August 2nd, 2008 by Dr. Val Jones in True Stories
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I posted this true story on my blog previously, but I think it bears repeating (especially with the recent news of increased violence against physicians and threats at gunpoint). Details of the story were altered to ensure privacy of all involved.
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The son of a business tycoon experienced some diarrhea. He went to his local emergency room immediately, explaining to the staff who his father was, and that he required immediate treatment.
Because of his father’s influence, the man was indeed seen immediately. The physicians soon realized, however, that there was nothing emergent about this man’s complaints. After several blood tests and a stool sample were taken, he was administered some oral fluids and monitored for several hours, they chose to release him to recover from his gastroenteritis (stomach flu) at home.
The man complained bitterly and said that he wanted to be admitted to the hospital. The physicians, with respect, explained that he didn’t show any signs of dehydration, that he had no fever, his diarrhea was indeed fairly mild (he had only gone to the restroom once during the hours of his ED visit – and that was when he was asked to produce a stool sample). The man’s pulse was in the 70’s and he had no acute abdominal tenderness.
The man left in a huff, and called his father to rain down sulfur on the ED that wouldn’t admit him.
And his father did just that.
Soon every physician in the chain of command, from the attending who treated him in the ED right up to the hospital’s medical chief of staff had received an ear full. Idle threats of litigation were thrown about, and vague references to cutting key financial support to the hospital made its way to the ear of the hospital CEO.
The hospital CEO appeared in the ED in person, all red and huffing, quite convinced that the physicians were “unreasonable” and showed “poor judgment.” Arguments to the contrary were not acceptable, and the physicians were told that they would admit this man immediately.
The triumphant young man returned to the ED for his admission. Since the admitting diagnosis was supposedly dehydration, a nurse was asked to place an IV line. The man was speaking so animatedly on his cell phone, boasting to a friend about how the doctors wouldn’t admit him to the hospital so his dad had to make them see the light, that he moved his other arm just at the point when the nurse was inserting the IV needle. Of course, the poor woman missed his vein.
And so the man flew into a rage, calling her incompetent, cursing the hospital, and refusing to allow her to try again.
At this point, the ED physicians just wanted him out of the emergency room – so they admitted him to medicine’s service with the following pieces of information on his chart:
Admit for bowel rest. Patient complaining of diarrhea. Blood pressure 120/80, pulse 72, temperature 98.5, no abdominal tenderness, no white count, patient refusing IV hydration.
Now, this is code for: this admission is total BS. Any doctor reading these facts knows that the patient is perfectly fine and is being admitted for non-health related reasons. With normal vital signs, and no evidence of dehydration or infection, this hardly qualifies as a legitimate reason to take up space in a hospital bed. And when the patient is refusing the only treatment that might plausibly treat him, you know you’re in for trouble.
The man was discharged the next day, after undergoing (at his insistence) an abdominal CAT scan, a GI consult, an ultrasound of his gallbladder, and a blood culture. His total hospital fee was about $8,000.
Do you think he paid out of pocket for this? No. He submitted the claim for payment to his insurance company. Their medical director, of course, reviewed the hospital chart and realized that the man had no indication for admission, and refused medical care to boot, so he denied the claim.
So the son appealed to his father, who then rained down sulfur on the insurance company, threatening to pull his entire business (with its thousands of workers insured by them) from the company if they didn’t pay his son’s claim.
The medical director at the insurance company dug in his heels on principle, assuming that if he continued to deny the claim, the hospital would (eventually) agree to “eat the cost.”
In the end, the insurance company did not pay the claim. The CEO of the insurance company called the hospital CEO, explaining that it was really the doctor’s fault for admitting a man who didn’t meet admission requirements. The hospital CEO agreed to discipline the physician (yes, you read that corretly) and eat the cost to maintain a good relationship with the insurance company that generally pays the hospital in a timely manner for a large number of patient services.
Welcome to the complicated world of cost shifting in healthcare.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 28th, 2008 by Dr. Val Jones in Expert Interviews, Health Policy
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I had the chance to interview Drs. Carmona, Satcher, and Novello about the current state of America’s war on cancer. I’ll post each conversation in a separate blog entry. This post explores Dr. Novello’s views on creating a healthcare navigation system for patients with cancer.
Dr. Val: How are cancer patients navigating the system currently?
Dr. Novello: They are relying primarily on their oncologists to help them navigate. But even though oncologists want to help their patients as much as possible, the reality is that they are taking care of thousands of patients at a time and simply don’t have the bandwidth to assist with the level of detail necessary.
Cancer is extremely complicated and patient care is not just about diagnosis, staging, and treatment. It also includes tests for genetic markers, coordination of genetic counseling, finding appropriate clinical trials for the patients to participate in, locating a continuity of care supervisor, rehabilitation services, scheduling chemotherapy, radiation, and surgical treatments.
Cancer doesn’t happen in a vacuum – patients also have other medical conditions that need to be managed along with the cancer diagnosis. In addition, one must create a comprehensive follow up plan for survivors, including scheduling of surveillance tests to identify possible recurrences. If a cure is not an option, then palliative care and hospice services must be coordinated. In addition to that, patients must create a living will, designate someone to have power of attorney over their care, and prepare for the legal aspects of their passing. This is why a diagnosis of cancer can be overwhelming to most people, and they are in desperate need of a structured program to help them navigate the complexities and to ensure that the ball is not dropped anywhere along the way.
Dr. Val: What’s the best way to help cancer patients more successfully navigate the healthcare system?
Dr. Novello: We need to create a simple, comprehensive, and accurate way to offer guidance to all Americans with cancer so that they can get the best care possible. You know how some hospitals have painted lines on the floor to help people to navigate from A to B in the building? Well we need this kind of line system for cancer care.
Ellen Stoval at the National Coalition for Cancer Survivorship, Lance Armstrong and his Foundation, members of the Institute of Medicine and the Centers for Disease Control and Prevention, and members of the President’s Cancer Plan at the National Cancer Institute, have formed a coalition to delineate the features of an ideal cancer patient navigator system. Senators Kennedy and Hutchison are preparing a bill for congress – it would ensure that Medicare covers a cancer patient navigator service. It remains to be seen who will build the service, and how it will be distributed.
Dr. Val: What are the key elements of a cancer patient navigator system?
Dr. Novello: The coalition is unanimous in their opinion that the navigator must provide culturally sensitive, clear information in the native language of the patient. A cancer patient navigator should include assistance with:
Diagnosis: Every patient needs to know the name and stage of the cancer that they have.
Treatment: The treatment plan (including chemotherapy, radiation, and/or surgery) that is recommended for them.
Scheduling: A schedule of all their appointments.
Pain Management: A comprehensive plan for pain management so that the patient is not denied access to narcotics if needed.
Psychosocial Services: Access to psychosocial services to assist with coping strategies for depression and family and marriage counseling.
Insurance Assistance: a plan for financing the cost of treatment – specifically an insurance advocate who can help the patient understand and maximize their insurance benefits, and if they’re uninsured, a way to get coverage for the care they need.
Peer Support: A list of support groups that can assist the patient with their emotional needs.
We need everyone to support this upcoming bill so that all cancer patients will have access to a navigation tool that will help them get the care they need in a timely fashion. Successful navigation of this healthcare system can mean the difference between life and death for cancer patients.
Dr. Novello is the Vice President for Women and Children’s Health Policy at Florida Hospital in Orlando, Florida.
*See the National Call to Action on Cancer Prevention and Survivorship*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 11th, 2008 by Dr. Val Jones in Health Policy
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Tom Daschle, former Senate Majority Leader from South Dakota, was the keynote speaker at the Fighting Chronic Disease: The Missing Link in Health Reform conference here in Washington, DC. His analysis of the healthcare crisis is this:
US Healthcare has three major problems: 1) Cost containment. We spend $8000/capita – 40% more than the next most expensive country in the world (Switzerland). Last year businesses spent more on healthcare than they made in profits. General motors spends more on healthcare than they do on steel.
2) Quality control. The US system cannot integrate and create the kind of efficiencies necessary. The WHO has listed us as 35 in overall health outcomes. Some people ask, “If we have a quality problem, why do kings and queens come to the US for their healthcare?” They come to the best places like the Mayo Clinic, the Cleveland Clinic, or Johns Hopkins. They don’t go to rural South Dakota. We have islands of excellence in a sea of mediocrity.
3) Access. People are unable to get insurance if they have a pre-existing condition. 47 million people don’t have health insurance. We have a primary care shortage, and hospitals turning away patients because they’re full.
His solutions are these:
- Universal coverage. If we don’t have universal coverage we can’t possibly deal with the universal problems that we have in our country.
- Cost shifting is not cost savings. By excluding people from the system we’re driving costs up for taxpayers – about $1500/person/year.
- We must recognize the importance of continuity of care and the need for a medical home. Chronic care management can only occur if we coordinate the care from the beginning, and not delegating the responsibility of care to the Medicare system when the patient reaches the age of 65.
- We must focus on wellness and prevention. Every dollar spent on water fluoridation saves 38 dollars in dental costs. Providing mammograms every two years to all women ages 50-69 costs only $9000 for every life year saved.
- Lack of transparency is a devastating aspect of our healthcare system. We can’t fix a system that we don’t understand.
- Best practices – we need to adopt them.
- We need electronic medical records. We’re in 21st century operating rooms with 19th century administrative rooms. We use too much paper – we should be digital.
- We have to pool resources to bring down costs.
- We need to enforce the Stark laws and make sure that proprietary medicine is kept in check.
- We rely too much on doctors and not enough on nurse practitioners, pharmacists, and physician assistants. They could be used to address the primary care shortage that we have today.
- We have to change our infrastructure. Congress isn’t capable of dealing with the complexity of the decision-making in healthcare. We need a decision-making authority, a federal health board, that has the political autonomy and expertise and statutory ability to make the tough decisions on healthcare on a regular basis. Having this infrastructure in place would allow us the opportunity to integrate public and private mechanisms within our healthcare system in a far more efficient way.
What do I think of this? First of all, I agree with much of what Tom said (especially points 2-7) and I respect his opinions. However, I was also very interested in Nancy Johnson’s retort (she is a recently retired republican congresswoman from Connecticut).
Nancy essentially said that any attempt at universal coverage will fail if we don’t address the infrastructure problem first. So while she agrees in principle with Tom Daschle’s aspirations and ideals, she believes that if we don’t have a streamlined IT infrastructure for our healthcare system in place FIRST, there’s not much benefit in having universal coverage.
As I’ve always said, “equal access to nothing is nothing.”
I also think of it this way: imagine you own a theme park like Disney World and you have thousands of people clamoring at the gates to enter the park. One option is to remove the gates (e.g. universal coverage) to solve consumer demand. Another option is to design the park for maximal crowd flow, to figure out how to stagger entry to various rides, and to provide multiple options for people while they’re waiting – and then invite people to enter in an orderly fashion.
Obviously, this is not a perfect analogy – but my opinion is that until we streamline healthcare (primarily through IT solutions), we’ll continue to be victims of painful inefficiencies that waste everyone’s time. It’s as if our theme park has no gates, no maps, no redirection of crowd flow, no velvet-roped queues, and the people who get on the rides first are not the ones who’ve been waiting the longest, but the “VIPs” with good insurance or cash in the bank. It’s chaotic and unfair.
Quite frankly, I think we could learn a lot from Disney World – and I hope and pray that next year’s healthcare solution is not simply “remove the gates.”
What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
May 27th, 2008 by Dr. Val Jones in Expert Interviews, Health Policy
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I attended the STOP Obesity Alliance press conference on May 22, 2008, in Washington, D.C. During the conference a new strategy to reduce obesity rates was announced — which provides employers with an obesity management benefit for their employees. I asked Carl Graziano, the vice president of communications for DMAA: The Care Continuum Alliance, to explain what this new benefit is and how it works. (DMAA was formerly known as the Disease Management Association of America.)
Dr. Val: How does the DMAA “prototype obesity benefit” work?
Graziano: The prototype is just that — a suggested approach based on the best available evidence on effective obesity interventions. While we provide a template for possible covered services and suggested pricing, it will be up to individual end users to tailor this benefit to their particular budgets, corporate cultures and values. Generally, we recommend three tiers of coverage, starting with enhanced primary care services, nutritional counseling and pharmaceuticals. A second tier would add treatment by an obesity specialist, and a third level would provide coverage for bariatric surgery and associated supporting services. Plan participants could be subject to an additional premium and co-payments for these services, as with other “riders,” such as vision and dental benefits.
Dr. Val: Which employers are planning to offer this benefit?
Graziano: We’re pleased to have the support of the Service Employees International Union (SEIU), which will consider our benefit approach as it develops coverage for its members. We expect that as experience with the benefit design and awareness grows, other employers will tailor it to their specific needs. As the STOP Obesity Alliance survey shows, while most employers believe in the appropriateness of obesity-related services, less than half say their companies devote enough attention to the problem of obesity. We believe this reflects a lack of guidance on how to provide obesity benefits, and that’s why we developed our suggested approach.
Dr. Val: What can people do to make sure that their employer offers this benefit or something similar?
Graziano: Because this benefit prototype will be freely available from and promoted by DMAA, we expect growing awareness of it among benefits managers over the next year — both through their own efforts to stay current on benefit design trends and recommendations from employees and others.
Dr. Val: How do we know that this program works? What outcomes have you demonstrated so far?
Graziano: Designing a formal approach to obesity benefits is largely uncharted territory, which is precisely the reason why DMAA saw a need to initiate research in this area. That said, our benefit design is strongly rooted in the best available evidence that interventions deliver high-value, positive outcomes. We are breaking new ground here, but we believe the benefit’s value-based approach offers the best chance of positive clinical and financial outcomes in a real-world setting.
Dr. Val: What’s the most important aspect that the public should know about the DMAA obesity benefit?
Graziano: It’s important that the public understand that personal behavior — eating healthfully, exercising and making other lifestyle changes — is essential to the success of any overweight or obesity intervention. While our benefit approach may ultimately contribute to new and expanded care options for the overweight and obese — a change that’s much needed in the face of a growing obesity epidemic — the commitment of plan participants to these interventions will play a large part in reversing the overweight and obesity trend.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
May 26th, 2008 by Dr. Val Jones in News, Opinion
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American physicians are appropriately frustrated about the high cost of medical malpractice insurance, and the frequency with which false and/or exaggerated claims are filed against them. In the Philadelphia region, a spine surgeon must pay upwards of $300,000.00 a year in malpractice insurance. The law allows Obstetricians to be sued for mishandling the birthing process until the “child” is 20 years old. In many states, there is no cap on the amount of money awarded in a true case of negligence, and juries set the pay out – which can exceed 20 million dollars per verdict.
Interestingly, Texas instituted a new policy in which firm caps were placed on malpractice claims. The cost of medical malpractice insurance dropped precipitously, and over 7000 physicians flooded into the state.
I recently interviewed Canadian Senator Michael Kirby about the medical malpractice process in Canada, and he laughed at how litigious the American system is. He said that keeping the malpractice system from being abused is quite simple: fine plaintiffs who bring forth frivolous suits, set caps on pay outs, and allow awards to be set by judges, not juries. You can listen to our discussion here.
However, there is a flip side to this coin – when providers are permitted to practice without any real legal recourse. I was astonished to learn (from my blogging colleague across the pond, Dr. John Crippen), that in New Zealand midwives are permitted to practice without any form of malpractice insurance. In fact, a recent case demonstrated obvious negligence resulting in the death of a newborn baby. What recourse did the mother have? Apparently, her legal actions resulted in a payout of $2,000.00 and a promise of closer oversight of the practices of midwives.
Wow.
On the spectrum of “reasonableness” for medical malpractice policy, I believe the Canadians win, followed perhaps by Texans. What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
