Over the past 3 decades, total U.S. spending on cancer care has more than quadrupled, reaching $125 billion last year, or 5% of the nation's medical bill, according to a recent estimate. By 2020, it could grow by as much as 66%, to $207 billion. Multiple forces are driving the spiral: a growing and aging population, more people living longer with cancer, and new "personalized," or "targeted," therapies that can come with sticker-shock prices of $50,000 or more per patient. New and more costly, however, haven't necessarily meant better. Although targeted treatments have helped improve survival rates for many cancers, some extend life for just a few weeks or months (see p. 1542). And the prices can be sobering: more than $1.2 million to extend a lung cancer patient's life for 1 year in one scenario involving a costly but common drug. That example is unusual, but such numbers have sparked a growing—and sometimes feisty—debate over how best to calculate the benefits of new cancer treatments, whether their use will lower or raise per-patient expenses, and who should decide whether using them is worth the cost.
Correctly Controlling Care Costs (Series)
The Cost of Care --the Elephant in the room
A mini-series that exposes the fundamentals of reform, largely missed in the current debate.
First, see Paul Krugman's "Patients Are Not Consumers."
"The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car. [But,] 'Consumer-based' medicine has been a bust everywhere it has been tried....there’s something terribly wrong with the whole notion of patients as 'consumers' and health care as simply a financial transaction."
"Medical care, after all, is an area in which crucial decisions — life and death decisions — must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge. Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping."
Then David Malakoff's "Can Treatment Costs Be Tamed?"
Read the Full Text [free registration required]
Please visit my related articles, below; they are brief, but if you are one of those who must read the end, first [a la "When Harry Met Sally," Billy Crystal], I suggest you go right to #10.
- Wrong Priorities-I.E., Business Over Patient Needs
- Spending Too Little of Insurance Premiums on You and Me
- Inefficiency That Robs Patients of Their Rights
- Healthcare Organizations Who Think They Can Practice Medicine
- The Phenomenon of a Captive Audience
- Access Problems Creates a Flood of Downstream Costs
- Less Costly Trumps Effective
- Callous Disregard for Patients in Their Time of Need
- Failure to Observe the Cardinal Rule of Medicine: First of All, Do No Harm.
- Failure to Observe the Cardinal Rule of Managing Care—Measure and Manage!
1. Wrong Priorities
Witness the outrageous 20-30% administrative overhead of medical insurance companies....
This discussion point is part of a blog-series, "The Short Shrift of Healthcare." See "Reforming Healthcare & Managed Care" on HCPLive.com
That includes a covert and obnoxious 'cost-savings-is-more-important-than-patient-care' reward system. This is even true for non-profits. It's the difference between medical business and the business of medicine—taking care of patients or profit$.
As stated in the Consumer Watchdog, Dec. 24, 2009, health insurers' rate increases among other intolerable, unaccountability must be monitored, if not prior-approved (cross-ref. Calif. Proposition 103).
Submitted by Nirav Patel (verified) on Wed, 2010-01-06 16:14.
Another Perspective: I don't think health insurance companies are 100% EVIL (many of the rules they impose on doctors keeps them from doing crooked things and ordering extra stuff which could hurt the patient) but are so bad right now because they do whatever they want. Break the Anti-Trust exemption and force them to be more transparent and see if they can keep that 20%-30% buffer to play with. We can use the blogs to spread the word about the companies that use the least amount of money on APPROPRIATE care. Even though they spent the money, they can just give it to certain doctors on their payroll to keep the money under their control. Don't put anything past 'em'!
From jgk:
I agree, Dr. Patil. Here's a fundamental of managed care that is in keeping with your ideal of positive support of doctors--"Measure and Manage."
"Health care reform will eventually pit the goal of expanding health insurance coverage against strong pressure to reduce the growth in health care costs. If left to measures in the proposed reform legislation, cost containment will be driven primarily by marketplace incentives, programmatic initiatives, and organizational changes that would partially offset the costs of expanding coverage.[1] These proposed economic policy changes and incentives, however, are not guaranteed to lead either to individual clinical decisions that will be in patients’ best interests or to enhancement of the public’s health. Rather, these forces are relatively blunt instruments that might nudge the health care system toward efficiency, without precise direction."
"Thus, to ensure that the health of the population is enhanced, rather than diminished, by the reforms, these measures must be accompanied by the sharper tools of comparative-effectiveness research (CER). Unless we are willing to allow our health care to be driven solely by financial and regulatory incentives, CER should become an important part of the equation. Rather than being resisted by the clinical and public health communities, it should be embraced."
Mushlin AL, Ghomrawi H. * "Health Care Reform and the Need for Comparative-Effectiveness Research.: Posted by the N Eng J Med, Jan. 6, 2010 [* From the Department of Public Health, Weill Cornell Medical College, New York.]
10. Cardinal Rule for Managing Care--Measure and Manage; Manage and Measure
From my perspective (a 30-year veteran physician executive), the syllogistic logic of these issues ought to be inescapable -- to help the patient, health care quality must be maintained if not improved (outcome measurement and monitoring is critical) and cost must be decreased at the same time through efficiency, discretion, and giving patients what they need (ie, better value for health care).
For more on this, see "What is Value in Health Care," where you will hear, once again, that the incentives in health care must be aligned and there must be accountability for substandard care.
I See the Elephant in the Room -- Making Care Affordable
Friday, December 17th, 2010
In which the author offers a 10-item to-do list for making health care more affordable.
On December 3, 2010 I posted, "We Deserve Better: 10 Steps to Delivering Quality Health Care." In that post, I moved past the little we currently have to show for our quality management efforts and offered the following 10 practical steps to meaningful health care reform that encompasses public health and preventive services, forces shared responsibility and self-examination, and applies peer pressure where and when it is needed:
We Deserve Better: 10 Steps to Delivering Quality Health Care
Friday, December 3rd, 2010
Ten action items for improving the quality of care delivered by the US health care system.
In my previous post, “When Medical Quality Suffers, People Are Harmed,” I discussed the consequences of medical and surgical errors. It is disheartening to read the US statistics surrounding this topic. We pale in comparison to many other countries (even some third-world nations). Speaking as a former physician executive, often in charge of quality improvement and appropriate utilization management, I'd like to present 10 immediate steps that will reduce poor quality of care.
Ten Steps That Reduce Poor Quality Care
1. Group practice of medicine, preferably operating around a hospital that includes peer review, performance incentives, shared information and a computer-based tracking system.
2. More effective public health and preventive services available to the entire population, based on its dynamic needs.
3. Group-based payment for health services, structured through the use of insurance or taxation for sharing the costs of health care, broadly across people and time.
4. Shared responsibility and accountability by patients, doctors and/or systems of care, as the case may be for: adverse life-style choices where there has been little of no intervention, non-compliance where patients are quite capable of adhering to appropriate medical/surgical recommendations, failure to cost-share and prevent clearly unnecessary care, excesses, and failure to use or follow peer-reviewed standards of care.
5. Enhance coordination between medical and community services. We also need to make improvements in medical education that will strengthen the social content of curriculum and expand the supply of general practitioners, (in contrast to specialists).
6. Align the incentives to ensure that everyone's on the same page with a single goal of providing efficient, effective, and accessible care. I as a practitioner should be able to earn a premium, the healthier I make you. Should that fail, at least recognize my efforts and its quality. Note: this is not the same as “pay per performance” (See: "Pay for Performance and Other Impotent Incentives" and "Quality Incentive Payment Systems: Promise and Problems"). We must align the incentives so that patient, practitioner and facility have the same objective—the right care at the right time and place. There cannot be any incentives for delaying care—bureaucratic hurdles, as it were. There can be no incentives for over-utilizing—for instance, giving unnecessary antibiotics or shotgun, “blind alley” testing. There can be no incentives for under-utilizing, such as, over-referral (ie, dumping patients), delaying or cutting short physical therapy, skipping patient education, mental health care, etc). Incentives should include, but not be limited to providing payment when pre-established goals and objectives are met. In other words, wherever possible, we should be aligning payment and quality in the interest of motivating improvement.
7. Transparency and public reporting See "Error Reporting and Disclosure" especially as it discusses systems improvement such as electronic error reporting.
8. Encouraging real, salutary quality improvement It would be misleading to say that mere transparency had motivated surgeons, for instance, to make improvements that they would not have done otherwise. I believe that most if not all concerned professionals are or should be interested in continuous quality improvement. Indeed, I have found that most practitioners will pick up on real or even putative deficiencies, learn from the introspection, and develop new techniques, improving what has to be improved, incrementally if necessary. In "Deaths Drop after Release of Bypass Surgery Results,” it is not proven that this was cause and effect, but it's certainly suggestive that patients will choose wisely if given the needed information. On the other hand, if you think that certain surgeons, given the spotlight will avoid the riskier cases, we should be seeing a decrease in the number of bypass surgeries. I cannot find any evidence of that. If anything, the average age and number of co-morbidities in bypass cases seems to be increasing.
9. This brings us to the final point of the need to be closing the feedback loop in real-time (ie, at the point of contact with the patient and with believable data). For that one needs acuity adjusted data, which will allow comparing apples to apples, not apples to oranges.
10. Finally, one needs a longitudinal perspective -- all care over time, regardless of setting, the definition of a reliable type of observation -- an 'episode of care.' (See: "Report Cards That Support")
The United States ranks last when compared to six other countries: Britain, Canada, Germany, Netherlands, Australia and New Zealand. Indeed, America spends twice as much on healthcare compared to residents of other developed countries, but gets less healthcare quality, efficiency, and equity, according to a “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally,” a report published June 23, 2010 by the Commonwealth Fund. You can read the executive summary of the report here. Download a PDF of the full-text version of the report here.
The report looks to the healthcare legislation passed acrimoniously in the US designed to substantively improve the cost and quality of our healthcare.
I e-mailed Karen Davis, PhD, coauthor of the report, who has helped me in the past to sort through the geopolitical issues about what is meant by "value," to ask her opinion about America’s performance in healthcare as a nation, particularly in terms of incentives as a means to quality and value improvement.
Noting that the Commonwealth Fund report "Health Reform's Impact: Health Spending to Shrink by $590 Billion, Family Premiums by $2,000, Over Next Decade,” stated that "significant payment and system reform provisions in the Patient Protection and Affordable Care Act will begin to realign incentives within the health care system and reduce cost growth,” I asked Davis how, exactly, in the ideal, organized healthcare system can or will incentives be realigned? I also asked her whether, knowing what we do from the balloon analogy, if there is evidence that such efforts will have a net positive benefit and whether such efforts could be durable.
feedback, feedback loop, incentive alignment, align the incentives, informatics, medical informatics, medical practice, patient safety, medical error, patient-physician communication, patient-physician relationship, health care, primary care, family medicine, quality of careHere is what she wrote in response:
Dr. Kaplan,
"Thanks for your nice note and ongoing interest in Commonwealth Fund work. The Cutler-Davis study you mentioned refers to several specific payment and system reform provisions in the Affordable Care Act that change financial incentives within the health system to reward quality and value rather than volume. These include higher reimbursement for preventive care services and patient-centered primary care; bundled payment for hospital, physician, and other services provided for a single episode of care; shared savings or capitation payments for accountable provider groups that assume responsibility for the continuum of a patient’s care; and pay-for-performance incentives for Medicare providers. These provisions, among others, were projected to lead to substantial health system modernization and savings of $590 billion over 10 years."
"Further Commonwealth Fund case studies and reports have shown that successfully realigning financial incentives offers the opportunity to stimulate greater organization as well as higher performance. I’m attaching an article I wrote with Dr. Paulus and Dr. Steele of the Geisinger Health System in Pennsylvania that details some of the successful payment and delivery system changes undertaken there. You may also be interested in the report on realigning incentives and organizing delivery written by several Fund colleagues. We recommend that payers move away from fee-for-service toward bundled payment systems that reward coordinated, high-value care. In addition, we recommend expanding pay-for-performance programs to reward high-quality, patient-centered care."
Clearly, we're on the same page....
9. The Cardinal Rule of Medicine: First of All, Do No Harm--Reducing Dx Errors
Reducing Dx Errors in the Patient-centered Medical Home
Thursday, August 19th, 2010
The use of electronic medical records (EMRs) and the patient-centered, medical home (PCMH) concept can reduce diagnostic errors as they combine to improve coordination, communication, and the continuity of care. However, it is neither the EHR, the PCMH, nor the combination; rather, it is the corporate culture, the ever-evolving system of care and the willingness to 'close the feedback loop.'
According to "Reducing Diagnostic Error Through Medical Home–Based Primary Care Reform,” the patient-centered medical home (PCMH) is one important conceptualization that potentially can address safety concerns in primary care, especially diagnostic error (ie, missed, delayed, or incorrect diagnoses).
This issue is “possibly the leading type of error in primary care. Diagnostic errors are the single largest contributor to ambulatory malpractice claims (40% in some studies) and cost approximately $300,000 per claim on average.”
The underpinning of this concept of practice improvement and safety is that it makes changes that: “improve coordination, communication, and continuity of care” and that it employs “electronic health records (EHRs), which, despite their current limitations, can enhance access to data and advanced decision support to reduce diagnostic error.”
It is important to note that the above commentary relies on Vincent, et al's framework of five “rights” for reducing diagnostic errors:
- Right Teamwork
- Right Information Management
- Right Measurement and Monitoring
- Right Patient Empowerment
- Right Safety Culture
Vincent, C., S. Taylor-Adams, and N. Stanhope. 1998. "Framework for Analyzing Risk and Safety in Clinical Medicine." British Medical Journal 316 (7138): 1154-57.
Vincent, C. 2003. "Understanding and Reporting Adverse Events." New England Journal of Medicine 348 (11): 1051-56.
Less Costly, Better Care
HCPLive, Published Blogs
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2. Profits Before Patients
What kind of business are practitioners, health care (HC) organizations, or including HC insurance companies in?
When they're spending too little of insurance premiums on health care?
The concept of the Medical Loss Ratio—the percentage of the premium dollars collected by the insurance company's that are actually spent on health care—helps explain how insurance companies are using you as their financial engine and what their priorities are.
The "health insurance industry says its average MLR is 87%," but, according to Senate research, it's significantly lower.
Note: this discussion point is part of a blog-series, "The Short Shrift of Healthcare." See "Reforming Healthcare & Managed Care" on HCPLive.com
As stated in the Consumer Watchdog, Dec. 24, 2009, "The Senate bill's requirement that insurers spend 80% or 85% of the premiums they collect on health care services will—absent strict rate regulation—perversely encourage insurers to raise their premium rates. In the same way that a Hollywood agent who gets a 20% cut of an actor's salary has an incentive to seek the highest salary, insurers will have incentive to increase health care costs and raise premiums so that their 20% cut is a larger dollar amount."
3. Inefficiency Pays
I feel they picked my pocket! Consider what happened to me—I broke my leg (a 4" fibula fracture). An orthopedist inserted a 4-inch plate, but the surgical wound wouldn't close. After a month of therapies, Anthony, my wound specialist ordered the KCI’s proprietary V.A.C.® Therapy System. He got "prior approval" from Oxford, and I was given the necessary equipment—a suction device to wear on my belt, 24 hours a day, specialized coverings that breathed, tubing, waste canisters, etc. These "supplies," were integral, mind you to V.A.C. therapy. Nevertheless, Oxford hit me for $1700 saying they were an "uncovered benefit" (whatever that means).
Note: This discussion point is part of a blog-series, "The Short Shrift of Healthcare." See "Reforming Healthcare & Managed Care" on HCPLive.com
Are these supplies any different than requiring a spacer for a child's asthma medicine (puffer) or tubing and a mask for their nebulizer treatment? Is that different than how insurance companies weasel out of their responsibility with the infamous pre-existing exclusion clauses? Here's a patient-ER scenario, all too commonplace in the callous world of health insurance: Insurer, not saying, but implying: "We'll decide later if it was medically necessary. Start your chemo. We'll review the indications, and we're sorry" if you died/suffered/deteriorated in the process!"
P.S. Why are the "supplies" so expensive? Because KCI sterilizes and packages this equipment--5 packages to a cardboard boxes that they claim they sterilize. In other words, you must buy five even when you need one; they charge the patient who is already hurting too much to argue, $237.45 or even $253.30 per box. Thus, this suppler gets their money and, like the insurance companies, they are escalating the cost of care.
I need to add that while I was at the Wound Center, I saw a number of patients in need of extraordinary wound care (diabetics, peripheral vascular disease) being denied necessary care by their insurers because of contract exclusions, preexisting conditions, bureaucratic delay, or insurmountable hurdles—I am dismayed when it's profits before patient care!
4. Managed Care Organizations Practicing Medicine (Without a License)
Just today in pediatrics, Aetna refused to pay for a visit of a child with a probable goiter and strong family history who needed diagnostic lab tests—they do not accept rule-outs. Last week Oxford levied a $50 deductible and $25 co-pay for the most efficacious eardrop we have in our armamentarium; Reason? This drop, containing an antibiotic and a steroid was not available generically; they were forcing me to use a plain eardrop – not what the doctor ordered!
Mental Health Parity; Let the HMO's Be Damned!
To improve the insurance coverage of mental health care, employers and group health plans are ruled against discrimination, * i.e., providing less coverage for mental health conditions than physical ones.
Note: this rule was originally approved in 2008 and it will finally become law in July 2010. "The administration said the new requirements could increase premiums by four-tenths of 1 percent, or $25.6 billion over 10 years. Businesses with 50 or fewer employees are exempt."
- However, under it, insurers can still second guess practitioners and challenge payment for lack of “medical necessity.” This is shameful on its face as any practitioner can attest—the patient is often in crisis, demanding treatment that is uncomfortable for the average doctor because of poly-pharmacy, black-box warnings on meds, and the unpredictable nature of mental illness itself.
- Then there's the insidious fear of litigation.
- How about Insurers' Hustle, Hurdles and Hubris? How arrogant of insurers when it comes to behavioral medicine--patients do not always know when they're not going to be able to cope and, by definition, they're unaware when on the 'slippery slope' of a breakdown. Compounding this is the stigma of mental illness that itself contributes to delays in diagnosis and treatment. Enter managed care with its promises of coverage, only to be followed by hurdles [see: "Battling for Health Coverage as Cancer Spreads"], denials and delays. Think you can legislate fair treatment? Think again--adding insult to injury, insurers "can still require prior approval of some services and can still charge consumers more for using doctors and hospitals that are not on a list of preferred providers."
- It is disgraceful that this coverage is job-related and it is outrageous that the immoral disparity was ever allowed. (But, it has not been that long since those with mental illness were incarcerated as the mainstay of treatment. [See Dorothea Dix's reform efforts in1844])
- The standards, guidelines and methods used to manage mental health benefits must be comparable to those for other medical care and cannot be applied more rigorously. Discrimination is manifest by disparities such as: setting separate or higher co-payments or deductibles or applying stricter limits on the treatment of mental conditions, addiction disorders or physical illnesses.
Disparities are, unfortunately all too common in the insurance industry. "By sweeping away such restrictions, doctors said, the rules will make it easier for people to obtain treatment for a wide range of conditions, including depression, autism, schizophrenia, eating disorders and alcohol and drug abuse."
5. The Phenomenon of a Captive Audience
Off the record...health care is a mess. On the record...health care is a mess.
From: A State Medical Director for managed entitlement programs, Justin
We're a captive audience, stuck between the proverbial 'rock and a hard place'....
Big Pharma's making our drugs the most expensive in the world and getting Congress to protect their trade; it's a quid pro quo for support and TV adds in favor of health care reform.
We recently saw how "several prominent House Democrats" acknowledged, that they had "to give up a public option for insurance coverage in health care reform negotiations with the Senate." I don't know about you, but I hate to see serious reform reduced to politicians seeing what concessions they can extract for their vote.
Politics: the conduct of public affairs for private advantage.
- Ambrose Bierce
Then there's human nature showing what can happen if you're 'stuck.'—Docs ordering more visits when paid by the visit; referring more when not at risk for those referrals, especially the tough cases; reducing care when prospectively paid (e.g., capitation), and the worst example yet – an orthopedist telling a fibula fracture patient to use a boot and crutches or stay in bed for 3-6 weeks when he learned he would not get a surgical fee. (Yes, it really happened!)
From: The Executive Director of a large, academic group practice, Gilbert
Sent Feb. 27, 10:33 AM EST
Indeed, the patient is a captive audience and vulnerable, but there's hope---A lot of Federal (taxpayer) dollars are going to be spent on comparative effectiveness research over the next few years, and if there's a better use of my money I'm not aware of it. It is widely acknowledged that much of what we spend is wasted on unnecessary tests, advertising-driven consumer demand, unproven treatments and procedures that benefit device companies, specialists, and facility owners far more than patients.
It's also equally clear that reining in those costs is going to be incredibly difficult, because much of it occurs in the somewhat grey area between procedures that are clearly useless or harmful, and those that are undeniably appropriate. And while that grey area is where hundreds of billions are spent every year, it is also there where patients need real protection.
Justin's response, sent Feb. 28, 10:01 AM EST
Off the record...we are all to blame; On the record...we are all to blame.
Off the record...vested interests, including those who already seem to have their insurance issues taken care of (the people of Mass.), are not interested in fundamental change out of fear it will come at their expense (it will...insurance reforms, especially expansion to those who don't have it, costs money and surprisingly most of the money will come from people with current jobs and good health insurance).
On the record...same.
For example, with respect to insurers not paying for necessary supplies—my view depends on the details of the contract. I don't have enough information to say. I know that medical supplies are sometimes not even covered at all (in Child Health Plus, for example, I don't believe that spacers are a covered benefit because it is a 'supply' and only diabetic supplies are covered by legislation). Why? Because the folks who decide the benefits (your employer) didn't want to pay the extra premium for coverage of supplies (or, in the case of child health plus, the legislature/budget).
From: Jgk, responding Feb. 8, 2010 5:48 PM EST:
So, the patient is 'stuck' because the healthcare insurer forgot what business they're in.
Would it be right for an insurer to deny a spacer when that is vital for the administration of a beta2 agonist or ICS? How about a nebulizer mask and tubing for the same purpose? In other words, we should change the name of insurer to money launderer! Moreover, the employer is meddling in my health care insurance needs!
From: Fredrick (MD, PhD, JD)
Sent: Mar 30, 2010 4:53 PM
If a person buys an Indemnity insurance contract, he expects the insurer to pay for what the doctor orders. A failure to do so is Breach of Contract! For HMOs the problem is that the "discretion" allowed to the MBAs is frequently exploited to their own benefit, and "public opinion" notices that.
The solution to the problem is to remove medical discretion from the MBAs and their tame medical 'experts', and repose it in a disinterested non-profit body to make those efficacy calls, but always with an easy out for special cases.
But, quis custodiet ipsos custodes? If it is a government agency, as set up in the new health bill, people will note that the government is one of the largest payers. Can it be trusted not to try to minimize its costs? If it is a professional organization, can they be trusted to ignore the financial needs of their own practitioner members? And, what is the effect of commercial lobbying on the ultimate decisions?
I think this is the obvious place for a Science Court, where the pros and cons of a treatment or procedure are argued in Public by experts on each side, and decided by scientist-judges strictly vetted for absence of conflicts of interest.
Jeff, as I have argued before, they should not come up with one decision in each case, but with 2 rebuttable presumptions--an upper and lower level. Above the upper level, the procedure is rebuttably assumed to be proper; below the lower level, it is rebuttably presumed improper; and, between the levels, the doctors' decision is left undisturbed.
By "rebuttal", I mean that outside the middle range, the doctor must present evidence why in the particular patient the presumptions should not be applied. The nature of acceptable evidence should also be decided by the Science Courts. All their decisions should have Sunset provisions, to be sure that they are reviewed periodically.
As the saying goes, Justice must be SEEN to be done! Now, in this area, I don't think our existing institutions are capable of even reaching just decisions, much less ones that will carry conviction to the public that's ultimately paying the bills.
6. Access Problems
When patients require specific therapies and an insurance company makes the frail or sickly patients jump thru hoops, denying or delaying care, it's time to move away from the insurance model. How furious should we be when the insurer uses technicalities to refuse coverage, makes patients wait incessantly on the phone, transfers calls to G_d knows now many departments and then, after seemingly hours, the connection breaks, etc.?
Returning to my own experience [Article 3] getting post-op wound therapy, I was stuck with huge out-of-pocket expenses, I later learned from the Wound Center that patients more needy and less well off then I were refused vital therapy.
(It is this kind of crap that motivates me to write this column.)
Anyway, we all know that these refusals, delays and denials are mostly in the interest of maximizing corporate profits at the expense of patient's lives or limbs.
Is that any different than a doctor ordering the wrong test, wrong specialty consultation or wrong med and then making the patient pay for the wrong care?
Can we excuse fractionalized care where one hand (err, doctor) doesn't know what the other is doing?
Is that different from predictable, repetitive, avoidable mistakes in the hospital setting?
________________________
- This happens daily, for example, when patients use the ER rather than a medical home (their doctor's office) for routine or non-urgent care.
- This happens when insurance companies, in the guise of increasing patient accountability, levy co-pays and deductibles (which we all know have more to do with revenues than making patients think twice about visiting a doctor or ER, especially in a time of (perceived) need or anxiety. It's the old parable about the balloon: when you squeeze it one place, it pops out in another place.
- We note: "increasing copayments for ambulatory care reduced the use of outpatient care among elderly enrollees in managed-care plans, but this decline was offset by an increase in hospitalizations, particularly among enrollees with low socioeconomic status and those with chronic disease. Increasing copayments for ambulatory care among elderly patients may have adverse health consequences and may increase spending for health care."
Trivedi AN, Moloo H, Mor V. "Increased Ambulatory Care Copayments and Hospitalizations among the Elderly." [Free text] N Engl J Med 2010;362:320-8 [Brown University]
7. Effective care trumped by less costly care
Pet Peeves: antibiotics for short term, ostensibly viral diseases -- bronchitis, sinusitis, nasopharyngitis or otitis media; half of abdominal CT scans or the half of back MRIs that show bulging disks on persons sans back pain. Who's failure is it to not control costs?
Ref.: Chen P. "The Doctor’s Failure to Cut Costs" NY Times March 3, 2010 (Extracts are for discussion purposes, only)
In an editorial in The New England Journal of Medicine, Dr. Howard Brody, professor of family medicine and director of the Institute for the Medical Humanities at theUniversity of Texas Medical Branch in Galveston, writes that the medical profession, unlike other groups, has made little effort to curtail future medical costs. Physicians, Dr. Brody maintains, are not “innocent bystanders” to spiraling health care costs but have been complicit in their failure to take an active role in curtailing them.
Doctors have two responsibilities. First, they have a moral duty as an individual advocate. A doctor has a responsibility to his or her individual patients to make them healthier and to help them live longer.
But doctors have a second moral duty: they have an obligation to the general public to be prudent stewards of scarce resources. Doctors only get about 10 percent of health care costs in their pockets, but they control about 80 percent. That isn’t our money — it’s someone else’s — and the public has entrusted us to spend it as wisely as possible.
Q. So is it all about the money?
A. No. It’s an unfortunate joining of money with other issues and motives. We have an American public that generally believes more is better. And rather than giving up bad habits, exercising and eating right, they would rather believe that the answer to health is in high technology.
When you combine this love affair with high technology with a reimbursement system that pays so much more for technology — and less for thinking and sitting and talking with patients — you end up with an expensive kind of medicine, which, when practiced by doctors, puts more money into their pockets.