Health and Medical News and Resources

General interest items edited by Janice Flahiff

[Reblog] The Smoking Gun: How U.S. Health Care Came to Cost Insanely More

From the 20 May 2015 post at The Health Care Blog

Screen Shot 2015-05-23 at 5.40.35 AM

Health care that costs more than it needs to is not just an annoyance; it’s a big factor in income inequality in the United States. The financial, physical and emotional burden of disease are major drivers of poverty. At the same time, the high cost of health care even after the Affordable Care Act means that many people don’t access it when they need it, and this in turn deprives large swathes of the population of their true economic potential as entrepreneurs, workers and consumers. People who are burdened by disease and mental illness don’t start businesses; don’t show up for work; and don’t spend as much money on cars, smartphones and cool apartments. Unnecessary sickness is a burden to the whole economy.

How did we get this way? What was the mechanism that differentiated U.S. health care from all other advanced countries? The usual suspects (such as “We have the most sophisticated research and teaching hospitals,” or “It’s the for-profit health insurers” or “Doctors make too much”) all fail when we compare the United States with other sophisticated national systems such as those in Germany and France. Other countries have all of these factors in varying amounts — private health insurers, world-class research, well-paid physicians — and cost a lot, but still spend a far smaller chunk of their economy on health care. Blame has been leveled in every direction, but in reality no single part of health care has been the driver. The whole system has become drastically more expensive over the last three decades.

What’s the Mechanism?

Since the difference between the United States and other countries is so large and obvious, there should be some way we can look at health care spending that would make that mechanism jump out at us. And there is a way.

That first big leap is between 1982 and 1983. What was different in 1983 that was not there in 1982? DRGs, diagnosis-related groups — the first attempt by the government to control health care costs by attaching a code to each item, each type of case, each test or procedure, and assigning a price it would pay in each of the hundreds of markets across the country. The rises continue across subsequent years as versions of this code-based reimbursement system expand it from Medicare and Medicaid to private payers, from inpatient to ambulatory care, from hospitals to physician groups and clinics, to devices and supplies, eventually becoming the default system for paying for nearly all of U.S. health care: code-driven fee-for-service reimbursements.

Cost Control Drives Costs Up?

How can a cost control scheme drive costs up? In a number of ways: In an attempt to control the costs of the system, the DRG rubric controlled the costs of units, from individual items like an aspirin or an arm sling to the most comprehensive items such as an operation or procedure. The system did not pay for an entire clinical case across the continuum of care from diagnosis through rehab; or for an entire patient per year on a capitated basis, which would capture the economic advantages of prevention; or for an entire population. While it is more cost-effective (as well as better medicine) to provide a diabetes patient with medical management, in-home nursing visits and nutritional counseling rather than, say, waiting until the patient needs an amputation, the coding system actually punished that efficiency and effectiveness. Under this system, we got paid for our inefficiencies, and even for our mistakes: Do-overs would often drop far more to the bottom line than the original procedure did.

The system punished, rather than rewarded, spending more time with patients, trying to help patients before their problems became acute, or maintaining a long-term, trusted relationship with patients. Under a code-driven fee-for-service system, getting serious about prevention and population health management would be a broad road to bankruptcy.

If extra items were deemed necessary (an extra test or scan, say), there were codes for that, and reimbursements awaiting. In so doing, the system rewarded doing more (“volume”) rather than whatever would be the best, most appropriate, most efficient treatment path (“value”). It provided a written, detailed catalog of reimbursements which rewarded diagnoses of greater complexity, rewarded new techniques and technologies with new and usually higher reimbursements, and especially rewarded systems that invested in a greater capability to navigate the coding system. At the same time, the reimbursements were constantly open to pressure from the industry. Each part of the industry, each region, each specialty, each part of the device industry, became fiercely focused on keeping those reimbursements up, and getting new codes for more costly procedures.

The business and strategic side of health care became a matter of making money by farming the coding system. Do more of what gets better reimbursement, less of what does not. Make sure every item gets a code and gets charged for. The codes became a manual for success, a handbook for empire.

The Smoking Gun

The smoking gun is right there in the chart, at the big split between the trajectories of the United States and other countries. And today, at this moment, the code-based fee-for-service payment system is still by far the basis of the majority of all revenue streams across health care.

The unifying factor between multiple new strategies unfolding in health care right now, including patient-centered medical homes, pay for performance, bundled prices, reference prices, accountable care organizations, direct pay primary care and others, is to find some way around the strict code-based fee-for-service system, either by avoiding it entirely or by adding epicycles and feedback loops to it to counter its most deleterious effects.

There is no perfect way to pay for health care. All payment methods have their drawbacks and unintended consequences. But the code-based fee-for-service system got us here, and any path out of the cost mess we are in has to get us off that escalator one way or another.

May 23, 2015 Posted by | health care | , , , , , , | Leave a comment

The Empowered Patient Strikes Back (Book and Web site)

From the 21 December 2012 post at The Health Care Blog

…Julia Hallisy learned about patient safety the hard way. Hallisy’s daughter, Kate, was diagnosed with an aggressive eye cancer when she was five months old. Over the next decade, she went through radiation, chemo, reconstructive surgery, an operation to remove her right eye, a hospital-acquired infection that led to toxic-shock syndrome and an above-the-knee amputation…

…Hallisy decided to write a book that might help others. In 2008,  I reviewed it on HealthBeat

..

At the time I wrote: “Remarkably, The Empowered Patient is not an angry book. It is not maudlin. To her great credit, Hallisy manages to keep her tone matter-of-fact as she tells her reader what every patient and every patient’s advocate needs to know about how to stay safe in a hospital.”

Recently, Hallisy emailed to tell me know that the book has now become a non-profit foundation: The Empowered Patient Coalition.

Go to their website and you will find fact sheets, checklists, and publications including, A Hospital Guide for Patients and Families that you can download at no chargeI found the Hospital Guide eye-opening. I have read and written a fair amount about patient safety in hospitals, but it told me many things that I did not  know…

[Great outline of doctor/nursing hierarchy]

[Questions Patients and Advocates Should Ask]

[What To Look For In Your Medical Record]

 

December 22, 2012 Posted by | health care | , , , , , | Leave a comment

A changing doctor-patient relationship – latimes.com

 

English: Livingston, TX, 9/25/05 -- A doctor t...

English: Livingston, TX, 9/25/05 — A doctor talks to a patient with a broken neck at a triage center at Livingston Hospital. Doctors and nurses on FEMA’s Disaster Medical Assistance Team from North Carolina care for patients brought to the 50 bed hospital. The hospital does not have enough staff to care for all the patients evacuated from Texas cities in the path of hurricane Rita. Photo by: Liz Roll (Photo credit: Wikipedia)

 

 

 

From the 13 September 2012 article at the LA Times

 

Until now, doctors have pretty much called the shots in the doctor-patient relationship. But change is on the way. Patients, say ahhhhh — it’s about to be all about you.

The new approach is called patient-centered care, and it’s a very good thing, according to Dr. James Rickert, the founder and president of the Society for Patient Centered Orthopedics in Bedford, Ind. “It will mean better outcomes, more satisfied patients and lower costs,” he says.

Here are just a few ways your relationship with your doctor may evolve in the not-too-distant future:

Your doctor won’t be the boss of you...

In a patient-centered healthcare universe, doctors will make sure their patients have all the information they need about all their options — and patients will have to tell their doctors their priorities.

“Research suggests that patients want to participate,” Barry says, “but they may be afraid to push back, afraid they’ll be labeled bad patients. Then it’s important for clinicians to draw them out.”

You may have a whole team taking care of you...

You and your doctor will spend more time on the Internet.

That’s because e-visits will replace some traditional kinds of appointments.

“It’s so easy,” says Dr. Redonda Miller, an associate professor at the Johns Hopkins University School of Medicine in Baltimore. “Patients love it — 50% of what we do in the office could by done by email.”

You may also avail yourself of the extensive medical information that can found on the Web. Your doctor should advise you about reliable sources, says Hedy Wald, a clinical associate professor of family medicine at Brown University. “We don’t want people thinking it’s a cure to put egg yolks on their heads.”

Facilities will be designed with you in mind...

 

 

 

 

 

September 17, 2012 Posted by | health care | , , , , | Leave a comment

   

%d bloggers like this: