waits and delays.
• Patient instructions for acute and chronic conditions. What to do at home; what signs of problems or improvements to look for; when to call if symptoms develop or improvements don’t occur as expected.
• Guided self-management messaging for chronic conditions.  Instructions in self monitoring, lifestyle, medications management, action plans, etc.
• Visit preparation for scheduled visits.  This could include questions to ask the doctor or provider and biometric instructions, e.g. the need to fast before a test.

A great start but still a long way to go since it does not guide the interoperability issues and the need of the patient to have the data in a form they can use (paper or any proprietary format just doesn’t count). You can bet we will start down this track with the usual suspects producing their proprietary system that you have to log in and set up an account for each and every office and facility you visit. None talking tot he other or sharing he information in a way that allows other systems to use. Reminds me of the status with ATM’s when you had to find your bank’s ATM since cards only worked in that ATM. It was also a non connected network (this particular fact worked in favor of an old medical school friend who used this to extract cash from his empty account after midnight when the machine was unable to check his balance and therefore had to allow him access to cash!)

Meanwhile we the consumer must fight tooth and nail with these systems and facilities that are focused on their profits and keeping their patient’s – god forbid they made it easy for a patient to select another doctor or facility by providing information that was portable. Until the incentives and the money lines up behind this it seems unlikely that things  will change dramatically.Meanwhile there is a big lobby of interested parties focused on keeping control and the information (seen as power) out of the hands of the consumer.

Patients and Doctors Need to Reform Too

There is much discussion and commentary on the Healthcare Reform, new clinical systems and the investments being made through the stimulus package. But not so much has been written about Patient reform. The NY Times piece A Hurdle for Health Reform: Patients and Their Doctors focused on the issue of patient and physician behavior and the all to frequent insistence on treatment can be a poor choice. It is a poor choice for economic reasons – why pay for a treatment that has little or no effect. And why start using a drug that has no demonstrable improvement in outcomes vs an older well tried and tested drug. Apart from the fact that we already pay 77% more for comparable drugs – in no small part due to the effective lobbying and marketing drug industry machine. But we also find our treatments based on Physician Pillows (they reflect the most recent impression left on them – often by drug companies) for a newer supposedly better drug but:

when it comes to comparative effectiveness, the track record of the American public and their doctors is not encouraging. Even when such comparisons are available, we tend to ignore them. In 2002, for example, one of the largest government-financed clinical trials ever found that generic pills for high blood pressure worked better than newer drugs that were up to 20 times as expensive. But most hypertension patients still use costlier drugs marketed by pharmaceutical companies

Of and by the way – the side effects for these newer drugs are by the very nature of their recent introduction as yet undiscovered, so the American public is providing a great service to other countries and their patients testing out new drugs on their behalf! If you’d like to read more I can recommend this book by Marcia Angell, a senior lecturer at Harvard Medical School “The Truth About the Drug Companies: How They Deceive Us and What to Do About It“. Shocking insights into the industry that is there to make money. The first recommendation on Amazon is pretty compelling

I should start with a disclaimer. I’m a Vice President within one of the largest drug companies in the world and I have spent close to twenty years marketing drugs. So I guess I’m not supposed to like this book. But the truth is I thought it was fantastic. First, for those of you who are not familiar with the healthcare industry, you should know that Ms. Angell is better capable of writing this masterpiece than any other author. She used to be Editor-in-Chief of The New England Journal of Medicine, which is considered the most prestigious medical journal in the world.

But this volume is much more than simple entertainment. It is quite possibly one of the best analyses of the state of the U.S. drug industry today, complete with footnotes backing up every statement the author makes. You will learn not only that in 2002 the top ten drug companies made a higher profit than the other 490 businesses together on the Fortune 500 list. You will also understand how the drug industry has been able to achieve such a business success and how this success, as is often the case throughout history, will likely be their downfall

Yikes – and this from a Drug Company employee!

So what to do – start with more education, include and understanding of what works and what does not and above all else, don’t take the treatment you receive as gospel. Would you pay for “Synthetic” oil for an oil change that is more expensive without understanding why it is worth spending that extra money – if indeed it is. I hope not. The same should be true for your health and with the availability of information, support groups and tools to analyze healthcare will be a much more inclusive process involving the patient and the whole team in making decisions than it has in the past.

Do you have your own experience of good or bad choices;  if so please share them and let me know what you think f the current state of healthcare today