Advantages of Electronic Health Records

With the requirements and incentives built into the Affordable Care Act, many healthcare facilities will be transitioning to electronic medical records. Read the guest post below from Jenny Richards to find out more about the pros of using electronic or digital medical records:

Medical records are vital as they can often make the difference between a patient receiving care that is appropriate or treatment that is based on just the experience of the attending medical staff and diagnostics performed in a hurry. Often paper records may not be legible, complete or even systematic requiring doctors to make educated guesses about the line of treatment to be followed. It can also be extremely optimistic to expect patients who are travelling to carry all their medical records with them just in case they fall ill or need medical attention for any reason whatsoever. Digitization of medical records that are already in paper form or generating records in the electronic form and uploading them to cloud storage has quite a few benefits resulting in a simpler and better treatment environment.

Reduction of Paperwork

Getting treated for any ailment can generate quite a large amount of paper not only for the patient but also for the care provider or hospital. These records ideally should be preserved for reference. When you take into account the number of patients this can easily amount to a humongous task in terms of sheer physical work, let along the responsibility of ensuring their safety and confidentiality. An electronic health record system eliminates most of the paperwork and can be extremely useful in giving easy and fast access to information with a proper classification and search procedure. The result of this exercise will be that both patients and doctors will have almost instantaneous access to medical records from anywhere in the world without having to locating the required documents and then transporting them to wherever they are required. The vital time that is saved in accessing the medical records can put to better use by the medical staff in treating the patient and having patient interaction that is more meaningful. Electronic records also ensure that the content is legible and not open to any misinterpretation by doctors trying to read often very difficult-to-read handwritten documents.

Reduction of Erroneous Drug Prescriptions

A sophisticated electronic health record system also enables doctors to prescribe drugs electronically. The process automatically compares the medical history of the patient and generates an alert if the drug being prescribed is not suitable for the patient. This electronic system acts as a surveillance system over the doctor’s actions and prevents erroneous drugs from being prescribed. This system acts to substantially prevent a lot of patient distress and hospitalization stress and expenses that would have easily occurred. The electronic health record system also enables doctors to compare between the various drug compositions offered by various manufacturers to select the most appropriate or even suggest a generic alternative that saves money. If you wish to know more, you could browse through recent HFA.co.in guide on DMR's.

Better Care Coordination

In complicated cases, the patient is often attended by a number of specialists, who will need to maintain independent records in the absence of an electronic health record system. Since it may be very difficult for doctors to keep on comparing notes on the diagnostics they may have ordered, it may so happen that the patient undertakes the same test a number of times resulting  in a complete waste of time and money. An electronic system of maintaining health records that can be shared online by multiple doctors can be extremely effective in implementing a treatment plan that is collaborative and effective.

An Effective Tool in Preventive Care

It is a common and unfortunate human foible not to undertake medical checkup tests and screenings unless there are some symptoms that have already manifested themselves. When there is an electronic medical record system that is online and accessible by people with portable connected devices, they can be easily reminded of tests that are recommended keeping in mind the profile of the person, his age, sex, family history, his own medical history, etc. Reminders may be sent to the patient in a variety of ways such as email and SMS to enable him schedule an appropriate appointment. The incremental cost of implementing these warnings is miniscule whereas the potential benefits are unimaginable. Learn more about the importance of digitized medical records by instructables.com.

What Doctors Can Do About The Healthcare Crisis

This is a guest post by Ellie Moon about the growth of costs in healthcare and what healthcare providers can do about the coming healthcare crisis.

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Medical care today can be a minefield. Doctors are ever more pressed to work longer hours and provide greater levels of care while the needs of patients seem to be ever increasing. In one this is great for business as medical insurance is taken up by patients who are worried that their local health care provider can’t meet their needs.

Costs spiraling

Thomson Reuters reported that health care costs have been increasing for patients at about 7% per year. This is combined with increases in employer contributions at approximately 12% and yet people are still buying up insurance because of fears over lack of services and provision and a desire to have the best possible drugs. Around the world there are various protections in place to protect patients and ensure that critical care is delivered; the NHS is perhaps one of the best examples of this but there is also the European Health Insurance card system and the Emergency Medical Treatment and Labour Act in the U.S. So is there a problem in these government sponsored schemes and services or does private medical care provide better care for patients?

There have certainly been cases where patients have felt greater stress and worry over the quality of their care and this has impacted on the recovery time. It would seem sensible if hospitals, doctors and the administration systems behind the care provided are more focused on reassuring patients over the quality of their care rather than on what is available based on the patient’s insurance package or based on the local hospital’s resources. Unfortunately, these are the times we live in and some patients will get better care simply because they have better insurance and more money. So is there a role for hospital staff to do their best to ensure that the best possible care is made available for everyone?

Of course there is. The amount of litigation that hospitals and staff face is rising and so whilst it is clear that the legalities and consents in a patients care are correctly covered, so is the need to ensure that the patient and the patient’s family feels valued and respected. Doctors need to ensure that they use their emotional intelligence and respond to the needs of those in their care. Medical professionals need to take into account the patient's worries (which could have little to do with their illness but everything to do with their finances) and give the patient time to express their concerns and be listened to. In short, a patient needs to have time to express their worries and concerns and have them relieved or at least lessened, so that they can then focus on getting better.

Medical Staff and Patient Care

Often medical staff are challenged by the behaviour of a patient who is reacting to their situation in a manner charged by emotion. Rational thought can become difficult when faced with bad news, especially regarding your health and there are many thoughts which could be going through the patient's mind:

• "I’m ill – I could die"
• "I don’t want to die…"
• "Why can’t I have that treatment, I can’t afford this…"
• "This illness is not fair…"

All of these thought processes are understandable when viewed outside a fraught environment but when faced with all the challenges of illness and financial difficulty an argument can become heated and people make accusations. In some cases this can even led to legal action much of which could be avoided if medical staff had the time and resources to exercise a little more empathy and consideration. It is clear that a doctor can’t solve the financial or personal problems a patient may have; however expressing an understanding of those problems can go a long way to helping the patient feel reassured and feel that they had a good experience in hospital (even if they didn’t have gold plated insurance).

So, doctors need to consider the wider context or life outside the hospital and what the patients are going through personally as individuals. A kind word, an understanding comment or smile can reassure patients and their families and build the essential trust needed for them to feel comfortable or at least not upset in the doctor's presence. The patient may, unfortunately be in a position where the care available is not going to meet their needs but this doesn't mean it can't be provided in the best possible way. As medical professionals it is important to provide a safe and neutral environment in which patients can be treated and recover with the help of the best medical package they can afford.

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Ellie Moon used to work retail for a living but five years ago she took the leap and began writing full time. As a freelance writer she has had the opportunity to write for a huge range of companies, including a PMI insurance service, which she finds much more satisfying than answering phones all day.


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More Medical Deportations

As previously discussed on this blog, medical deportations are a tragic reality. The cases are sad enough when the deportees are illegal immigrants, but what happens if they are in fact legally in the U.S.? Another shameful medical deportation:

Soon after Antonio Torres, a husky 19-year-old farmworker, suffered catastrophic injuries in a car accident last June, a Phoenix hospital began making plans for his repatriation to Mexico.

Mr. Torres was comatose and connected to a ventilator. He was also a legal immigrant whose family lives and works in the purple alfalfa fields of this southwestern town. But he was uninsured. So the hospital disregarded the strenuous objections of his grief-stricken parents and sent Mr. Torres on a four-hour journey over the California border into Mexicali.

For days, Mr. Torres languished in a busy emergency room there, but his parents, Jesús and Gloria Torres, were not about to give up on him. Although many uninsured immigrants have been repatriated by American hospitals, few have seen their journey take the U-turn that the Torreses engineered for their son. They found a hospital in California willing to treat him, loaded him into a donated ambulance and drove him back into the United States as a potentially deadly infection raged through his system.

By summer’s end, despite the grimmest of prognoses from the hospital in Phoenix, Mr. Torres had not only survived but thrived. Newly discharged from rehabilitation in California, he was haltingly walking, talking and, hoisting his cane to his shoulder like a rifle, performing a silent, comic, effortful imitation of a marching soldier.

“In Arizona, apparently, they see us as beasts of burden that can be dumped back over the border when we have outlived our usefulness,” the elder Mr. Torres, who is 47, said in Spanish. “But we outwitted them. We were not going to let our son die. And look at him now!”

Antonio Torres’s experience sharply illustrates the haphazard way in which the American health care system handles cases involving uninsured immigrants who are gravely injured or seriously ill. Whether these patients receive sustained care in this country or are privately deported by a hospital depends on what emergency room they initially visit.

There is only limited federal financing for these fragile patients, and no governmental oversight of what happens to them. Instead, it is left to individual hospitals, many of whom see themselves as stranded at the crossroads of a failed immigration policy and a failed health care system, to cut through a thicket of financial, legal and ethical concerns.

While one can empathize to some degree with hospitals that do not have the funds to adequately care for patients with questionable legal status, knee-jerk deportations are certainly not the solution. While deportations may be necessary in some cases, they should clearly be a last resort and even then, only instituted by the proper legal authorities, not in an unregulated manner by hospitals. The problem is systemic, but it is one we should all be ashamed of.. Patients, legal or not, deserve better.

Chronic Kidney Disease: America's Malady

Kidney disease is on the rise in the United States, yet it still gets less attention than other diseases such as cancer. Many factors, such as high blood pressure or even carbonated beverages, contribute to the disease. Regardless of the cause though, the burden of dialysis treatment takes a toll not only patients but on the healthcare system as a whole. For many, awareness of chronic kidney disease comes too late:

In February 2005, Rita Miller, a party organizer in Chesapeake, Va., felt exhausted from what she thought was the flu. She was stunned to learn that persistent high blood pressure had caused such severe kidney damage that her body could no longer filter waste products from her blood.

“The doctor walked over to my bed and said, ‘You have kidney failure — your kidneys are like dried-up peas,’ ” recalled Ms. Miller, now 65, who had not been to a doctor or had her blood pressure checked for years.

“The doctor said, ‘Get your family here right away,’ ” she said. “They were telling me I might not make it. I was in shock. I started dialysis the next day.”

Ms. Miller, who has since moved to Connecticut to be with her children, was one of the millions of Americans unaware that they are suffering from chronic kidney disease, which is caused in most cases by uncontrolled hypertension (as in her case) or diabetes, and is often asymptomatic until its later stages. The number of people with the disease — often abbreviated C.K.D. — has been rising at a significant pace, thanks in large part to increased obesity and the aging of the population.

An analysis of federal health data published last November in The Journal of the American Medical Association found that 13 percent of American adults — about 26 million people — have chronic kidney disease, up from 10 percent, or about 20 million people, a decade earlier.

It is clear why CKD has a great impact on patients' lives, but why does chronic kidney disease have such a large impact on the system?

In 2005, more than 485,000 people were living on dialysis or with a transplant, at a total cost of $32 billion. Medicare pays for much of that, because it provides coverage for patients needing dialysis or transplant even if they are not yet 65. In fact, kidney disease and kidney failure account for more than a quarter of Medicare’s annual expenditures.

In other words, unlike almost any other disease, the federal government fully covers treatment for nearly everyone requiring dialysis, due to a quirk in the law. Therefore, moreso than any other condition, CKD becomes a disease that society as a whole must grapple with, especially as its incidence rises.

Do Individual Mandates Matter?

Health insurance mandates are a major topic these days. Basically, to get around the politically difficult challenge of implementing truly universal healthcare, politicians and legislatures have embraced mandates as a stop-gap measure. Instead of providing care, these entities mandate individuals to obtain care for either themselves or their family members (i.e., their children) or face penalties. While in theory this should increase the rates of coverage to near-universal, it is not actually a guarantee of providing adequate care to anyone or to everyone.

My support of mandates has waxed and waned over time. It seems like they could be a good idea, but it really depends on how their implemented and enforced. If done poorly, they could actually do more harm than good. Healthcare Economist has a few thoughts on the same topic in Thoughts on individual mandates:

Health insurance require that all individuals buy health insurance. Most voters views on an individual mandate depend on how you frame the question. If you ask voters: “Should everyone buy health insurance?” Most people will say yes.

If you ask “Should the government compel all ndividuals to buy health insurance regardless of the cost?” Then the response is much less positive.

Keep reading to see what else he has to say. Interesting stuff, and an issue that potentially may affect all of us in the near future.

The McCain Healthcare Plan

As I noted in a previous post on the future of healthcare in America, both candidates have dynamic proposals for reforming our healthcare system. Previously, I have discussed the Obama healthcare plan and what I found interesting about it. Today, I will address John McCain's healthcare plan. The entire plan can be found here: Straight Talk on Healthcare Reform

Here are the key points that I found interesting:

• John McCain Will Reform Health Care Making It Easier For Individuals And Families To Obtain Insurance. An important part of his plan is to use competition to improve the quality of health insurance with greater variety to match people's needs, lower prices, and portability. Families should be able to purchase health insurance nationwide, across state lines.
  
  An interesting proposal, but seeing as most families receive their health insurance through their employer, I am not sure how this would be implemented. I assume he means that employers will be able to do this on behalf of their employees. Furthermore, while competition may indeed prove beneficial, health insurance differs from other goods due to the complex nature of what is covered. If policies end up competing primarily on price without regard to benefits, it is not clear how families would be better served.
  
  
  
• John McCain Will Reform The Tax Code To Offer More Choices Beyond Employer-Based Health Insurance Coverage. While still having the option of employer-based coverage, every family will receive a direct refundable tax credit - effectively cash - of $2,500 for individuals and $5,000 for families to offset the cost of insurance. Families will be able to choose the insurance provider that suits them best and the money would be sent directly to the insurance provider
  
  Seems like a good idea, except from what I have heard, most plans start around $12,000 per year for a family of four, so I think the credit would have to be expanded.
  
  
  
• John McCain Proposes Making Insurance More Portable. Americans need insurance that follows them from job to job. They want insurance that is still there if they retire early and does not change if they take a few years off to raise the kids.
  
  Makes sense, but how will this be enforced? What if the company fired the employee for poor performance or illicit behavior? This gets to the heart of the problem of tying insurance to employment. Sure, employee pools make for good pseudo-random groups to insure, but it doesn't make sense in the grand scheme of things, especially when one considers that sick people generally are not good workers.
  
  
  
• John McCain Will Work With States To Establish A Guaranteed Access Plan. As President, John McCain will work with governors to develop a best practice model that states can follow - a Guaranteed Access Plan or GAP - that would reflect the best experience of the states to ensure these patients have access to health coverage. One approach would establish a nonprofit corporation that would contract with insurers to cover patients who have been denied insurance and could join with other state plans to enlarge pools and lower overhead costs. There would be reasonable limits on premiums, and assistance would be available for Americans below a certain income level.
  
  I don't understand how the government forming a "nonprofit corporation" (NPC) that covers apparently everyone that the insurance companies don't want to cover (ie, the costliest patients) is any different from a bastardized single payer system. If anything, this is worse than single payer, since this NPC would effectively take on the 'worst' patients leaving the insurance companies to cherry pick the lowest risks for themselves.
  
  
  
• CHEAPER DRUGS: Lowering Drug Prices. John McCain will look to bring greater competition to our drug markets through safe re-importation of drugs and faster introduction of generic drugs.
  
  I have the same issues here as I did with Obama's version, namely who is going to regulate this? The FDA? Also, McCain does not address the 2003 Medicare bill.
  
  
  
• TORT REFORM: Passing Medical Liability Reform. We must pass medical liability reform that eliminates lawsuits directed at doctors who follow clinical guidelines and adhere to safety protocols. Every patient should have access to legal remedies in cases of bad medical practice but that should not be an invitation to endless, frivolous lawsuits.
  
  Again, makes sense. However, without any specifics, it seems like empty rhetoric, especially under the current system, this is more a state-by-state issue, rather than a federal one.
  
  
  
• John McCain is very concerned about the rising incidence of autism among America's children and has continually supported research into its causes and treatment
  
  A nice sentiment, but is this really a national issue? Somehow, I feel like McCain has only come to care about this in the last 8 weeks or so...
  
  

Overall, I think McCain's plan has some intriguinig ideas but without more specific details, it is hard to evaluate them. Both plans seem to suffer from a lack of detail in terms of how they will pay for these proposals, implement them, or enforce them. Still, it bothers me that McCain seems to think that the solution lies in putting more power in the hands of patients without many safeguards to ensure that they actually receive adequate care. Having a $5000 tax credit isn't much solace to someone with a new diagnosis of cancer, especially if they are uninsured, since the cancer is now a 'pre-existing condition,' meaning they will not be insured in the future. Perhaps the non-profit corportation would pick up the slack here, but without much detail, who knows how that would work?

In the final judgment, I think both plans have significant deficiencies, but I believe the Obama plan to be the stronger of the two. Still, much change is needed before the U.S. healthcare system truly lives up to its potential. Your thoughts?

The Obama Healthcare Plan

As I noted in a previous post on the future of healthcare in America, both candidates have dynamic proposals for reforming our healthcare system. Today, I look at Senator Barack Obama's proposal for reform. The entire proposal can be found here: Barack Obama's Healthcare Plan (pdf).

If you click, you'll find a broad-ranging plan that is nearly 9 pages long. Here are the key points that I liked:

• Barack Obama and Joe Biden will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records. They will also phase in requirements for full implementation of health IT and commit the necessary federal resources to make it happen.
  
  I have written previously that electronic medical records need greater support in order to reap potential benefits, and this sounds like the type of commitment the healthcare community has been waiting for. A standards based approach is especially prescient.
  
  
  
• Barack Obama and Joe Biden will require hospitals and providers to collect and publicly report measures of health care costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and disparities in care and costs. Health plans will be required to disclose the percentage of premiums that actually goes to paying for patient care as opposed to administrative costs.
  
  Such transparency is key to forcing hospitals to improve. If the public is more aware of which hospitals are truly good and which are not, they will vote with their feet and their healthcare dollars, forcing underperforming hospitals to shape up.
  
  
  
• Barack Obama and Joe Biden believe we need to eliminate the excessive subsidies to Medicare Advantage plans and pay them the same amount it would cost to treat the same patients under regular Medicare.
  
  Makes sense, doesn't it? Why should the government pay more for what is essentially the same care provision? This is just common sense.
  
  
  
• Barack Obama and Joe Biden will allow Americans to buy their medicines from other developed countries if the drugs are safe and prices are lower outside the U.S.
  
  A good idea in theory (and a free market one, to boot). However, the plan does not provide specifics as far as which countries will be acceptalbe, and how one is going to judge which imported drugs are "safe." The FDA can barely handle monitoring domestic drugs as it is.
  
  
  
• The 2003 Medicare Prescription Drug Improvement and Modernization Act bans the government from negotiating down the prices of prescription drugs, even though the Department of Veterans Affairs’ negotiation of prescription drug prices with drug companies has garnered significant savings for taxpayers.32 Barack Obama and Joe Biden will repeal the ban on direct negotiation with drug companies and use the resulting savings, which could be as high as $30 billion,33 to further invest in improving health care coverage and quality.
  
  Thank you. Finally.
  
  
  
• Catastrophic health expenditures account for a high percentage of medical expenses for private insurers. In fact, the most recent data available reveals that the top five percent of people with the greatest health care expenses in the U.S. account for 49 percent of the overall health care dollar. For small businesses, having a single employee with catastrophic expenditures can make insurance unaffordable to all of the workers in the firm. The Obama-Biden plan would reimburse employer health plans for a portion of the catastrophic costs they incur above a threshold if they guarantee such savings are used to reduce the cost of workers' premiums. Offsetting some of the catastrophic costs would make health care more affordable for employers, workers and their families.
  
  Again, makes sense. This is how insurance is truly supposed to function. Instead of working to deny claims in a patient's time of need, this plan would simply cover catastrophic care. Of course, the obvious question is how much of a liability does this pose to the federal government. Furthermore, isn't this effectively nationalizing coverage anyway since the government would be the 'single payer' behind this scheme for the truly high cost cases? Hmm
  
  
  
• Obama and Biden will require insurance companies to cover pre-existing conditions so all Americans, regardless of their health status or history, can get comprehensive benefits at fair and stable premiums.
  
  A nice sentiment, and definitely something that is necessary, but without details on how this will be enforced or what the limits of "coverage" will be, it's not clear what the true impact of this is.
  
  
  
• They will also create a new Small Business Health Tax Credit to provide small businesses with a refundable tax credit of up to 50 percent on premiums paid by small businesses on behalf of their employees. To be eligible for the credit, small businesses will have to offer a quality health plan to all of their employees and cover a meaningful share of the cost of employee health premiums.
  
  Sounds good, but how much will this cost? What are the cut-offs for 'small business'? Who will enforce that the businesses are actually providing good plans? Again, hmm
  

Overall, I think the Obama plan is sound and has many innovative ideas along with many items that were due for a change. However, without more details on inclusion and exclusion criteria, it is difficult to gauge how much this all will cost. Furthermore, without an enforcement scheme, it is not clear how Obama plans to ensure that all these ideas become reality in a way that protects taxpayers from fradulent claims or plain ol' waste. However, given how competently Obama has run his campaign, I can only hope that his administration would similarly find ways to effectively manage the new healthcare bureaucracies he would be creating. Your thoughts?

I'll have a post soon about the McCain plan too.

The Future of America's Healthcare: Obama vs. McCain

Recently at dinner, a few friends and I were discussing politics and healthcare. While we all had our own opinions, we came to the sad realization that none of us really knew the candidates plans in depth. I had previously written about Obama's and Clinton's healthcare plans, but that was months ago, and did not include anything about McCain's proposals. Curious, I tried reading a little bit online about the two proposals. I came across an article in the New England Journal of Medicine regarding their positions:

McCain's plan embraces market forces and promotes individually purchased insurance (see red box). Its centerpiece is a change in the tax treatment of health insurance. Currently, workers do not pay taxes on health insurance premiums paid by their employers. The McCain plan would eliminate this tax exclusion and use the revenue generated — projected to be $3.6 trillion over 10 years — to pay for refundable tax credits for Americans obtaining private insurance ($2,500 for individuals, $5,000 for families). Uninsured Americans could use their credits to help buy insurance coverage on the individual market, and workers with employer-sponsored insurance could use theirs to offset the cost of paying taxes on their employers' premium contributions or to purchase coverage on their own.

^{The article discusses Obama's healthcare plan well:}

In contrast to John McCain's emphasis on markets and deregulation, Barack Obama's reform plan relies on an employer mandate, new public and private insurance programs, and insurance-market regulation (see blue box). The core of the Obama plan is a requirement that employers either offer their workers insurance or pay a tax to help finance coverage for the uninsured (some small businesses would be exempt, and others would be subsidized). The Obama plan would also create two new options for obtaining health insurance: a new government health plan (similar to Medicare) and a national health insurance exchange (a purchasing pool analogous to the Massachusetts Connector) that would offer a choice of private insurance options. Both would be open to persons without access to group health insurance or other public insurance, as well as to small businesses that wanted to purchase coverage for their workers. Income-related subsidies would be provided to help lower-income persons afford coverage. And private insurers could not deny coverage because of preexisting conditions or charge substantially higher premiums to sick enrollees: the Obama plan would end medical underwriting according to health status.

^{Admittedly, I am a bit biased towards Obama, but I think I'll discuss my thoughts in a future post after I have had more time to digest their proposals. Anyone out there already come to a conclusion? How does McCain's free market solution compare to Obama's hybrid government / competition plan?}

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What's the difference between the INS and U.S. Hospitals?

Answer: Only INS has the legal right to deport illegal immigrants.

Yet, some U.S. hospitals have taken it upon themselves to deport patients who are illegal when they overstay their welcome. In this NYTimes piece, writer Deborah Sontag chronicles the journey of an illegal immigrant from Guatemala Luis Alberto Jiménez and his misadventures with Martin Memorial hospital in Florida. After work one day, Mr. Jimenez was in a car driving home when the car he was in was struck by a drunk driver. He was taken Martin Memorial where he was initially given a poor prognosis due to his traumatic brain injury (TBI) and other trauma. He was in a comatose state for nearly a year. But then:

Eight years ago, Mr. Jiménez, 35, an illegal immigrant working as a gardener in Stuart, Fla., suffered devastating injuries in a car crash with a drunken Floridian. A community hospital saved his life, twice, and, after failing to find a rehabilitation center willing to accept an uninsured patient, kept him as a ward for years at a cost of $1.5 million.
What happened next set the stage for a continuing legal battle with nationwide repercussions: Mr. Jiménez was deported — not by the federal government but by the hospital, Martin Memorial. After winning a state court order that would later be declared invalid, Martin Memorial leased an air ambulance for $30,000 and “forcibly returned him to his home country,” as one hospital administrator described it.

While I understand the hospital's dilemma, the article notes that other options were available:

Jack Scarola, representing Mr. Jiménez’s guardian, said that he empathized with the hospital’s “significant economic burden” but said that it was the “quid pro quo” of accepting Medicare and Medicaid funds to help finance the hospital’s services. (About 45 percent of Martin Memorial’s net operating revenues came from Medicare and Medicaid last year, based on state data.)
“Also,” he continued, “they chose the wrong way to deal with it. The right way would have been through the Legislature. There is no program in place to appropriately distribute care to undocumented persons who are catastrophically injured, and there should be. But you don’t stick a brain-injured immigrant on a private plane and spirit him out of the country in the predawn hours.”

Keep reading to see what kind of conditions the hospital left Mr. Jimenez in. In public hospitals, as many medical students know, the issue of 'disposition' often becomes a patient's most significant one, far outshadowing their medical concerns. Still, no matter how dire the disposition issue may be, hospitals and communities must find better solutions than dumping their patients overseas.

Medicare Update

Last week, I posted about the proposed 10.6% cut in Medicare payments and its impact on the healthcare system. Since then, President Bush vetoed a bill that would reverse this scheduled change, but Congress overruled his veto:

But the House voted, 383 to 41, on Tuesday afternoon to override the veto. Soon afterward, the Senate voted by 70 to 26 to do so. Although the Senate vote was close enough to provide some suspense, it was still over the two-thirds needed, as a number of conservative Republicans who typically side with the president broke with him on this issue.

The bill cancels a 10-percent cut in payments to doctors that would otherwise occur automatically because of a statutory formula that reduces payments when spending exceeds certain goals. The president said he supported the main objective of the bill, to forestall reduction in physicians’ payments, but that he had too many reservations about other aspects of the legislation.

Mr. Bush said he opposed the bill in part because it would reduce federal payments to private Medicare Advantage plans, offered by insurers like Humana, UnitedHealth and Blue Cross and Blue Shield. In his veto message to Congress, Mr. Bush also complained that the bill would “perpetuate wasteful overpayments to medical equipment suppliers.”

It will be interesting to see how this plays out the next time there is a scheduled change in Medicare payments. The current system seems untenable in the long run, but with all the vested interests, it seems like it will be hard to change the status quo anytime soon.

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Why Health Policy Matters: Medicare Payment Cuts

Medicare is a foreign concept to me as a medical student. I am inundated with tons of information about biological processes and disease, but I have received very little formal education about the business of medicine. Perhaps it seems too lowbrow for the higher purposes to which doctors should aspire. However, I think it is important to be aware of these things, and I find myself quite ignorant. My basic understanding of how doctors are compensated is that Medicare sets payment rates, and then insurance companies use these rates as a proxy for their own rates. Doctors then perform services, report them to Medicare or insurers, and the payers then pay the doctors accordingly. However, this system is facing a major threat. Medicare is about to cut payments by 10.6%:

Congress returns to work this week with Medicare high on the agenda and Senate Republicans under pressure after a barrage of radio and television advertisements blamed them for a 10.6 percent cut in payments to doctors who care for millions of older Americans. 

The advertisements, by the American Medical Association, urge Senate Republicans to reverse themselves and help pass legislation to fend off the cut. 

How to pay doctors through the federal health insurance program is an issue that lawmakers are forced to confront every year because of what is widely agreed to be an outdated reimbursement formula. But the dispute, which showcases the continued potency of health care issues, has reached a new level of urgency this year. Some doctors are reassessing their participation in the program and powerful interests on all sides are in a lobbying frenzy.

The real major problem here is that at the end of the day, patients suffer. Many doctors end up closing their practices to new Medicare patients because each patient would represent a "loss." The costs of the supplies needed to treat them would be greater than Medicare's reimbursement. As rational economic actors, one cannot blame the doctors for not accepting such a deal. The current government is a strong proponent of free market solutions, but here the free market is acting appropriately in response to external factors, but the result is clearly less than ideal. Our healthcare policy shows such cognitive dissonance, with the same factions railing about 'socialized healthcare' yet strongly lobbying to continue or increase the government-funded "socialist" Medicare program. A longterm solution is needed, but in the interim, Congress should maintain at least the current payment level if it has any interest in preserving Medicare.

Why Primary Care Matters

Kind of an old post, but kevinmd discusses on his blog why the shortage of primary care docs matters:

Primary care should be the backbone of any health care system. Countries with appropriate primary care resources score highly when it comes to health outcomes and cost. The United States takes the opposite approach by emphasizing the specialist rather than the primary care physician.

A recent study from The New England Journal of Medicine analyzed the providers who treat Medicare beneficiaries. The startling finding was that the average Medicare patient saw a total of seven doctors — two primary care physicians and five specialists — in a given year. Contrary to popular belief, the more physicians taking care of you does not guarantee better care. In fact, studies show that increasing fragmentation of care results in a corresponding rise in cost and medical errors.

Keep reading on here. Still curious? I've discussed this shortage before on scrub notes as well: A Shortage of Primary Care Physicians?

Tier 4 Drug Pricing

As a follow-up to my post last week about the economics of drug dosing, the Times has published another piece looking at the growing popularity of Tier 4 drug pricing among insurance plans.

"With the new pricing system, insurers abandoned the traditional arrangement that has patients pay a fixed amount, like $10, $20 or $30 for a prescription, no matter what the drug’s actual cost. Instead, they are charging patients a percentage of the cost of certain high-priced drugs, usually 20 to 33 percent, which can amount to thousands of dollars a month."

As I've previously argued, private insurance fundamentally makes no sense:

"But the new system sticks seriously ill people with huge bills, said James Robinson, a health economist at the University of California, Berkeley. “It is very unfortunate social policy,” Dr. Robinson said. “The more the sick person pays, the less the healthy person pays.”

Traditionally, the idea of insurance was to spread the costs of paying for the sick.

“This is an erosion of the traditional concept of insurance,” Mr. Mendelson said. “Those beneficiaries who bear the burden of illness are also bearing the burden of cost.”"

Any reasonable analysis of the insurance system should have predicted that this would occur. It was only a matter of time.

A Second Opinion on Second Opinions

The idea of getting a second opinion makes a lot of sense, especially in complex cases. However, in practice, it is difficult to broach the topic as it feels like a violation of the trust one hopes develops between a physician and their doctor. However, a recent article on second opinions in the NYTimes shows that second opinions deserve a second look:

Some studies have examined the frequency and efficacy of second opinions related to invasive procedures like biopsy and cancer surgery. Rates of discrepancies between doctors vary, and for the most part they do not lead to changes in treatment. For 30 percent of patients who voluntarily seek second opinions for elective surgery and 18 percent of those whose insurance companies require it, the second doctors disagree with the first.

Thirty percent? That's pretty high, but it makes sense given how complex cases can become. I think one way to approach the problem would be to make second opinions a standard requirement for particular diagnoses that are more likely to have ambiguities, such as how to treat complex hematologic cancers. Doing so might make the practice more acceptable.


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The Economics of Drug Dosages

I recently read an interesting article on the economics of drug dosing. The article discusses the medication used to treat Gaucher Disease, the most common lysosomal storage disorder. If untreated, the disease can cause many problems, including severe bone/joint damage. The drug costs over $200,000 per year! I must admit I have never really given it much thought, but if a drug can cost, but at those prices, it definitely gives one pause:

The drug in question, Cerezyme, is used to treat a rare inherited enzyme deficiency called Gaucher disease. Some experts say that for most patients, as little as one-fourth the standard top dose would work, saving the health care system more than $200,000 a year per Gaucher patient. “It is economic malpractice to give a much higher dose of an expensive drug than is required,” said Dr. Ernest Beutler, an authority on Gaucher disease at the Scripps Research Institute. Some other Gaucher specialists argue otherwise, saying that skimping on the medicine could endanger patients.

The economics of this drug are staggering:

With Cerezyme, which is made by Genzyme, the profits are sizable. Gaucher disease, which can have complications like ruined joints, is rare; only about 1,500 people in the United States are on the drug and about 5,000 worldwide. Sales of Cerezyme totaled $1.1 billion last year, making it a blockbuster by industry standards.

A BILLION dollars from a drug used by at most 5000 people? I am willing to bet that most of the people outside the U.S. do not get the medication, meaning that in the U.S. the cost of the drug may be even higher than the value quoted above. To be fair, here is Genzyme's defense:

Genzyme, which became a leading biotechnology company because of Cerezyme, says that it has raised the price only once — 3 percent last year — since introducing the drug in 1994. The company says it needs the high price to make a sustainable business of serving such a small number of patients and to pay for research on new products. Genzyme also says it provides the drug free, if necessary, so that no one goes without the product because of its cost. But critics say the company’s development costs were minimal, because the early work on the treatment was done by the National Institutes of Health, which gave Genzyme a contract to manufacture it. And analysts estimate the current cost of manufacturing the drug to be only about 10 percent of its price. Insurers generally cover the drug because there are so few patients. But finding or staying on insurance can be difficult.

The collective costs can be staggering:

Ms. Mangum began treatment in 2000, at a cost of more than $400,000 a year. The next year, the premiums for everyone in her insurance pool went up by $180 a month.

I am not sure what can be done about this under the current system, but if one thinks about the true purpose of insurance, I think it becomes clear that a national healthcare system is necessary to protect and cover the costs for individuals who have these rare but treatable diseases.

A Shortage of Primary Care Physicians?

A recent piece in the NYTimes discusses Massachusetts' experience after enacting its health insurance reforms which mandated coverage for all its citizens. The article discusses how the structure of reimbursements has shifted how many people enter into primary care. It's little surprise that this is the outcome, given situations like this:

Dr. Atkinson, 45, said she paid herself a salary of $110,000 last year. Her insurance reimbursements often do not cover her costs, she said.

“I calculated that every time I have a Medicare patient it’s like handing them a $20 bill when they leave,” she said. “I never went into medicine to get rich, but I never expected to feel as disrespected as I feel. Where is the incentive for a practice like ours?”

I imagine some politicians out there believe that the "magic of the market" can solve this problem. To a certain degree, as the supply of PCPs shrinks, salaries should rise, but given the way the private health insurance system works, this "market correction" does not seem likely. Doctors are too weak in the system, and the insurance companies end up looting both them and their patients. Think about it: the insurance company not only sets the "price" (the premium / deductible) for the patient, but also for the physicians (in terms of reimbursement rates). Why should this be the case? Can you imagine if your auto insurance company charged you to let you buy a car and then decided how much to pay the car dealership when you went to get that car? It's just ridiculous.

Why Incentives Matter (Even For Physicians)

The inexorable rise of healthcare costs in America is no secret. As a recent NYTimes article notes, there are several reasons underlying the increase in costs:

Overutilization is driven by many factors — “defensive” medicine by doctors trying to avoid lawsuits; patients’ demands; a pervading belief among doctors and patients that newer, more expensive technology is better.

The most important factor, however, may be the perverse financial incentives of our current system.

These incentives reward doctors who perform more procedures. As reimbursement rates fall, volume increases to make up. Even when doctors try to do the 'right thing,' reality forces them to bend to the market. As the author notes:

Not long ago, I visited a friend — a cardiologist in his late 30s — at his office on Long Island to ask him about imaging in private practices.

“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was."

To be honest, as a future physician, I suppose I have the "incentive" to not criticize a system that will eventually pay my bills, but I think in the long run, the inefficiencies built into our healthcare system harm physicians as much as anyone else. As costs rise, people will target physicians more and more as sources of the cost. Reimbursement rates will fall further, worsening the downward spiral. As rates fall, physicians will continue to cede power to insurance companies who dictate rates. At the same time, there will be greater demand for non-physician professionals (such as PAs) who can provide similar services at lower cost. All in all, without a change in the incentive structure, physicians will continue to squeeze each other out of the market, and that's not good for anyone.

Want more? Check out how salaries vary across medical specialties, or the Democratic candidates' healthcare proposals.

Democratic Candidate Healthcare Proposals

I was recently discussing politics with a friend who is interested in health policy (and is also a med student). I realized that while I knew the general ideas that the candidates had, I wasn't too familiar with the specifics. I had tried previously to go to candidate websites, but I found myself getting bogged down, as each one had a different way of presenting their proposals. I asked my friend if there were any sites that simply compared the different policies. He directed me to health08.org, a website run the Kaiser Family Foundation. The site was easy to use, and let me compare any candidate's plan against any other candidate's plan.

As I tend to be liberal-leaning, I compared Senator Clinton's plan with Senator Obama's and Senator Edwards'. The comparison was fairly helpful, as it went through the plans and compared them on a point-by-point basis. Here's a summary of each plan, and my opinion of them:

Clinton: Every American is required to have coverage. To make this affordable, the plan will provide income-related tax subsidies. Plan options, both public and private, will be available through a "Health Choices Menu," which would be operated by the Federal Employee Health Benefits Program. Coverage through employers and public programs would continue. Employers of small businesses would receive a tax subsidy to offset their costs. Cost estimate: ~$100 billion, partly financed by rolling back tax cuts on those making over $250,000.

Obama: Every child will be required to have coverage. Employers will either have to extend benefits or contribute to a new public plan. A new "National Health Insurance Exchange" would facilitate enrollment in the new public plan. Employers would receive tax benefits to offset catastrophic costs. Cost estimate: ~$60 billion, partly financed by rolling back tax cuts on those making over $250,000.

Edwards: Every American is required to have coverage, with a goal of universal coverage by 2012. The plan would create nonprofit "Health Markets" in which public and private options would compete with each other. Expanded public funding for coverage of low income adults would also be provided for. There is no provision for employers. Cost estimate: ~$100 billion, partly financed by rolling back tax cuts on those making over $200,000.

The three candidates are providing the same healthcare plan with minor tweaks. I think Obama's would benefit from mandating coverage, but on the other hand, the plans with mandates do not technically guarantee coverage. Simply by saying you must be covered doesn't necessarily make it so. And what are we going to do if people choose not to buy? Fine them? Put them in jail? Maybe I am not understanding the mandate, but if they really want universal coverage, they should just expand the Medicare payroll tax deduction and call it the "National Healthcare" payroll deduction. Of course, that will never happen, but I'm jus' sayin'... Anyway, given what I've read, I think Clinton's and Edwards' plans sounds the best and have more detail. Obama's is good, but not as broad as theirs; however, his plan might be the one that is most realistically implementable. It is interesting to see his views on policy. I think Obama would be in support of mandates if crafting a system from scratch, but in this climate, perhaps he believes that a more incremental change is more feasible. I suppose I should admit a bias towards Obama, but I think any one of the candidates I mentioned above would be more than competent.

To be fair, here is what I understand of some of the other candidates' plans (in no particular order):

Giuliani: Healthcare reform 9/11. Now.

Paul: Ban healthcare as it was not mentioned in the Constitution.

Huckabee: Plan members will ask themselves, "What would Jesus do to heal himself?" instead of making claims.

Kucinich: Mars has healthcare for all, so why can't we? I was the first to propose the Martian plan.

Thompson: Healthcare reform in U.S. America... [yawns]... is something.... umm, line?

=) Anyway, hopefully whoever is elected president in 2008 will bring about meaningful change to our system, which is clearly in need of reform.

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