Home / Tag Archives: Access to Care

Tag Archives: Access to Care

Why Bundling Payments Won't Reduce Costs – Part 1

Probably one of the largest pending changes in health care is payment reform. Right now, payment for medical services is essentially a fee for service model. Patients (or their insurers) are generally charged for the services utilized. If a patient goes to hospital for chest pain, and a physician evaluates the patient, either the patient or the patient’s insurer pays the physician for those services. If the physician orders an EKG and lab tests, either the patient or the patient’s insurer pays the hospital for the EKG and lab tests. If the patient is admitted to the hospital, the hospital gets paid a given fee for the admission. It goes on and on. The feds want to reduce costs by changing the payment model for medical care to a “bundled” approach. I don’t think it’s going to work. Bundling won’t change the behaviors necessary to save money. This will be a two part post on why. This part will discuss incentives and how they drive utilization of health care. Next part will apply those concepts to bundled health care. Why is our current system going bankrupt? It is all about incentives. There are three main concepts driving health care costs: profit, demand for services, and fear. Before we can see the effects of a policy change on health care costs, we need to understand how these concepts drive the actions of the major players in the health care market. For Providers, the incentive is currently to provide more services. Demand for services is created by illness. When ill, patients often demand as many medical services as the providers are willing to provide. Patients may seek alternative providers if their demands are not met. There is little incentive to provide less care with increased demand. Profit is created by providing services. In a fee for service environment, the more services that are provided, the more that the providers are paid. If patients want the testing or services, more often than not, they get the testing or services. Unhappy patients tend not to come back. No patients = no income. The most pervasive fear for providers is fear of liability – either legal or professional. This fear is often mitigated by providing more services. Increased testing decreases the fear of liability because if there is a bad patient outcome, the provider can point to all the testing and argue that they should not be liable because “we did everything we could.” It is uncommon for a provider to suffer adverse consequences for performing too much testing. Fear of liability may lead to extremely expensive and questionably beneficial medical care. Hospitals also fear regulatory sanctions. It is comical to watch hospital administrators scurry about when there is a JCAHO survey. Poor performance on a JCAHO survey threatens a hospital’s Medicare reimbursement. For Insurers, there is an incentive to increase customers who pay into the system, but who do not take money out of the system. Demand for services is still created by illness, but as demand for services goes up, insurer profits go down (or, in the case of government insurance, debts increase). Insurers profit by having healthy and wealthy subscribers. Healthy subscribers pay into the system, but don’t take as much out of the system. Insurers can increase profits by raising insurance premiums, but must be careful when setting prices. If premiums are raised too high, healthy insurers may drop their coverage because they perceive too much of a disconnect between the premiums that they are  paying and the services that they are utilizing. In that case, the profits from increased premiums ...

Read More »

Healthcare Update — 10-03-2011

More medical news from around the web at the Satellite Edition of this week’s update on ER Stories … Australian emergency physician punches and slaps restrained patient who spat in his face. He was terminated from his position. A court held that the termination was unfair. Australian doctors considered going on strike after learning how the doctor was treated after the incident. When you read the comments section of articles describing patients who assault emergency department staff, many people seem to think that staff should accept abusive behavior due as being “part of the job.” Shouldn’t patients therefore accept abusive behavior from medical staff as being “part of the visit”? A view of medical malpractice reform misconceptions from physician-attorney William Sage. I disagree with several of his premises. For example, one question Dr. Sage asks “How likely is it, really, that ‘sinister forces’ outside [of medicine] are the reason why tens of millions of Americans lack access to services, or why even those who can afford it often get mediocre care at inflated prices?” Ask physicians who don’t provide care to patients with certain government insurance plans and who stop taking emergency call or stop performing certain procedures (such as brain neurosurgery) due to liability concerns. Ask doctors who won’t or can’t prescribe medications that are safe through billions of prescriptions because the FDA issues a black box warning that the drugs might have caused adverse reaction in one millionth of a percent of the people receiving them. Then ask patients who can’t afford to purchase certain drugs such as albuterol, colchicine, or (soon to be) Primatene Mist because drug companies jacked up their prices based upon a governmental technicality in approving the medications. Nah. No “sinister forces” here. Recent Massachusetts Medical Society survey shows many interesting findings. Specialties in critical short supply included internal medicine, urology and psychiatry. Primary care specialties had severe shortages for 6 straight years. More than half of physicians would be unwilling to participate voluntarily in either global payment programs or accountable care organizations. Oh – and “the fear of being sued continues to be a substantial negative influence on the practice of medicine, affecting access to and availability of physician services.” Nah. No “sinister forces” here, either. Another timely rebuttal to some assertions in Dr. Sage’s article. Study in Archives of Internal Medicine shows that 42% of physicians believe that their patients are receiving too much care. Guess what factor contributed to more aggressive care in 76% of cases. Click this link to find out. Hint: “Sinister force” alert. CMS coming out with bundled payment plans for 2012. Look for the pendulum of clinical care and testing to swing the other way. And look for more people to accuse “greedy doctors and hospitals” of limiting care in order to make more money when, in reality, the government is limiting care through underpayments to providers. Another reason that getting a ZeePack for your cough might not be a good idea (aside from the fact that it won’t work) … it might cause you to get Crohns disease or ulcerative colitis. Twelve percent of patients diagnosed with Crohns or UC had been prescribed three or more doses of antibiotics in the two years prior to their diagnosis. Only 7% of patients who had developed Crohns or UC had not been prescribed antibiotics. In other words, people prescribed frequent antibiotics were up to 50 percent more likely to get Crohn’s disease or ulcerative colitis within next two to five years. My guess is that they were more likely to get MRSA and C. difficile as well. Study abstract ...

Read More »

Refusing to Treat Obese Patients

I discussed whether or not ambulances should be required to add equipment costing $12,000 in order to be able to transport 850 pound patients in a previous post, so I won’t belabor the point here. Providing medical care to morbidly obese patients presents multiple challenges. Then I read an article in the Florida Sun Sentinel about how some obstetrician/gynecologists in South Florida are refusing to provide medical care to obese women. Fifteen out of 105 Ob/Gyns refuse to treat patients based upon either weight or BMI. Some won’t take any patients who weigh more than 200 lbs. In the article, other obstetricians without such a policy state that “no doctor should be unable to treat patients just because they are heavy.” The “ability” to treat patients is only one of the issues involved, though. Morbidly obese patients are more likely to develop surgical and post-op complications.  One of the physicians in the article mentioned that ultrasounds are more difficult to perform and interpret in obese patients. If a physician misses a critical finding on ultrasound due to a patient’s obesity, a plaintiff’s attorney will argue that the patient should have been referred to someone with more experience under those circumstances. Malpractice insurance costs in Florida are some of the highest in the country. In fact, the costs are so high that the article states that half of Florida obstetricians go without malpractice insurance. If physicians want to decrease their risk in managing patients by excluding patients who are at higher risk for complications, shouldn’t they be able to do so? Many commenters to the article have harsh words for doctors who are unwilling to treat obese patients. The article itself cites physician groups, medical ethics experts and advocates for the obese, all of whom said that refusing to treat patients based on obesity would “violate the spirit of the medical profession.” Insurers can refuse to provide insurance based upon pre-existing conditions (at least for a few more years) or can jack up premiums so high that the insurance is unaffordable. Good luck getting life insurance or disability insurance if you have a history of cancer. Airlines can refuse to transport people that are deemed an excessive “risk.” Banks can put limitations on those who enter their premises. Try walking inside a bank wearing a ski mask some day. Lawyers can reject any potential client for any reason. I don’t understand why people find it morally reprehensible if some doctors want to try to limit their liability by refusing to care for patients who are a higher risk for adverse outcomes. This whole situation is a perfect example of the “perfect care” or “available care” paradigm. The more that physicians who care for higher-risk patients are sued for less than perfect outcomes, the less that those physicians will be willing to treat higher-risk patients.

Read More »

Gaming ObamaCare

Remember my post a few months back about how some large companies were getting waivers so they didn’t have to pay into the new health care system? Things are getting worse.  According to this article on The Hill, the feds just granted new insurance waivers to more than 500 groups, bringing the total number of individuals covered by waivers to 2.1 million. The system just isn’t going to work. Let me get my soapbox out here. [Tap tap tap] Is this thing on? Good. First, there’s still this misconception that the “mandate” to purchase insurance will somehow translate into accessibility of medical care. It doesn’t work that way. I’ve said it before. Purchasing health insurance doesn’t mean that you have access to health care any more than purchasing car insurance means that you have access to a car. If your insurance is cut-rate,  chances are that your medical care will be cut-rate. You can’t make a silk purse out of a sow’s ear. The general idea of “insurance” is conceptually sound. Everyone pays into a system to spread the risk of paying for a catastrophic event. You pay$100 per month to presumably avoid having to pay $100,000 or more if you have a major medical event. The amount of money paid into a system is dependent upon how much money is taken out of the system. If there is a surge in the number of people needing medical care, one of two things happens: More money has to be paid into the system or less money has to be taken out of the system through rationing of medical care or providing lower quality less expensive medical care. There aren’t any other variables to change. Cost, availability, and quality. That’s it. The proposed system creates too many loopholes. It caters to special interests. It changes the cost/availability/quality variables in ways that the public doesn’t realize. So lets look at a few examples. First, what exactly are we getting for our money in the current system – or in the proposed system? Many people don’t know. With regular insurance plans, your policy guides coverage. Maybe you have exclusions for certain conditions. Maybe there is a limit on how much the insurance company will pay for a certain type of care. Maybe certain types of care (like dental care or vision care) is unavailable. But at least you know what you’re getting. Can anyone say with certainty what type of medical care they’re going to get once they start paying into the new and improved health care system? I sure can’t. The lack of specifics opens everyone up to being refused care once they’ve paid into the system. After all, the feds and/or insurance companies can just say “We never agreed to pay for that type of care.” In essence, we’re paying for what’s behind the curtain without really seeing what’s behind the curtain. Speaking about “exclusions” on insurance, under the current plan, “exclusions” on insurance policies will be limited. True that insurance companies have used exclusions and rescissions unethically in the past, but when used appropriately, exclusions keep people from gaming the system. If you’ve had a bum knee for 20 years, you shouldn’t be able to pay one month’s insurance premiums and then be entitled to the newest titanium replacement, the services of the best orthopedist, and unlimited therapy. If everyone gamed the system that way, the system would collapse because there would be a tremendous funding input/output mismatch that couldn’t be sustained by just increasing insurance premiums. No one would purchase “insurance” because they know that they could just get ...

Read More »

Caring for Morbidly Obese Patients

Not sure how I feel about this. Boston Emergency Medical Services debuts an ambulance with a mini-crane and reinforced stretcher to transport patients weighing up to 850 pounds. It cost $12,000 to retrofit the ambulance. My problem is this: I think we need to do our best to provide medical care to all patients. But patients need to take some basal level of responsibility for their own health. If you’re saying that you got to be 850 pounds due to a “glandular problem,” you’re blowing smoke. See this post (hat tip to MDOD) and then come talk to me. Let’s say you want to go hiking in some secluded location or you want to go spelunking far beneath the surface of the earth. When you take those risks, you implicitly accept the chance that if something happens to you, there’s not going to be an acute care clinic at the 3,000 foot mark on the mountain you want to climb. If you get hurt, you aren’t going to have access to the medical care that might otherwise be available to you. You may take your cell phone with you and may make arrangements for air medical transport if needed, but even with those precautions, you just might die from your injuries based solely on the risks you took – and no one is to blame but you. If alcoholic patients drink to the point that they develop liver failure and then they continue drinking alcohol, most hospitals will not perform liver transplants. You got yourself into that situation, you refuse to help yourself get out of that situation, the system isn’t going to invest massive amounts of resources into your care – and no one is to blame but you. Should people who eat themselves to death be treated any differently? Should it ever be right to tell patients that if they let themselves get so obese that traditional ambulances can’t carry them that dispatchers will tell refuse transport and they will be responsible for their own transportation to the hospital? If we continue down the road that we must accommodate the medical needs of every morbidly obese patient, are we then going to require that all hospitals purchase CT scanners and MRI scanners to accommodate patients of all weights – if those scanners even exist? Will every hospital be required to maintain an additional set of beds, commodes, bathroom fixtures, blood pressure cuffs, and a plethora of other utilities solely to treat morbidly obese patients. Or perhaps we create regional system of care for morbidly obese patients. One regional hospital gets all the necessary equipment to manage the medical needs of morbidly obese patients and any morbidly obese patient requiring testing or admission must be transported to one of these centers. Hospitals can transfer trauma patients if they don’t have a trauma surgeon, shouldn’t they also be able to transfer bariatric patients if they don’t have a bariatric specialist? This post is not meant as an attack on morbidly obese people, but more intended as a reality check. What should be a rational method of dealing with morbidly obese patients? If we require EMS and hospitals to make all these expensive modifications for morbidly obese patients, where do the accommodations end for other patients with other medical conditions needing costly medical care? And how long is it going to be before the Law Firm of Dewey, Cheatem, and Howe files a claim against a hospital when a patient dies because the hospital didn’t have those modifications?

Read More »