Daniel Redwood, DC, is a Professor at Cleveland Chiropractic College in Overland Park, Kansas. He is the Editor-in-Chief of Health Insights Today, Associate Editor of Topics in Integrative Healthcare and a member of the editorial boards of the Journal of the American Chiropractic Association.
This sums up the bizarre economics of the hospital business in the United States as well as anything I’ve seen. Oversimplification? Sure. But what a clarifying example!
With blood oozing from deep lacerations, the two patients arrived at California Pacific Medical Center’s tidy emergency room. Deepika Singh, 26, had gashed her knee at a backyard barbecue. Orla Roche, a rambunctious toddler on vacation with her family, had tumbled from a couch, splitting open her forehead on a table.
On a quiet Saturday in May, nurses in blue scrubs quickly ushered the two patients into treatment rooms. The wounds were cleaned, numbed and mended in under an hour. “It was great they had good DVDs, the staff couldn’t have been nicer,” said Emer Duffy, Orla’s mother.
Then the bills arrived. Ms. Singh’s three stitches cost $2,229.11. Orla’s forehead was sealed with a dab of skin glue for $1,696. “When I first saw the charge, I said, ‘What could possibly have cost that much?’ ” recalled Ms. Singh. “They billed for everything, every pill.”
There is little science to how hospitals determine the prices they print on hospital bills.
“Charge master prices are basically arbitrary, not connected to underlying costs or market prices,” said Professor Melnick, the economist. Hospitals “can set them at any level they want. There are no market constraints.”
Prices for any item or service are set by each hospital and move up and down yearly, and show extraordinary variability, health economists say. The codeine that costs $20 and the bag of IV fluid that costs $137 at California Pacific are charged at $1 and $16 at the University of California San Francisco Medical Center, across town. But U.C.S.F. Medical Center charges $1,600 for an amniocentesis, which costs $687 at California Pacific.
In our states — Washington, Kentucky and Connecticut — the Affordable Care Act, or “Obamacare,” is working. Tens of thousands of our residents have enrolled in affordable health-care coverage. Many of them could not get insurance before the law was enacted.
People keep asking us why our states have been successful. Here’s a hint: It’s not about our Web sites.
Sure, having functioning Web sites for our health-care exchanges makes the job of meeting the enormous demand for affordable coverage much easier, but each of our state Web sites has had its share of technical glitches. As we have demonstrated on a near-daily basis, Web sites can continually be improved to meet consumers’ needs.
The Affordable Care Act has been successful in our states because our political and community leaders grasped the importance of expanding health-care coverage and have avoided the temptation to use health-care reform as a political football.
The cholesterol guidelines released last week are already poised to drastically increase the number of people prescribed statin drugs, and this calculator that the American College of Cardiology just unveiled will help people miscalculate their risk (substantially upwards, of course) even more.
“[It] overpredicted risk by 75-150%, depending on the population. A man whose risk was 4 percent, for example, might show up as having an 8 percent risk. With a 4 percent risk, he would not warrant treatment….. Miscalibration to this extent should be reconciled and addressed before these new prediction models are widely implemented. If real, such systematic overestimation of risk will lead to considerable overprescription.”
“Something is terribly wrong,” Dr. Nissen said. Using the calculator’s results, he said, “your average healthy Joe gets treated, virtually every African-American man over 65 gets treated.”…
In response to my op-ed in the Kansas City Star this week, I received a wide range of comments. Most were quite supportive. Others were, shall we say, less than enthusiastic about various aspects of the health reform law.
My reply to those commenters:
Regarding the questions you shared with me about the Patient Protection and Affordable Care Act …
The United States is the one nation in the developed world that has not made a decision as a nation to consider health care a fundamental right. The health reform law (Patient Protection and Affordable Care Act of 2010) is the first major step in that direction since the passage of Medicare and Medicaid in the 1960s. It has many moving parts because it builds on the existing flawed system rather than switching to a single payer system, as was done in varying ways in other nations. Some of those other countries maintained private insurance companies but only as nonprofit entities; others went all in with government as the sole payer and/or administrator. The United States is the only developed nation that has private insurers that have to answer to shareholders. I would argue that this is a bug, not a feature.
In my view, all systems have their own unique strengths and weaknesses. The pre-PPACA U.S. system has the unique track record of having the highest (by far) overall per capita health care expenses in the world at the same time that it has many of the worst health outcomes in the developed world. So we begin with a system that is highly problematic, and to cap it off also leaves tens of millions (50M?) uninsured, something does not exist in any of these other nations. Before diving into any particular strengths and weaknesses of PPACA, I think it’s critical to acknowledge that the system on which it seeks to improve is drastically flawed. On at least that one point, I would imagine that both proponents and opponents may agree.
The Kansas City Star has just published my op-edbased on my experiences this year on the Missouri Citizens and Legislators Working Group on Medicaid.
At least a dozen physicians from safety net clinics shared stories of their uninsured, “working poor” patients (most of whom would be covered if Missouri accepts Medicaid expansion) who can’t afford the medicines or other treatments prescribed for their diabetes, heart disease, hypertension or chronic pain. As a result, they spiral downward, suffering greatly as their previously manageable ailments become unmanageable (such as treatable diabetes descending into kidney failure) , at which point their now-severe disabilities allow them to finally qualify for Medicaid, but too late to regain their health.
To put Obamacare victims’ strife in perspective, let’s take a trip down memory lane. You know, the golden years of American health care in … oh, let’s say 2007, back when you could be denied coverage for something as benign as acne or as mundane as pregnancy.
Back then, anecdotes about people who were denied coverage abounded. They included this 12-year-old boy who died in 2007 from an abscessed tooth after his family’s Medicaid lapsed. And this 17-year-old boy whose insurance was revoked after he tested positive for HIV. This woman who was denied coverage for breast cancer because she wasn’t diagnosed at the correct clinic. And this woman whose double mastectomy was denied after her insurance company learned she had visited a dermatologist for acne treatment the year before. Ah, yes, those were the days!
For those who put more stock in headlines, here are a few that help convey the state of the American health care system back in its heyday.
It’s not all anecdotes and headlines. She goes from there to a series of links to policy papers and the like.
We are currently in the early stages of what will likely be a decade-long transition to a new model. There will be bumps along the way. There are some now. But it’s important to remember why there was such a hue and cry for reform in the first place.
On the basis of a review of scientific evidence and findings from expert panels, the agency made a preliminary determination that the oils “are not generally recognized as safe for use in food” and should be eliminated, FDA Commissioner Margaret Hamburg, MD, said on a conference call with reporters.
The decision “is very welcome and strongly supported by massive scientific evidence that trans fat has many adverse effects on health,” Walter Willett, MD, DrPH, of the Harvard School of Public Health, said in an email to MedPage Today. “Trans fat has no place on the table, and this step will help make the diets of Americans safer.”
Harvard School of Public Health’s Walter Willett, PhD, puts the change into context:
Willett added, “Further removal of trans fats will also likely nudge down rates of diabetes, obesity, and other conditions as well.”
“Importantly, by getting trans fat off the table entirely, we will be able to focus attention on other aspects of diet that also need to be improved,” he said. “This will likely have a ripple effect worldwide because other countries are considering similar actions.”
Atul Gawande is a medical physician in Massachusetts whose work on implementing checklists before surgery has saved countless lives worldwide and will save countless more. He is among the most perceptive writers on the American healthcare system.
The law’s actual manifestation, however, is rather anodyne: as of October 1st, healthcare.gov is scheduled to open for business. A Web site where people who don’t have health coverage through an employer or the government can find a range of health plans available to them, it resembles nothing more sinister than an eBay for insurance. Because it’s a marketplace, prices keep falling lower than the Congressional Budget Office predicted, by more than sixteen per cent on average. Federal subsidies trim costs even further, and more people living near the poverty level will qualify for free Medicaid coverage.
How this will unfold, though, depends on where you live. Governors and legislatures in about half the states—from California to New York, Minnesota to Maryland—are working faithfully to implement the law with as few glitches as possible. In the other half—Indiana to Texas, Utah to South Carolina—they are working equally faithfully to obstruct its implementation. Still fundamentally in dispute is whether we as a society have a duty to protect people like Paul Sullivan. Not only do conservatives not think so; they seem to see providing that protection as a threat to America itself.
Obstructionism has taken three forms. The first is a refusal by some states to accept federal funds to expand their Medicaid programs. Under the law, the funds cover a hundred per cent of state costs for three years and no less than ninety per cent thereafter. Every calculation shows substantial savings for state budgets and millions more people covered. Nonetheless, twenty-five states are turning down the assistance. The second is a refusal to operate a state health exchange that would provide individuals with insurance options. In effect, conservatives are choosing to make Washington set up the insurance market, and then complaining about a government takeover. The third form of obstructionism is outright sabotage. Conservative groups are campaigning to persuade young people, in particular, that going without insurance is “better for you”—advice that no responsible parent would ever give to a child. Congress has also tied up funding for the Web site, making delays and snags that much more inevitable.
Some states are going further, passing measures to make it difficult for people to enroll. The health-care-reform act enables local health centers and other organizations to provide “navigators” to help those who have difficulties enrolling, because they are ill, or disabled, or simply overwhelmed by the choices. Medicare has a virtually identical program to help senior citizens sort through their coverage options. No one has had a problem with Medicare navigators. But more than a dozen states have passed measures subjecting health-exchange navigators to strict requirements: licensing exams, heavy licensing fees, insurance bonds. Florida has attempted to ban them from county health departments, where large numbers of uninsured people go for care. Tennessee recently adopted an emergency rule declaring that anyone who could be described as an “enrollment assister” must undergo a criminal background check, fingerprinting, and twelve hours of course work. The hurdles would hamper hospital financial counsellors in the state—and, by some interpretations, ordinary good Samaritans—from simply helping someone get insurance.
This kind of obstructionism has been seen before. After the Supreme Court’s ruling in Brown v. Board of Education, in 1954, Virginia shut down schools in Charlottesville, Norfolk, and Warren County rather than accept black children in white schools. When the courts forced the schools to open, the governor followed a number of other Southern states in instituting hurdles such as “pupil placement” reviews, “freedom of choice” plans that provided nothing of the sort, and incessant legal delays. While in some states meaningful progress occurred rapidly, in others it took many years. We face a similar situation with health-care reform. In some states, Paul Sullivan’s fate will become rare. In others, it will remain a reality for an unconscionable number of people. Of some three thousand counties in the nation, a hundred and fourteen account for half of the uninsured. Sixty-two of those counties are in states that have accepted the key elements of Obamacare, including funding to expand Medicaid. Fifty-two are not.
Medical practice guidelines are voluntary. Sometimes, this leads to clearly dysfunctional outcomes.
This interview with the author of a new article in JAMA Internal Medicine underscores the conclusions reached in the 2010 study by Bishop and colleagues at the National Spine Center in Canada, published in Spine Journal, which found management of low by pain by primary care medical physicians (PCPs) to be highly “guideline-discordant” with regard to medications. (Bishop’s article also found that for low back pain, guideline-based care that includes spinal manipulation by chiropractors is significantly more effective than usual care by PCPs).
The new JAMA Internal Medicine article’s lead author is John N. Mafi, MD, chief medical resident and fellow in general medicine at Beth Israel Deaconess Medical Center in Boston:
We saw a decline in use of NSAIDs that was discordant with the guidelines. The guidelines recommend it as a first-line treatment. What we are seeing instead is a rise in narcotic prescriptions. The guidelines are cautious about narcotics and say to be cautious and recommend them only as second- or third-line therapies.
There is also discordance between the guidelines and physician use of imaging. In patients with new-onset back pain, ordering an MRI or CT scan is not indicated in most cases. Finally, we saw a rise in referrals to specialists, though primary care clinicians are usually able to manage patients with routine cases of back pain themselves with minimal treatment.
news@JAMA: What do you think is driving physicians to pursue these more aggressive treatment approaches?
Dr Mafi: We are a society that demands instant solutions, but back pain doesn’t play by these rules. It takes time, and unfortunately, the fancier treatments haven’t been shown to decrease patient’s pain or increase their quality of life. That’s why we have to rely on the less-is-more approach.
news@JAMA: What do you think is driving the shift from NSAIDs to narcotics?
Dr Mafi: It is in part patient expectations and a sentiment that emerged in the 1990s physicians weren’t paying enough attention to patient pain. The Joint Commission made pain the fifth vital sign. In response, there has been an overcorrection and now narcotics are reached for first. Since that time, there has been a 300% increase in narcotic prescriptions and rise in narcotic overdoses and deaths. In 2008 almost 15000 people died—more than for cocaine and heroin overdoses combined. There are huge public health implications.
1. Mafi JN, McCarthy EP, Davis RB, Landon BE. WOrsening trends in the management and treatment of back pain. JAMA Internal Medicine. 2013 (epub before print).
2. Bishop PB, Quon JA, Fisher CG, Dvorak MFS. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. The Spine Journal. 2010;10(12):1055-1064.
This intransigence will bring with it a great deal of unnecessary suffering, death and, not so incidentally, economic hardship in its wake. Will they change their minds eventually? Only if their own citizens force them to.
But in Rome, 27 percent of adults under 65 are uninsured, a rate that holds true across the state. Last year, the city’s two hospitals report spending more than $80 million delivering uncompensated care, often in the emergency room, where costs run high. Taxpayers and those with health insurance will end up paying for that care through government subsidies and higher premiums, industry experts say.
Rome’s dilemma is exactly the situation that the Patient Protection and Affordable Care Act, also known as “Obamacare,” was designed to fix — but that fix isn’t coming to Georgia.
The Patient Protection and Affordable Care Act provides for expansion of insurance coverage for low-income and middle-class adults, with the goal of reducing the $41 billion spent covering uninsured care each year.
A key provision, set to kick in on Jan. 1, 2014, offers states federal funding to expand Medicaid coverage to all adults making up to 133 percent of the poverty line, or $25,975 for a family of three. In Georgia, over half of that group is uninsured.
But in the Deep South and Florida, Republican governors and state legislatures have turned down the funding, citing cost concerns and philosophical opposition to the safety net insurance program, which was signed into law on July 30, 1965. In Louisiana, Mississippi, Alabama, Georgia, South Carolina and Florida, the move will exclude 2.7 million low-income residents from Medicaid eligibility, according to the Urban Institute.
“In Georgia, these people are the working poor,” said Dr. Leonard Reeves, a family physician in Rome who volunteers at the city’s privately-funded free clinic. “I had an uninsured patient in his late 30s who worked every day of his life, and one day he finally came in when he felt he couldn’t go on any more.”
Dr. Reeves diagnosed the man, who was married and worked part-time as a forklift operator, with diabetes, but it was too late for insulin. After years without basic treatment, his kidneys had failed, and he needed weekly dialysis treatments to stay alive.
“He’s now on disability,” said Dr. Reeves. “If he’d had that insurance, he’d still be paying into the tax rolls instead of taking from them. There’s an old saying — ‘An ounce of prevention is worth a pound of cure.’ And that’s exactly what we’re talking about here.”