Navigating Healthcare – Patient Safety and Personal Healthcare Management

Wise Up to Hidden Healthcare Fees

It’s perverse but the healthcare system in the United States is making you sick. Don’t believe me – then maybe you have a high-end plan with no deductible and full access and no ceiling. But there are not many of those and for the rest of us, I imagine your interaction with the system is as frustrating and stressful as mine – probably on a spectrum depending on your plan (High deductible plan or the more traditional Preferred Provider Organization (PPO) and co-payments.


Fee for Service Healthcare

The cynical view might be this is deliberate since our system remains firmly stuck in a fee for service model – healthcare providers are paid to do something…anything. From its original development, this made sense – our capacity to treat conditions was limited and the cost of these treatments in line with our ability to pay for them. But along this journey science and in particular the incredible progress of medical research got involved and we have been on a veritable tear of progress and innovation, or as the Exponential Medicine group would say Exponential progress.

Original from Foundation Teaching Economics

There is a continued push towards a more robust and accountable model – Accountable Care Organizations have been set up and these models of total care and coverage and responsibility tested for effectiveness and economic effect. There is lots of disagreement on the success or failure of ACO’s and it is fair to say that the jury is still out. But intuitively we know that taking care of the complete picture and being responsible for the total care of patients health is better for the patient and for outcomes. I have seen it time and again where individual mandates or focus induce unwanted/unexpected/unintended consequences elsewhere in the whole system.

Discharging Patients Early – Unintended Consequences

Discharging patients from the hospital early typically results in better outcomes. Early programs that incentivized this behavior and rewarded programs that got patients out of the hospital early were deemed successful but failed to take account of the downstream impact of readmissions resulting from too early a discharge and subsequent complications for that patient that could have been avoided.

Fixing a Broken System

The recent book “American Sickness” by Dr Elisabeth Rosenthal “An American Sickness” takes on the existing system and is filled with strategies for patients faced with mounting medical bills, an intractable and aggressive healthcare system that is unflinching in seeking payment and by many estimates the leading cause of personal financial crisis and insolvency. While the figures remain under debate my own personal reality living with a High Deductible Plan that has found me

  • Self-treating Fractures
  • Becoming my own compounding pharmacy and
  • Spending months and many hours fighting multiple bills


In the case of one screening procedure, that under the current regulations are fully covered but thanks to either mistaken coding or perhaps even deliberate coding, remains outstanding and in two of the three cases, the billing organizations despite my attempts at regular communications, response and protests were handed over to debt collection agencies.

So I am with Dr. Rosenthal and “breaking down the monolithic business”.

The situation is far worse than we think, and it has become like that much more recently than we realize. Hospitals, which are managed by business executives, behave like predatory lenders, hounding patients and seizing their homes. Research charities are in bed with big pharmaceutical companies, which surreptitiously profit from the donations made by working people. Americans are dying from routine medical conditions when affordable and straightforward solutions exist.

Employer Sponsored Insurance

Central to the challenges is the arcane concept that you access to healthcare and health insurance should be linked to your employment. As one friend of mine commented, “There are some who believe this is a deliberate policy on the part of employers to lock in employees to jobs they may not want but have to take because they need the health insurance and can’t afford the challenge or cost of changing (health insurance”. I don’t quite go down that rabbit hole and think Dan Munro’s explanation in his great book “Casino Healthcare

that detailed the history linked to the war effort and the need to find other incentives after they introduced: “An Act to further the national defense and security by checking speculative and excessive price rises, price dislocations, and inflationary tendencies, and for other purposes.” (EPCA) in 1942 – wages were frozen to stop inflation but as is so often the case left the door open for unintended consequences that found employers looking for ways to compete for a shortage of labor. And as they say what follows is history – Employer Sponsored Insurance (ESI) was born.

History of the NHS

It is interesting to note that the NHS model was also a product of the war that found the wounded servicemen and women in need of healthcare. A need that was serviced by the “Emergency Hospital Service” (aka Emergency Medical Service) that provided a model and experience to the country that became the model for what is now the NHS established in 1946.

But whatever the history, reasons, and background – this remains a millstone around American’s. It can add to job reductions and General Motors have stated that their employee healthcare costs add $1,500 – 2,000 to the price of every car they produce. It makes us less competitive internationally and crippling many with overheads that add to the cost of goods sold. It also puts employers at the table on healthcare decision making for their employers that present potential conflicts of interest given their need to service their share holders and remain profitable.

Finding a pathway to resolving this big intractable healthcare mess is going to take some major re-thinking and compromise on all sides. In the meantime, I suggest focusing on individual incremental approaches locally.


Incremental Steps to Coping With Healthcare

The list of 6 Questions to ask your doctor before your appointment and 5 questions to ask before you stay in a hospital are excellent resources from Dr. Elisabeth Rosenthal, that are featured in the book and on the website. So in the spirit of the incremental approach, I offer up two credit card size templates containing the

  • 5 Questions to Ask During Your Hospital Stay
  • 6 Questions to Ask Before Every Doctor’s Appointment


Formatted in a handy Avery 5371 White Business Card Template that can be printed – double sided and put in your wallet: Questions When Using Healthcare Avery Template 5371

Do you have any tips or suggestions in dealing with the healthcare system? Disagree with any of this – feel free to leave your comments or reach out.

Wise Up to Hidden Healthcare Fees was originally published on Dr Nick – The Incrementalist


Abuse of Resources – Its Everyone’s Responsibility

Posted in Healthcare Information, Healthcare Policy by drnic on September 8, 2009

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.

Online Symptom Checkers

Posted in Healthcare Information, Primary Care by drnic on February 16, 2009

A long review of online symptom checkers (a Google system of searching medical texts) appeared on this Dutch web site WebWereld that made for interesting reading

The downside to these tools is the problem medical students, doctors, nurses and most other healthcare professionals suffer from – the recurrent fear they are suffering from <insert latest disease you read/studied here> (as a balancing side bar to this I went to medical school with someone who suffered a ruptured brain aneurysm and recognized his symptoms and walked himself to the ED/Casualty)

As the writer points out in many cases getting an appointment is tough proposition in the best of circumstances no matter what country you are in and when you do it requires getting there, waiting in a room full of lots of other people who are sick (increased risk of contracting additional infection!) and unless you are really lucky waiting interminably to be seen. Add to that the distinct probability that you receive treatment that may not be warranted (antibiotics for a viral infection for instance) simply because the expectation has been set that you took the day off, made the trip the least you should receive is a prescription for your trouble.

The sites reviewed

WebMD – which interesting did not produce different results even if you answered the questions it asked differently
Revolution Health – basic mapping to the body and symptoms and really more about educating the user than diagnosing (to include the usual disclaimer of calling your healthcare professional no matter what)
Mayo Clinic – still very broad with little to narrow searches to anything useful – yikes a general site for clinical diagnosis seems like a bad idea and sure enough no ability to get to useful information quickly enough – now you would expect this given the name to be a better performer but with 10,000 medical conditions and enormous lists of symptoms to choose form unwieldy

Their summary (not all scientific but worth listing)

  • WebMD: 12 clicks to get a list of 15 possible causes
  • Revolution Health: 2 clicks to get a list of 13 possible causes
  • 5 clicks to get a list of 7 possible causes
  • 9 clicks to get a list of 3 possible causes
  • 1 click to get a list of 6 possible causes

The New York times feature today covered the struggles of young adults balancing limited income with large insurance premiums and high cost of living. As one participant put it

There was no way that I could pay my rent, buy insurance and eat

So despite the limits of these systems they are being used and for many probably with reasonable success but this is tempered with the negative effect that include antibiotic misuse and resistance or masking of problems with pain medication:

We see people with urinary tract infections taking meds better suited for ear infections or pneumonia — the problem is, they haven’t really treated their illness, and they’re breeding resistance….Or they take pain medicine that masks the symptoms. And this allows the underlying problem to get worse and worse

There is no easy answer to this but as discussed in the NY times article coverage is cost prohibitive for many and the bills out of line with people’s financial circumstances.As with all caveats – Your Mileage May Vary (YMMV). It is hard to assess the usefulness of these sites as a fully trained physician. Years in medical   and clinical practice mean that you intuitively apply filters to this information and can navigate these sites as aide memoir’s to help as Zebra Hunters. So for those of you not clinically trained I’d be interested in your thoughts on any of the above sites – how did you find them

For the purposes of complete information these sites are long step away from real diagnostic support tools which base their clinical decision support on a more detailed history that is detailed enough and with specifics to help narrow the choices for causes for specific symptoms based on knowledge of disease symptoms and signs. The rule of thumb is that 80% of the diagnosis comes from the history, 15% from the physical examination and the remaining 5% from additional investigation. That mix has changed with the array of diagnostic tests and imaging choices but this is not necessarily a better more cost effective service. Case in point some years back when a relative of mine injured themselves skiing and was transported to the first aid station. They waited for their spouse to show up before allowing any kind of investigations to be carried out (in this case X-rays of the foot). Their spouse happened to be a clinicians who examined and diagnosed the specific fracture much to the amazement of the local clinicians who said that was impossible to tell without an X-ray….end result correct diagnosis and the treatment remained the same despite the X-ray. Sure it could have been more complicated but did it require an urgent (and expensive X-ray) there and then… way!

But there is real scope in the clinical world to use Diagnostic support tools and one I saw some years back showed tremendous promise – First Opinion. There are others Isabelle is probably the most well known and the concept is sound but the challenge is seeing the wood for the trees and getting to relevant information quickly. Integrated into an electronic medical record, driven by clinical data there is tremendous scope help support clinicians arriving at the right diagnosis quicker and more accurately and overcoming the tsunami of medical knowledge. But to get to that data requires the data to be entered somehow……forms, drop down boxes and hunt and click systems just don’t meet the need and turning clinicians into data entry clerks is not a viable or sound strategy. I made this point recently in a presentation and this was commented on in  the MTExchange forum regarding the concern over transcription jobs and the fear that this these jobs are disappearing. EMR vendors are using transcription as part of their ROI justification suggesting that the “elimination of transcription costs is as a sales selling point”. As Julie Weight said in her posting:

The fallacy in this is that highly-skilled, highly-paid professionals then perform the task of a medical transcriptionist – which makes absolutely no sense. Physicians struggle enough with the financial justification for an EMR; coupled with resistance to change, it has pretty much guaranteed slow adoption of EMRs, especially in smaller practices.

And went on to hammer this point

you wouldn’t find Jack Walsh typing his own annual reports or Warren Buffet manually entering stock values into the computer (well, maybe Warren does – but I’ll bet Jack doesn’t)

Exactly! Stop the madness, allow clinicians to capture information without creating a burden of data entry for the sake of billing and administrivia. Clinical documentation is supposed to support clinical care, so lets give clinical documentation back to the clinician, provide them with the means to capture all the fine detail necessary in a detailed narrative description that contains this detail but include the data elements that are necessary to feed the EMR’s. Allow clinicians to capture the full Healthstory that contains both these elements and satisfies the clinical need and computer’s insatiable demand for structured data.