A reader sent along a tip about an excellent presentation given at Harvard Medical School by Zen Chu, a venture capitalist and medical device entrepreneur. You can download the presentation from the Center for Integration of Medicine & Innovative Technology (CIMIT) blog. It’s well worth having a look.
Here are some tidbits I picked up from the document:
Innovation without impact is worthless: Unmet clinical needs is a cliche, translational medicine must strive to become Standard of Care
A very high share of med-tech innovations originate with physicians, and those inventions have a higher impact on average
MDs look at value creation differently from investors, who attach more value to later stages of development than do the inventors. “Innovation is spark, development drives value.”
Incremental innovations are very useful, but creating a whole company based on one may doom the product
“Time is Life” –and there are a variety of accelerants and deccelerants to be aware of
Some techniques to identify opportunities include:
“Productize” a procedure: turn a service into a repeatable product, e.g., from stomach stapling to lap-band
Remove treatment ambiguity to anticipate or create the standard of care
Eliminate a provider or facility to reduce costs and provide an opportunity for profit
Import solutions from other countries
The presentation ends with a call for a Commercialization Grand Rounds.
I’m sorry I missed the live presentation, but glad to have at least had a look at the document.
More than half of all insured Americans are now taking at least one long-term prescription medication to manage a chronic condition, and almost two thirds of women over 20 regularly take at least one medication. We have officially become a nation of pill poppers. The saddest part of the whole mess is how many people are taking medications for conditions like hypertension and elevated cholesterol - things that could be at least somewhat managed with better diet and a little more exercise.
So how much of the increase in prescription usage is linked to pharmaceutical advertising on TV? In the last decade the drug industry has launched a huge advertising campaign - next time you’re watching TV, see how many ads go by before you see at least one for a prescription. The Colorado Health Insurance Insider has addressed this problem before, and it seems that lawmakers are starting to notice the impact that TV advertising of pharmaceuticals is having. Regulators will be considering a proposal tomorrow that would require more of a focus on the side effects mentioned during TV drug ads, including telling the consumer how to go about reporting side effects to the FDA. Studies have shown that with the current advertising tactics, 80% of viewers are able to recall benefits of drugs after watching a commercial, but only 20% correctly remember the side effects. Maybe if the not-so-warm-and-fuzzy aspects of the drugs were made a little more prominent, consumers would not be so eager to get their docs to write prescriptions for the latest and greatest drugs.
Since ever-increasing pharmaceutical costs account for a large chunk of the rising cost of health care and health insurance premiums, it would seem that reducing the number of prescription drugs that Americans take every day would go a long way towards reducing the overall cost of health care in this country. Of course, that’s not the trend that the pharmaceutical industry would like to see, since every new prescription means more money for their CEOs and shareholders. But health insurance companies and the American public should be striving towards reducing the number of new prescriptions, since a lowered overall cost of health care benefits just about all of us.
Son of Tex Ritter, star of "Three's Company" and later "8 Simple Rules."
And most of us remember his sudden death in 2003 due to aortic dissection.
It is the story after the story that caught my eye. Dr. Jeffrey Segal posted on em-news.com a commentary that looks at the numbers in medical malpractice.
Mr. Ritter's wife settled a wrongful death suit with a number of defendants, including the hospital where he was treated, for $14 million.
The trial went forward for the two remaining defendants, radiologist Matthew Lotysch, MD, and cardiologist Joseph Lee, MD. In March, a jury found the two were not negligent in their treatment of Mr. Ritter. The plaintiffs had asked for $67 million in damages. Let me repeat that: $67 million.
"Not negligent."
Sounds like they dodged a bullet.
Or did they?
Their attorney said the family wanted that figure so they could use the proceeds from the lawsuit to educate the public about aortic dissection disease. There was no mention if they intended to use the full $67 million for the useful goal of education, or if the lawyers wanted to use two-thirds of that amount for education and one third, or roughly $22.3 million, for educating themselves about how their homes would look with Bentleys in the driveway or with a new driveway altogether, say, leading up to a new house in Malibu.
No doubt, money can be a great motivator. What I do know is that there is a sizable disconnect here, between what is expected in the case of a high net-worth individual who alleges medical malpractice and what physicians can realistically be expected to pay in damages. Most physicians carry a mere $1 million in professional liability coverage, which means that they have to write a sizable check.
I found that figure shocking. "Only" $1M in med mal coverage? Really thought it would be higher . . . at least $5M.
I have more than $1M on my car and then an umbrella over and above that.
Most physicians are flattered if they are among the few to be asked by high-profile politicians, entertainers, sports stars, or billionaires to provide care. But is it possible that such high earners could possibly seek full indemnification for their salaries if something goes wrong? Most physicians never think about it. Maybe they should because the Ritter trial shows us that the legal system actually does allow forcing the physician who commits a wrong to make Tiger Woods, Bono, or Robert DeNiro whole again if negligent care is proven.
That's a scary thought.
Most high earners value their earning capacity and insure against it on their own. They buy disability and life insurance, so that if something untoward does happen, they actually can be made whole. But the law doesn't recognize that solution. The law says you take the plaintiff as you find him. So, if you negligently injure a billionaire, bankruptcy might be the only way out.
Good thing Dr. Ben Sobel was able to help Paul Vitti.
Next week, the video game producer will unveil its latest product aimed mostly at women, the Wii Fit, as part of its strategy to vastly broaden the world of gaming. Marketing to women has helped Nintendo defy industry expectations and garner blockbuster sales, soaring profits, and an audience of loyalists along the way including senior citizens, teen girls, and working moms.
Working moms.
Isn't that redundant?
In Nintendo-speak, women and moms in particular were the "chief household officer" that they were eager to attract.
Chief Household Officer.
Beats the heck out of Rosanne's "Domestic Goddess."
Nintendo Canada is wooing women through ad placements for Wii Fit in "pink collar" magazines such as Best Health and with the web site getupandplay.ca, launched to help teach moms about the Wii system and offers instructions on how organize a Wii party.
Wii party.
Move over Pampered Chef.
It also features recipes.
Perhaps I was a bit hasty.
Now if it can teach them to dance like Tina Turner, they might have a winner.
Fresh off of a tremendous Health Wonk Review, Jason Shafrin hosts next week's Cavalcade of Risk. Submissions are due by Monday (May 19th). Jason reminds you to include:
■ Your blog's url ■ Your post's url ■ The post's trackback URL (if available) ■ A (brief) summary of the post
David Williams: This is David Williams, Co founder of MedPharma Partners and author of the Health Business blog. I am at Consumer Health World in Las Vegas where I spoke today with David Hom, Chairman of the Board of the Center for Health Value Innovation.
David and I spoke about value based insurance design and health care consumerism. Hom would like to see consumers become CEOs of their own care, and he believes we are at the cusp of using information technology effectively to enable consumers to adhere to therapies. The Center’s approach represents a clear departure from business as usual, but the concepts are strongly rooted in improving the existing employer based model rather than overthrowing it.
David, thanks for joining me today.
David Hom: You’re welcome, David.
Williams: What is the Center for Health Value Innovation, and who is involved in it?
Hom: The Center was established to share best practices with employers, both large and small, both state and private. We have at the table all the key players in the health system, from health plans to insurance brokers to health systems, physician groups, employers, business coalitions and unions.
Williams: What was the impetus to get all of those groups together?
Hom: The impetus was really simple. It’s how do we create a safe environment for these organizations to share best practices, to innovate in health care in order to reduce the rate of health care inflation primarily through improving patient adherence to treatments for chronic conditions?
Williams: Who has an interest in doing that? Often, you hear about adherence as being something that’s pushed by the pharmaceutical companies as another form of marketing, but this sounds like something.
Hom: Absolutely. The ones that have been most upset about this are the health plans, physician groups and hospital systems. What this will do is it will reduce the level of intensity for ambulatory services. At the same time, it will reduce ED visits and hospitalization costs for payers.
Williams: You have the word “value” in the name of your organization. Value is a term that is being thrown around a lot in health care these days, starting with the Secretary of Health and Human Services. Can you tell me what you think about when you use the term value?
Hom: We define value from a payer perspective, which is how do we measure the dollars spent in health care? What does it do to employee productivity? How does it drive higher employee engagement and thus reduce disability days for organizations?
Williams: Is that a concept that people can agree on, or do people come at it from different angles?
Hom: I think, most people understand the concept of ‘an ounce of prevention is worth a pound of health care.’ They get through the solution multiple ways, but by and large people focus on this concept around data, aggregating data and then understanding what are the patterns within the data. What are the barrier issues for access to care? How do you remove the barriers –whether admin barriers or financial barriers? Then, how do you track the ROI? How do you measure the return on investment of those dollars?
Williams: How good are the data today that are being used? I’ve heard about value based insurance design, which seems to be mainly about reducing co pays in certain situations. Is that done in broad strokes? Will happen on an individual person basis or a dynamic basis over time?
Hom: We see this concept happening at the population base level, looking at what the patterns are, what the barrier issues are, and how to manage those issues. However, when you set your designs up, it drives individual consumer behaviors. That’s the most powerful thing.
When someone is highly compliant with their regimens –taking their annual physicals, doing their pap smears, doing their colorectal exams– they tend to be CEOs of their own health, which is what you want them to do.
Williams: What are you finding in terms of the evolution of consumerism in health care? How much credit do you give consumerism, and how much potential is there for consumerism to resolve some of the cost and quality issues that exist today?
Hom: In terms of consumerism, we are at the cusp. We are at the cusp of using emerging technologies to provide information on a chronic to the patient and guiding them through the health care system in an effective way.
The example I use is that when you go to the doctor, the doctor spends six minutes with you. You get a set of directions. You walk out saying, ‘What am I doing? How do I do it and when do I do it?’ And you get confused. We want to use technology as an enabler to train patients one at a time to adhere to what the physician recommends.
Williams: What sort of evolution is required of the typical physician, and does the Center play a role in that?
Hom: We work with a number of physician groups. The concept is to align pay for performance –which is how you assess physician practice patterns– to this concept of benefit design. If you are going to lower the barriers to access care, then how do you hold physicians accountable for the management of their diabetic patients, for example? And then, how do you steer patients to those physicians, and how do you modify the reimbursement rates to those physicians to pay for the appropriate care?
Williams: It sounds like what you are doing is mainly within the construct of the current system, the current private payment system whereas a lot of what’s being discussed on the campaign trail sounds pretty radical. Even the Republican, John McCain talks about blowing up insurance coverage from employers. How does that fit in with what you are doing, and do you think there is an opportunity to preserve the private system?
Hom: Absolutely. People often talk about health care from 30,000 feet. What we’ve learned is that not only is health care delivered locally, but health care decisions are made locally, too. You have to create successful case studies within geographic areas, test the hypotheses, roll out the interventions, measure them and then scale them to other organizations.
Williams: We’re here in Las Vegas at the Venetian Hotel at Consumer Health World 2008. I believe you are running a workshop this afternoon as part of the National Conference on Health Care Consumerism. Can you tell me about that? Who is participating? What are you hoping to get out of it?
Hom: We have a great panel today. We’ve got 10 folks representing insurance brokers, health plans, physician groups, hospital systems, PBMs, employers, business coalitions, really talking about health care innovation from a pay perspective. We’ll discuss what they have done to a) identify the problem; b) solve the problem; and then c) measure the results.
It is very action oriented. It includes case studies, and it will create tangible results for people to walk away with versus talking heads.
Williams: I have been speaking today with David Hom, Chairman of the Board of the Center for Health Value Innovation. David, thanks for speaking with me today.
Hom: Thank you, David. I appreciate it very much.
We've discussed Alzheimer's and other forms of dementia here in the past, as well as other senior care issues. Generally, these are related either to health insurance or to health care trends.
But there's another dimension to dementia, one which often isn't discussed: affected seniors who wander away, and face potentially dangerous consequences.
We're all familiar with Amber Alerts when children go missing. But there's something new afoot at the other end of the age spectrum:
Currently in its (you should excuse the expression) infancy, the Silver Alert system seems to be gaining ground slowly. With the graying of the population, especially as Baby Boomers reach their Golden Years, we'll likely see this picking up steam.
Workers Comp Insider has a good article about providing wellness care through workers comp programs. Perhaps if workers comp carriers were to focus on preventive care for employees, they would see a reduction in job-related injuries as time goes by. Simple things like weight-reduction and programs designed to improve core strength could probably go a long way towards warding off claims, since healthy bodies are less prone to injury, and tend to heal faster than unhealthy bodies.
And there’s a great article from Code Blue Now about the French health care system as it relates to doctors’ expenses and salaries. Let’s imagine how it would be if docs in the US didn’t graduate with such high student loan debts, and if we didn’t have such a crazy malpractice system, and if our health care system weren’t so convoluted with thousands of different health insurance companies, networks, billing systems, coding procedures, etc. Maybe then we could pay our doctors lower salaries and still provide health care for a lot more people than we currently do. Good food for thought.
If
you think you were overcharged for health care services, you should contact www.MYINSNET.com,
an insurance negotiating service that offers consumers assistance in negotiating
medical claims.This company states
they have saved insurance companies millions of dollars and an average savings per
claim is about 25%.The same techniques
and resources they’ve used to save insurance companies money are now available for
individual consumers. Any patient with
a medical bill greater than $200 is eligible to send their bill to INSNET for negotiation.Consumers
can use services such as INSNET to determine if the amount they paid for health care
services is reasonable.If the charges
are deemed excessive, INSNET will attempt to negotiate directly with the provider
and INSNET charges a fee based on the amount saved on the patient balance.
There is not risk for consumers because they charge no fee if there is
no savings.When you visit the MyInsnet,
be sure to indicate you heard about their service on OutofPocket.com and they will
offer you an additional savings.
This past weekend, I went to Washington, D.C. for a conference. I was able to slip away for a few hours to spend some time at the Newseum, a very interesting museum about News. Thus, this week I will present the Health Wonk Review in newspaper format.
COVER STORY
Health Affairs Blog: Health Reform In The 2008 Election. A conversation with a Harvard health policy professor, the president of Health Policy and Strategy Associates Inc, and a health policy correspondent for NPR.
Colorado Health Insurance Insider: Two former HHS secretaries discuss ways to cut the cost of Medicare. Donna Shalala advocates eliminating waste and streamline the process in an effort to provide universal health care while Tommy Thompson who advocates increasing Medicare premiums, increasing the age for Medicare eligibility, and cutting benefits.
Health Care Renewal: “Punching primary care in the face.” How the RBRVS Update Committee’s advice rebarding Medicare’s physician reimbursement system will affect compensation for primary and preventive care.
Health Access California: John McCain’s health care reform plans including creating high-risk pools. California, already has a high risk pool: MRMIP. How is it working? While MRMIP is a lifeline for individuals with pre-existing conditions, it is expensive, has an annual benefit cap of $75,000, and has a waiting list of 500 people.
Freedom and Individual Right in Medicine: FAQ on Free Market Health Insurance. In a free market, insurers should be able to exclude individuals based on a pre-existing condition and one should realize that it is not one’s social obligation to subsidize the health care of those who can’t afford it.
Bottom
Line Secrets published an article several years ago on tips you can use to fight
back if you think you are being overcharge for health care services. This article
was recently brought to my attention because this information still applies today.
Here is a brief summary of some of the tips.
To avoid paying more than you should for doctor bills
1. Remember to negotiate. Try asking your doctor for a discount.
2. Have blood tests done at a lab, rather than at your doctor’s office.
3. Don’t pay for follow up visits.
4. Ask your doctor if tests prescribed are necessary. Doctors often order unnecessary
diagnostic tests including MRIs, CAT scans and X-rays. Ask what these tests will determine.
Tips on how to spot over billing on hospital bills
1. Request a daily itemized bill.
2. Avoid using the hospital pharmacy. Have your prescriptions filled at your
local pharmacy.
3. Watch out for double billing and review your bill detail carefully.
4. Don’t pay for the last day at the hospital if you are discharged before noon.
Many doctors claim that the medical malpractice system is broken and needs to be fixed. Doctors have high malpractice insurance premiums and often practice defensive medicine to protect themselves against lawsuits. To help alleviate this problem, many politicians have asked for some sort of tort reform. Tort reform can be generally categorized into 4 types of legal changes:
Caps on noneconomic damages. Noneconomic damages cover items other than monetary losses, such as pain and suffering.
Caps on punitive damages. Punitive damages are awarded in addition to compensatory (economic and noneconomic) damages in order to punish defendants for willful and wanton conduct.
Modifications of collateral-source rule. Under the common-law collateral source rule (CSR), amounts that a plaintiff receives from sources other than the defendant (e.g., from his or her own insurance) may not be admitted as evidence in a trial.
Modifications of the joint-and-several liability (JSL) rule. In a trial with more than one defendant, the first step is to apportion blame for the harm. Under JSL, the plaintiff can then ask the “deep pockets” defendant to pay all of the damages, even if that defendant was responsible for only a small fraction of the harm. Modifications to the JSL rule often hold that the “Deep pockets” defendant must be at least 50% liable for the harm in order to be held 100% responsible for the damages.
Which of these reforms are helpful? A paper by Currie and MacLeod (QJE 2008) aims to answer this question. The authors look at variation in tort laws across states between 1989 and 2001. They claim that malpractice laws put doctors more at risk for a lawsuit is a good thing because it will cause them to behave more carefully. When doctors fear expensive lawsuits or a blow to their reputation, they may behave with more caution. Thus, capping punitive and non-economic damages should decrease caution. On the other hand the JSL rule puts doctors more at risk. They will not be protected from a suit simply be associating with a deep pockets hospital.
Empirical Results
To test this, the authors look at the number of Caesarean sections performed and the rate of induction or stimulation of labor. C-sections are popular with doctors because they receive additional compensation compared to a “regular” birth. However, performing a C-section on a mother who does not need it exposes them to additional risks. The authors find that “JSL reform reduces C-sections and complications of labor and delivery…In contrast, caps on damages are found to increase procedure use, and hence costs. They also increase complications of labor and delivery in some specifications.”
For a robustness check, the authors look at C-section rates for high- and low-risk babies separately. The authors assume that doctors have less treatment discretion for high risk cases, and the results demonstrate that tort reform had less of an effect on procedure rates or outcomes for high risk cases.
At the Colorado Health Insurance Insider, we’ve made our position on the relationship between pharmaceutical companies and health care providers very clear. When pharmaceutical companies provide tangible benefits to doctors, hospitals, and universities, the lines between objectivity and bias become very blurred. And for patients without health insurance, or with high deductible health plans, it’s even more frustrating to know that some of the money they’re paying for their high-priced medications is being used to pay for doctors to go to conferences in places like the Virgin Islands and San Diego.
So it’s nice to see that lawmakers are moving forward on a bill to require pharmaceutical and medical device companies to disclose payments and financial perks given to doctors. Eli Lilly and Co stands out from the rest of the pharmaceutical industry in supporting the bill, although they did convince lawmakers to raise the amount requiring disclosure from $25 to $500. That’s too bad, because $499 is a pretty sweet gift. It will pay for a great dinner or a round of golf and some good scotch afterwards. It will cover most of a plane ticket to a destination within the US. And yet it still would not need to be disclosed.
The legislation doesn’t limit payments to doctors; it simply requires that they be reported. Of course, I doubt the disclosure will be in the form of a big sign in your doctor’s office saying how much money she’s gotten from each of the major drug companies. Most likely, the data will be on file in some government office, available upon rare request. I suppose it could be used by the IRS to make sure that doctors report the value of the gifts and incentives they receive from pharmaceutical companies. But most likely, this bill will just create more bureaucratic paperwork, and have little impact on the actual behavior of pharmaceutical companies and health care providers.
It’s interesting also to note that the bill doesn’t require the reporting to start until the spring of 2011. Does it really take three years to start keeping track of money and gifts that you give out? This isn’t a program that requires lots of new infrastructure or extensive training of personnel. If lawmakers are serious about limiting the bias that is created when drug companies and medical suppliers give high-priced gifts to medical providers, it seems that they could do more to curb the practice rather than just disclose it, and implement whatever program they come up with a whole lot sooner than 2011.
“…the fine grain of Ms Salamon’s observations allows her to paint a compelling—and damning—portrait of a dysfunctional health-care system. She describes the chaotic emergency room, with patients waiting in holding patterns like aircraft at a busy airport, and the “frequent flyers”, as the staff call those they send away with prescriptions for medicines these patients cannot afford, knowing they will soon be back in a bad way once more.
She meets uninsured patients with seven-figure bills, destined never to be paid, who know that only if they stay do they retain the right to be treated. (The hospital can force them to leave only if they can do so on their own two feet.) And she meets some whose stay will be tragically brief, because lack of insurance has kept them away from doctors until it is too late. One such is a young mother from the Dominican Republic without papers but with cancer that is already terminal before she seeks medical help. She dies so quickly that there is little the hospital’s staff can do other than help her relatives arrange care for her three small children.”
A recent article, Click here
for the best health care, offers
some very practical advice on how consumers can make smarter decisions when selecting
doctors and hospitals - and how to plan ahead for medical expenses.
Selecting
the right doctor
Consumers can
find out about a doctor's experience and a hospital's success rates, and even find
information on what these services cost. First, get to know your doctor.
Do some research to find out what other patients have to say about the doctor.
Personal recommendations carry a lot of weight and people trust what other consumers
have to say. Check if your doctor is board certified. Search the American
Board of Medical Specialties to find out. Make sure your doctor has done
this procedure before.Use Vitals.com
to find out how many times a doctor has performed certain procedures in a year, and
look up historical data to determine if there are any sanctions or malpractice claims.If
you cannot find this information on public sources, call the doctor’s office and ask.
You want a doctor that has lots of experience.Know
the price before you visit the provider.If
you have out-of-pocket expenses, it’s well worth your time to call your doctor and
your insurer to determine the amount you are responsible for.
Selecting
the right hospital
Hospitals provide
a lot more performance data.Just like
doctors, hospitals get better with experience.You
can use Vimo.com to find out how many
times a hospital has performed a procedure.RevolutionHealth.com also
provides similar information.HealthGrades is
an excellent source of quality ratings for hospitals. You can purchase a report from
HealthGrades to obtain cost and quality information.
For many years price increases in the medical sector has outpaced overall inflation by a significant amount. According to the Bureau of Labor Statistics, here is the increase in consumer prices over the last few years.
Year
Medical CPI
CPI
Δ
2001
4.7
1.6
3.1
2002
5.0
2.4
2.6
2003
3.7
1.9
1.8
2004
4.2
3.3
0.9
2005
4.3
3.4
0.9
2006
3.6
2.5
1.1
2007
5.2
4.1
1.1
2008 (est.)
3.2
3.1
0.1
Average
4.2
2.8
1.5
Medical inflation is outpacing general inflation by an average of 1.5% per year. But is this measure of medical inflation accurately measured? Not according to paper by Joseph Newhouse (1992). Here are 4 reasons why not.
Medical CPI measures input, not final goods. The CPI for medical services focuses on inputs such as physician visits or hospital days. However, the service the patient consumers is treatment for a specific disease. An increase or decrease in the requisite number of doctors visits is a change in the input towards treatment. A true measure of medical CPI would measure how the price to treat a disease changes over time.
Actual Prices not observed. Generally, statisticians use the list price as the price of medical services. However, very few people pay this list price. Most individuals have insurance and these insurance companies negotiate bulk discounts. Thus, the list price is not the relevant price for most individuals.
Quality changes. Even if one uses the same amount of inputs in treating a disease, the quality of medical care has likely increased over time. Of course, observing quality changes in medical care is extremely difficult.
Medical CPI weight out-of-pocket expenses. Medical CPI weighs the cost to consumers of medical spending. However, since most people have health insurance, items which are paid more frequently out of pocket receive a higher weight. For instance, dental care is more frequently paid out of pocket and thus receives a higher weight in the CPI. [I am not sure if this weighting has changed in more recent versions of the medical CPI].
Welcome to the latest edition of Grand Rounds at the Health Business Blog. This is my fourth time hosting (fifth if you include the April Fool’s edition).
We’ll start things out with a little fun before getting serious
Who says radiologists don’t have a sense of humor? Not Totally Rad’siPhluoroscope is the latest antidote to the cocktail party consult syndrome.
Clinical Cases and Images advises that starting to drink in middle age may reduce cardiovascular events as much as statins do. If the effect is synergistic, expect to see combination products enter clinical trials soon. Liquitor anyone?
And if you want to play games while drinking, Vitum Medicinus likes to pour hot water in one ear and cold in the other to make your eyes quiver.
Medical manners, miscues and menschen
I was struck by the number and depth of posts discussing the complexity of relationships among doctors, administrators, patients, nurses, and chaplains.
Other Things Amanzi offers a story from his surgical training. A senior physician had essentially left a patient to die –pronouncing his diagnosis of a fatal condition by phone and refusing to come in to help out– but our blogger and a colleague saved that patient’s life. The next day another senior doc took the two trainees to task (in public) for not performing the surgery exactly the way he would have, while the doc who’d given up on the patient and abandoned the trainees sat by silently.
Dr. Anonymous interviewed Beth Israel Deaconess president Paul Levy. The Blog That Ate Manhattanwas eating it up at least for a while. Here’s an administrator who gets it, who’s empathetic toward docs and generally a good guy. But then she reacts (or possibly overreacts, as she admits) to a comment Levy made about dealing with a difficult doc in a negotiation. In the comments section Levy explains himself further: Doctors should be expected to communicate and negotiate well as part of their jobs, and not just in dealing with administrators. Meanwhile GruntDoc was listening to the podcast, too. He didn’t take umbrage at Levy’s comment. In fact he’s a bit embarrassed that doctors display such “horrible” negotiation skills.
In case you think you can’t teach an old doc new tricks, The Entrepreneurial MD presents Secrets of developing new habits. Physicians fall into certain patterns of thinking, but they can become creative and innovative again by pushing themselves out of their comfort zone (and perhaps learning to negotiate and communicate). For the RoboDocs who aren’t quite ready to leave their comfort zone, the NEJM ran an article entitled Etiquette Based Medicine. In Sickness and In Health is saddened by NEJM’s cookie cutter approach to etiquette in the doctor/patient relationship, e.g., “Sit down. Smile if appropriate.” She considers it a poor substitute for real empathy and connection.
I’m more sanguine on the concept –courtesy and manners can go a long way for patients, even when it’s not heartfelt. Over time, following such mechanical steps may actually lead to a change of heart. But if your doctor isn’t the compassionate (or polite) type, you could do a lot worse than to receive a visit from Rickety Contrivances of Doing Good, a volunteer chaplain. What she calls Two Moments of Grace I would call, A Touch of Class. Her offer to get a glass of water for a fatigued family is greatly appreciated, and her “few trite, awkward sentences” for another patient help that person turn the corner.
Medical Pastiche offers up commentary on 7 famous medical TV shows. Some are more realistic portrayals than others, but as a whole they offer insights into doctoring and the nature of medical relationships. In any event they do have an impact on real-life patients and medical professionals –current and potential. Meanwhile, Mind, Soul, and Body was introspective and insightful in his choice of pediatrics over adult medicine. My favorite reason: “Kids don’t have that unmistakable adult hospital smell.”
Emergiblog offers words of wisdom to graduating nurses. Among them: “Please, please remember that you practice nursing and not medicine… Act like the consummate professional, and you will find that the doctors will treat you accordingly. Those who don’t have a problem. You do not.”
Suture for a Living offers aspirational words for physicians to live by, circa 1871 but still relevant today.
Patient tales
HealthBlawg went to Israel and had a pretty good experience at the emergency room. For one thing, no one asked about payment. Delayed arrival at Shakespeare’s Falafel Stand was the only real downside.
Chris is going to be quite a good husband if Six Until Me’s story of nighttime low blood sugar woes is any indication. At a minimum he’ll get used to hearing the term “honey” thrown around.
In case you’re still having trouble sleeping after all that wholesome advice, How to Cope with Pain has tips on getting better sleep and so does Highlight Health. How to Cope recommends using the bed only for sleep and sex. Apparently insomniacs had been giving the kitchen a bad name.
Health Wonk Review it ain’t, but we’ve got a few policy posts
Freedom from Smoking worries that tobacco control money is being cut in tough economic times. He may not realize that we need smokers to pay cigarette taxes for all the new domestic initiatives –like universal health insurance.
Taking Accutane for acne? You might be blackballed when you try to get insurance, says InsureBlog.
ASTHMA IQ helps physicians implement clinical guidelines, says Allergy Notes.
Wait Time & Delayed Care applies the Boston Consulting Group’s richness vs. reach framework to explain the tradeoff between quality service and wait times in health care. (I wish he’d continued in the same vein as the BCG authors, who used the construct to explain how the Internet breaks the compromise between richness and reach. Workflow innovations and health care IT display some of the same potential in health care.)
Efficient MD is launching a new wiki for health care professionals. “Clinical pearls” and “life hacks” are among the rewards to be found there, we are told. Perhaps they can resolve Wait Time’s issues.
Thanks for reading Grand Rounds. You can read my previous Grand Rounds editions here, here, here and here.
If you’re battling cancer and your health insurance provider won’t pay for a new drug that may or may not improve your condition, should you be allowed to buy it on your own if you have the means to do so? I think most Americans would answer with a vehement yes. We value our individual freedoms, and our capitalistic marketplace that allows us to buy pretty much whatever we can afford (and lots that we can’t thanks to credit cards and financing).
In the UK, there is currently a heated debate about whether patients in the National Health Service should be allowed to privately purchase treatments that are denied by the NHS. The NHS provides health care for everyone in the UK - there is no uninsured population falling through the cracks. And everyone has access to the same health care - unlike our system with hundreds of different health insurance plans available and tremendous differences in coverage from one plan to the next. But the NHS is not a money tree, and faces the same budget issues that any universal health care program does. In order to reduce costs, they have opted to not cover certain high-priced medications and treatments. They have chosen to offer health care to the entire population rather than provide high-cost treatment to a select few. In theory, it’s a good plan. Do what’s best for the majority. But what if you’re one of those people with a life-threatening illness and you’re being told that not only will your health insurance not pay for a possible treatment (that happens all the time with private health insurance too), but that you’re not allowed to mortgage your house and use the money to pay for the treatment on your own? Seems a bit Draconian.
The NHS stand is that if they allow wealthy people to purchase their own medications outside the NHS, there is no motivation for the pharmaceutical companies and health care industry as a whole to keep costs in check. They would rather see the costs kept to a reasonable level so that the treatments can be made available to everyone through the public health service. At the Colorado Health Insurance Insider, we’ve written about the financial devastation faced by families when a high-priced medication is not covered by their health insurance carrier. But it seems that it would be even worse to not have the option to at least try to purchase the treatment on your own. These are people’s lives we’re talking about - most of us would be willing to spend everything we have to save our own life or that of a loved one. After all, money and assets aren’t worth much if you’re dead.
I can see the virtue in the position that the NHS is taking. By standing up to the pharmaceutical companies and not allowing patients to pay sky-high prices for treatments that have been denied by the health care system, they are hoping to bring down the cost of the drugs so that they can afford to provide them to all patients. But the health care industry is a global market. Pharmaceutical companies are not limited to providing treatments only in the UK. The huge “free-market” private health care system in the US provides plenty of grease for the wheels of the capitalistic model of health care. As long as pharmaceutical companies can continue to operate on a strongly for-profit model in the US, restrictions on sales in other countries will have little impact. I would love to see the NHS succeed in their attempts to push for lower prices on high-end medical treatments, but it seems that they will need some powerful allies in their fight. And I would hate to be the person with the rare illness who gets told that my health insurance won’t cover my treatment and I also can’t pay for it on my own.
On Friday I posted on Consumer Driven Health Care. These consumer driven health plans (CDHPs) involve individuals having direct discretion about how health care dollars are spent. If you are interested in CDHP, there may still be some confusion over which H?A you prefer. Is a HRA (Health Reimbursement Account or Health Reimbursement Arrangement) or a HSA (Health Savings Account) better? Scott Borden of OFM Benefits Consulting gives some simple explanations in his Kansas City Star article (”…Health Insurance for Workers“).
Get a Good Deal on Your Health Insurance Without Getting Ripped-Off named to "10 Must-have Investing and Insurance books"
"Dummies and Idiot’s guides may get you started in investing and help you understand the intricacies of your insurance policies, but these books are must-haves if you want to be an intelligent investor and consumer." - writes Dave Ralis of PhillyBurbs.com, the online version of the Bucks County Courier Times, who placed Get a Good Deal on Your Health Insurance Without Getting Ripped-Off on his list of "10 Must-have Investing and Insurance Books".
Jonathan Pletzke is a consumer expert on health insurance and author of the health insurance bookGet a Good Deal on Your Health Insurance Without Getting Ripped-Off, available online and at bookstores nationally. Additional details can be found at the consumers health insurance book and resources website www.BestHealthInsuranceBook.com. Copyright 2007-2008 Aji Publishing.
The Senate Finance Committee has held the first of eight congressional hearings aimed at figuring out how to fix health care in America. This week’s hearing included testimony by former HHS secretaries Donna Shalala and Tommy Thompson, who offered somewhat opposite strategies to tackle the mounting health care crisis facing the US. Thompson’s idea was to start by addressing shortfalls in the Medicare budget, which he said would run out of money in another decade. He proposed increasing Medicare revenue (likely meaning an increase in premiums for retirees?), increasing the age for Medicare eligibility, and cutting benefits in the program. None of these ideas are likely to go over well with America’s aging population - the baby boomers who are approaching retirement age will be less than pleased to have fewer health insurance benefits, higher premiums, and more years to go before they qualify for coverage. Shalala disagreed with Thompson, and would rather that we focus on simplifying the current health care system to eliminate waste and streamline the process in an effort to provide universal health care.
I must say, it seems sad that we currently don’t provide universal health care for our citizens until they reach age 65. In most developed countries, everyone has access to a system like our Medicare program, and they don’t have to wait until they have gray hair to qualify. Making people wait even longer doesn’t seem like a very noble solution (maybe they hoping that more people will die before reaching the eligible age, and never get Medicare benefits at all?). Cutting benefits doesn’t seem like a good idea either. Medicare is already somewhat lacking in benefits, and seniors without private Medigap policies can get stuck with some serious medical bills in the event of a long hospitalization or serious illness. Increasing premiums could be a viable solution to some extent. Since so many seniors are on a fixed income, any premium increase would have to be small, but a series of small increases several years in a row might help keep Medicare solvent.
We’re going to have to address cost control issues before we can tackle health care reform. Any way we look at it, we’ll have to reduce waste and excessive expenses in the health care industry, and pass the savings along to consumers who are struggling under the burden of health care expenses. Overall, I’d say that at the Colorado Health Insurance Insider, we agree with Donna Shalala’s thoughts on health care reform. Limiting benefits and restricting coverage to fewer people (which would be the result of an age increase for Medicare eligibility) is counterproductive to the overall goal, which should be to provide all Americans with access to truly affordable health care.
Jonathan Pletzke is a consumer expert on health insurance and author of the health insurance bookGet a Good Deal on Your Health Insurance Without Getting Ripped-Off, available online and at bookstores nationally. Additional details can be found at the consumers health insurance book and resources website www.BestHealthInsuranceBook.com. Copyright 2007-2008 Aji Publishing.
I am pleased to announce
the new release of OutofPocket.com, version 2.0. Our new search engine enables
consumers to look-up prices for health care services, and allows providers to list
their prices/services in the directory - free of charge.In
addition, the search engine features expanded search technology and searches
for health care price data across other public price transparency tools.
I welcome all your
feedback and comments on this new release and I would appreciate if you could help
us spread the word.As you know, the
more people that contribute and use this tool, the more powerful it will become for
everyone.
Thank you for all
that you do to help promote health care price transparency.
NEW FEATURES IN OUTOFPOCKET.COM
VERSION 2.0(1) Enhanced search
engine provides more relevant search results(2) Easy for consumers
to post/share their own visits and prices they paid for services(3) Comprehensive
search results - searches other websites that publish pricing and websites that offer
price transparency toolsPRICE DATA COLLECTED
FROM MULTIPLE SOURCES·Providers
can submit price lists for their services·Consumers
are invited to post/share prices they paid for actual visits, along with their personal
recommendations on the provider
·Claims
Data from Businesses, Health Plans or TPAs·Government
CMS Medicare payment data
·Websites
that publish prices for health care services including hospitals, diagnostic testing
facilities, clinics and physician practices
·Price
Transparency Tools on public websites including health plan tools and state price
transparency toolsBENEFITS for BUSINESSES·Load
your claims data into OutofPocket.com to enable your employees to search for their
true out-of-pocket costs for specific service·Employees
can use OutofPocket.com to search for prices for specific services in your network
plan
·Encourage
employees to collaborate and post prices they paid for health care services, to share
these good deals with other employees·Eliminate
providers that overcharge - Use OutofPocket.com to direct your employees to affordable,
low-cost providers·Avoid
providers with poor performance by encouraging employees to share recommendations
on provider visitsBENEFITS for CONSUMERS·Look-up
prices, comparison shop and find the best value for routine health care services in
your neighborhood·Tool
makes it easy for you to post/share prices you paid for actual services with other
consumers·Share
your recommendations on a specific provider with other consumersBENEFITS for PROVIDERS·Add
your true prices/services to the directory – free of charge·Consumers
can easily find your services and link to your website·Include
additional information about your practice, services·Search
results links directly to your website·Provides
additional exposure for your services
The California
HealthCare Foundation (CHCF) offers some great tips for
consumers that are interested in comparison shopping for non-emergency hospital services.The
consumer tips provided by the CHCF are based on the results of a recent mystery shopper
study conducted at 64
California
hospitals. Here are some of the highlights,
but be sure to visit their site to read all the tips. Most important, be sure to ask
the right questions before using hospital services.
1.Call
first.Consumers should call a hospital
to obtain pricing information, rather than wait to ask for pricing in-person.
2.Know
the CPT or ICD-9 code.This is the
specific American
Medical Association (AMA) code assigned to each medical procedure or service and
is used for billing purposes.It’s actually
a lot like a specific part-number for an electronics you purchase.When
you know the specific code (part number), you can compare apples-to-apples.Once
your doctor has explained the service or procedure you need, ask your doctor for the
CPT code.It will save you time and money.
3.Ask
about a discount.If you don’t ask,
it almost certainly won’t be offered.Find
out how much and under what conditions discounts apply.You
might find that paying by cash or using your credit card entitles you to discount.
4.Find
out what’s included.There’s little
consistency among hospitals in terms of the type of prices quoted, making applies-to-applies
comparisons difficult. You should ask
as many questions as necessary until you are comfortable with the information about
what specific services are included.If
you are not getting the answers you need, ask to talk to someone in Admitting, Financial
Counseling, Billing or the Cashier’s Office.
Listen to a brief audio clip from an appearance on FM Talk 101 with Brad and Britt in the morning.
The format of the program was an introduction of Jonathan and the health insurance book Get a Good Deal on Your Health Insurance Without Getting Ripped-Off, followed by discussion with the hosts about the health insurance book, and then to the callers, who provided questions that Jonathan was able to answer well.
Jonathan Pletzke is a consumer expert on health insurance and author of the health insurance bookGet a Good Deal on Your Health Insurance Without Getting Ripped-Off, available online and at bookstores nationally. Additional details can be found at the consumers health insurance book and resources website www.BestHealthInsuranceBook.com. Copyright 2007-2008 Aji Publishing.
The latest Cavalcade of Risk blog carnival is lovely. It is hosted this time by I’ve Paid For This Twice Already and includes some excellent reads on risk (health insurance being my favorite). My blog posting on health insurance copayments is included.
Jonathan Pletzke is a consumer expert on health insurance and author of the health insurance bookGet a Good Deal on Your Health Insurance Without Getting Ripped-Off, available online and at bookstores nationally. Additional details can be found at the consumers health insurance book and resources website www.BestHealthInsuranceBook.com. Copyright 2007-2008 Aji Publishing.
Today’s post about hip replacement surgery reminded me of the huge difference in money, time, and anguish that can occur when a hip replacement is needed. We had a family member who has had a hip replaced in the “regular” way - with months of rehab, following a few weeks in the hospital. Had we known in advance about procedures like the one mentioned in the InsureBlog post “Nice joint. Thanks, I’m hip.”, our family member would have saved months of recovery, thousands of dollars in hospital costs, and been back on her feet in days, back at work.
When looking at the cost of health insurance and procedures, we often overlook the non-covered costs to the patient and family, which can sometimes exceed the costs of the procedure. Being out of work for months, needing additional care at home (or in a facility), and the physical pain and accompanying mental anguish are large costs, too. If you are in the market for a hip replacement, or know someone who might, shop around for different doctors and different approaches. There might be a huge difference.
And while I don’t know alternative treatments for many other maladies, there have got to be some other big ones, such as the difference between back surgery versus chiropractic or osteopathic medicine.
Jonathan Pletzke is a consumer expert on health insurance and author of the health insurance bookGet a Good Deal on Your Health Insurance Without Getting Ripped-Off, available online and at bookstores nationally. Additional details can be found at the consumers health insurance book and resources website www.BestHealthInsuranceBook.com. Copyright 2007-2008 Aji Publishing.
“Every day, I spend at least an hour after my workday to call patients back, to discuss lab results, to discuss test results,” Ryan Mire said. “That’s not compensated.”
Mire’s an internist based in Nashville, and he was speaking this afternoon on a panel with the un-subtle title “The Impending Collapse of Primary Care.”
The panel was part of an internal medicine conference in DC (we listened in via phone), and there was a fair bit of policy talk about how to improve primary care in this country. That’s all well and good, but we were especially struck by Mire’s description of “those simple things that I’m expected to do on an everyday basis, but I’m not compensated for.”
Certainly, any doc (or anyone else, for that matter) who is not getting paid by the hour is likely to do some uncompensated work. But the issue does seem pretty compelling in the case of primary care docs, who work in a payment system that tends to favor procedure-oriented specialties.
“Just in the last three weeks, I have actually noticed three medication errors from specialists who prescribed medications for my patients because they did not have the full history,” Mire said. “I received those consultation notes, saw what the specialist prescribed, and said, ‘Absolutely not, do not take that medicine.’”
Yul Ejnes, a Rhode Island internist also on the panel added a couple other typical primary care tasks that aren’t reimbursable: “talking with family members,” and “just sitting down and thinking” about a case.
“Sometimes I wonder whether I want to keep doing this,” Ejnes said.
A long-running fight over a UnitedHealth deal in Nevada revved up yesterday, with some marquee opponents filing court papers in DC in an effort to block the deal.
The insurer’s $2.6 billion acquisition of Sierra Health has already been approved by the Department of Justice and by state regulators.
But that hasn’t stopped opponents including the AMA and the Clark County Medical Society, the powerful health-worker union SEIU and the House Committee on Small Business from continuing to press their case with the Justice Department and in U.S. District Court, the Associated Press reports.
The basic argument against the deal is that it would give UnitedHealth an overwhelmingly dominant share of the HMO market in Nevada, perhaps as high as 90%. The head of SEIU’s Nevada branch says the company would have “unbridled market power,” and the House committee says the deal could lead to doctors and other providers getting squeezed on reimbursements.
The companies have said that Sierra Health will retain its own leadership, and expand its offerings without raising rates. What’s more, the acquisition has already gone through, UnitedHealth spokeswoman Cheryl Randolph told the Health Blog. “It’s a done deal,” she said.
Just last week, she noted, UnitedHealth sold part of its Nevada Medicare Advantage business to Humana to comply with requirements regulators put on the Sierra acquisition. “The deal, as approved, will be beneficial for all Nevadans,” Randolph said. “We think the information thats being put out now by these groups is without merit.”
As we’ve reported before, fights over insurance-industry consolidation have become rather common, with the AMA often arguing that consolidation in the insurance industry gives payers more leverage in setting reimbursement rates.
If you’ve ever had to stay in the hospital for a while, you know how different night and day can be.
After sundown the doctors get scarcer, the nurses fewer and the waits for just about everything get longer. There aren’t many bosses or seasoned pros around when things get sticky.
The result is a “stark discrepancy in quality between daytime and nighttime inpatient services,” David Shulkin, president and CEO of Beth Israel Medical Center in New York, writes in the current issue of the New England Journal of Medicine.
The lighter staffing in off-hours contributes to higher mortality rates, more complications from surgery and more frequent errors compared with the day side. Shulkin says we shouldn’t accept that. For starters, he writes, we need to scrap the notion that hospitals should run differently at night compared with the daytime. “We should be establishing equal standards for staffing and service and striving for acceptable outcomes for every hour of the week,” he argues.
We managed to reach Shulkin, in the afternoon we’ll admit, to talk about his experience prowling Beth Israel after dark. Earlier this week, he took his senior management team along for the first time on his midnight ride. The group cause quite a stir from the sounds of it. The night staff aren’t used to seeing that many bigwigs a
“Every day, I spend at least an hour after my workday to call patients back, to discuss lab results, to discuss test results,” Ryan Mire said. “That’s not compensated.”
A long-running fight over a UnitedHealth deal in Nevada revved up yesterday, with some marquee opponents filing court papers in DC in an effort to block the deal.