Health Business Blog

According to an email ad I received hocking Integrating Wellness with Disease Management Strategies & Programs:

Health care organizations across the country are slashing unnecessary utilization and costs, increasing patient satisfaction, and improving health behaviors and outcomes with disease management programs targeted at high-cost, chronic illnesses.

Actually, the evidence is much more mixed. Disease management is a great concept, but it’s not clear whether there’s a return on investment for plans or employers that compensates them for the extra management cost.

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BlueCross BlueShield of South Carolina is rolling out a service that tells patients how much insurance will cover and how much is the patient’s responsibility –right at the point of care. (For Patients, This Is a Virtue: A System to Tally Doctor’s Bills, Wall Street Journal.)

What’s BCBS’s motive, other than promoting goodwill?

Doctors have a hard time collecting patient balances. It’s costly to bill and patients don’t always take the bills seriously. Letting the patient know his balance while he’s still in the office should help doctors increase collections and reduce collection costs. With ever higher co-pays and deductibles, patient pay represents an increasing share of physician office revenues.

BCBS is indirectly helping physicians increase their revenues. As a result, BCBS wil be in a better position to hold down reimbursement rates to its physicians and thereby justify its investment in the new service.

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Overly generous reimbursement for MRI and CT has fueled over-utilization of imaging and acted as a magnet for shady dealings. I knew something was up when a successful fish restaurant in my neighborhood was replaced with an MRI/CT center.

Today’s Wall Street Journal describes some of the abuses that are occurring (Medical Center is Investigated for Scan Deals). What is boils down to is imaging centers paying physicians for referrals. Imaging is so profitable that the centers are willing to pay out a large percentage of gross revenue. The Journal provides an example of a contrast CT scan that is reimbursed for $2300, of which the referring doctor keeps $1450.

It’s illegal to pay directly for referrals, so the centers use a variety of methods to get around the restrictions., e.g., paying consulting fees, setting up bogus medical director positions, and nominally leasing equipment. Government agencies, aided by whistleblowers, are going after these practices.

You don’t see these kind of arrangements in many other specialties, because there isn’t enough profit margin to be worth fighting over. Simply lowering the contrast CT scan reimbursement to $1000 would wipe out the scams by drying up the pool of money for kickbacks.

Meanwhile, where are the whistleblowers in orthopedics?

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My wife had me take down some things for a party today. While doing so I accidentally smashed a crystal bowl from Tiffany’s, which had been a gift. Oops!

I’ve always hated Tiffany’s –it’s overpriced and the service is slow and haughty. So it was kind of a punishment for me to deal with replacing the bowl. It made me realize that Tiffany’s is a lot like the health care system.

• The store refused to tell my wife the price of the bowl over the phone. “We don’t quote prices off hand.” My wife told her the policy was stupid since they do provide prices on their website
• When I went to pick up the bowl at “customer service,” the clerk took my ID and vanished for 20 minutes before finally coming back with the bowl

Tiffany’s is still proudly in the dark ages (think overpriced mechanical watches that tell lousy time). Until now, most American health care consumers have been like prototypical Tiffany’s shoppers. They don’t care what anything costs, they assume they are getting the best quality in the world, and they put up with lousy customer service. As employees are forced to pay more out-of-pocket and consumer directed health care takes hold, that will change.

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In today’s The Wall Street Journal, journalist Andrea Petersen writes about “A New Approach for the Sickest Babies.” She describes:

“Doctors and hospitals are changing the way they treat dying babies. Terminally ill infants usually end up in the neonatal intensive care unit, a busy, high-tech environment with an arsenal of life-saving medical equipment. For many, their deaths will be protracted, accompanied by futile attempts at resuscitation and invasive procedures.

But a new movement aims to change that. A cadre of neonatologists and other medical professionals are bringing elements of palliative care and hospice to the tiniest of patients. Such programs focus on the aggressive management of pain and symptoms and attention to the emotional and spiritual aspects of dying. The approach has been available to terminally ill adults and the elderly, but it is only recently that doctors have extended such care to infants and their families. The goal is to allow gravely ill babies to die peacefully, without pain and in their parents’ arms.”

During the mid-1990s, I worked for VITAS Healthcare, the largest hospice company in the US. The hospice movement in the US started to gain steam in the mid-1970s. The National Hospice and Palliative Care Organization (NHPCO) describes “At the center of hospice and palliative care is the belief that each of us has the right to die pain-free and with dignity, and that our families will receive the necessary support to allow us to do so. Hospice focuses on caring, not curing and, in most cases, care is provided in the patient’s home.” Hospice can make a big difference to a patient’s quality of life and especially for their families.

I think it is interesting that hospice was included as a Medicare benefit in 1982, and it became one of the earliest and purest forms of managed care. NHPCO states “96% of hospice care is provided at the routine home care level which is reimbursed at approximately $114 per day.” This flat per-diem (adjusted for geographic cost differences) covers all care related to the terminal diagnosis including physician services, nursing care, DME, supplies, medications, homemaker and home health aide services, and a range of social work and psychosocial support services.

Hospice is an important service to people of all ages, and I am glad to see this compassionate care extended to our small and most fragile infants and their families.

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Go check out Grand Rounds 44, the best of the week’s medical blogging, at Pharyngula.

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In today’s The Boston Globe, the article “Know risks before saying OK to surgery” discusses the importance of the informed consent process. It tells a story of a woman who was asked to sign the informed consent forms after she had already been prepped for her surgery, having received anesthesia and without her reading glasses. She described that there was not enough time and (obviously) poor circumstances for her to understand what she was signing and there wasn’t anyone to ask.

The article suggests a few reasons why the informed consent process is flawed so often. One study addressed the fact that “many forms are written for people who can read at the 11th or 12th grade level or higher, despite the fact that many adults read at the 8th grade level or below.” But in another study, the “only thing that really worked was face-time with a doctor or nurse.”

There are a number of “just in time” clinical reference information tools available at or near the point of care such as UpToDate, which is endorsed by many specialty societies and may have over 50% physician penetration in some specialties, as well as MD Consult and Harrison’s Online. There has been strong demand from specialists and academic physicians, much more so than community-based primary care physicians. We believe that the shift toward evidence-based medicine and push towards better clinical quality information on both doctors and hospitals will imply an increase in demand over time. These tools provide excellent, detailed clinical content with clear patient education materials to be used during the informed consent process.

These point of care tools are beginning to be recognized as enablers of painless, fast payback quality improvement initiatives. As many doctors and hospitals now view the informed consent process as one important factor in managing malpractice, these tools are seen as having immediate payback. However, these tools cannot be used alone, but as a complement to the “face-time” with the doctor to answer all the patient questions. I would agree with The Boston Globe journalist who concludes: “Remember: Informed consent is supposed to be for you [the patient], not the doctor or hospital.”

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A series of letters in today’s New York Times responds to an article on Medicaid fraud. Here’s my overall summary:

NY Medicaid reimbursement is so low (e.g., $7.50 to see a hospital patient), that anyone earning a profit serving Medicaid patients must be committing fraud.

As the last author writes, “If Medicaid paid more for the time a doctor needs to practice good medicine, less money would have to be spent on criminal investigations.”

(Apologies for not including links or formatting. I’m blogging by Blackberry.)

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Standing in here for David Williams on the occasion of the birth of his son takes me back to my firstborn daughter’s experience with severe asthma. Molly was six years old, very sick and worsening. I spent hours searching for hope on the web and elsewhere. Within mainstream medicine there was no theory of the onset of asthma, therefore no path to healing. In the alternative world there were a thousand unconfirmed theories.

Diligence paid off and we found a nutritionist with a theory that was logically sound, supportable through established diagnostics, and came with a clear treatment plan, therefore represented a testable hypothesis about the onset of her asthma and how it might be reversed. In short, the theory was this: intestinal permeability resulting from environmental factors results in heightened immune reactions mediated through IgA and IgG, which results in inflammatory symptoms and may be reversible through treatment of the permeability, avoidance of the offending foods, and waiting for a relaxation of the immune reaction. Testing for permeability was positive and reversed through treatment. Testing for IgA and IgG sensitivities was positive and specific. A thoroughgoing elimination diet resulted in immediate cessation of symptoms and weaning from all medications over time and permanent reversal of all symptoms even after return to a normal diet

A good hypothesis needs more than a single data point for confirmation, but here are some questions that arise from our experience:

• How is it that the institutional history of the study of allergy, which arose out of IgE mechanisms and did not account for IgA or IgG, can still result in training allergists without reference to those important mediation pathways?
• How might it be possible to create an incentive for such hypotheses to become the subject of serious clinical trials, given that they are unlikely to result in a pharmaceutical product?

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Recently I wrote that I didn’t support mandatory nurse staffing ratios. So how do I feel now that my wife is dependent on the nursing staff for her post-surgical recovery over the next few days?

Well first let me say that the nursing care she is receiving is outstanding. The nurses are compassionate, organized and professional. Staffing levels seem to be adequate. We even had a nurse tell us that our insurance would pay for a breast pump, which I didn’t know. She gave us the card for a supplier and the pump is supposed to be delivered tomorrow.

Interestingly, adequate nurse coverage doesn’t mean quick service. The pharmacy seems to be a bottleneck here. Painkillers and anti-emetics have had lead times of 30 minutes or more. Additional nurses wouldn’t help, and having fewer nurses wouldn’t slow things down either. Not sure why they can’t stock some of this stuff on the floor, though.

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