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Fixing American Healthcare: The Primary Cause of Rising Costs

In Fixing American Healthcare, Dr. Rich explains that the major cause of rising costs in healthcare is an aging population that requires more resources. Though some have proposed that fraud and waste/inefficiencies are the primary sources of costs spiraling out of control, the truth is that they likely play a minor role compared to the tremendous costs of providing cutting edge treatments to an older and sicker US population. Dr. Rich argues that we don’t hear that much about the escalating cost of caring for older Americans because it makes us squeamish, so we instead focus on curbing costs due to fraud and waste. However, when fraud and waste are not the primary cause of increasing costs, enhanced attempts to quash them do not actually move the savings needle. Since certain groups are tasked with reducing escalating costs due to fraud (in particular), and their work does not result in savings, they must strive harder to find and punish those accused of fraud, perhaps even seeing fraud where it doesn’t exist.

Dr. Rich argues that true fraud is fairly rare, and that the majority of “fraud” cases involve people not complying with rules they had no knowledge of (in many cases even after asking about the rules from the people who made them). Other cases of “fraud” involve retroactive application of rules and then fining hospitals for not being in compliance before the rules were made. His assessment of the PATH audit debacle is quite interesting.

Now, obviously we want to decrease fraud and waste as much as possible – but in the midst of our desperate attempts to curb healthcare spending, we’ll need to have some honest and frank discussions about the elephant in the room: America is sicker than ever before, and we have developed expensive ways to cure/treat those sicknesses – ways that we can’t afford to offer everyone.

What should we do? Dr. Rich suggests that we come together as a nation and decide on some rationing rules. He argues that we’re already rationing our healthcare dollars in covert ways – let’s bring it out into the open so that it’s fair to everyone. Now, I doubt that this will sit well with Americans – but our current “system” is so dysfunctional that maybe the time for a rationing discussion has come?

In this climate of unlimited treatments and limited resources, the best option is to stay healthy as long as possible. That’s why I believe in preventive medicine, healthy lifestyle changes, and doing all that we can to avoid getting sick. In many cases (but certainly not all) eating healthy foods, exercising regularly, controlling our weight, getting our vaccines, and sleeping well each night can go a long way to keeping us out of the hospital. It’s not easy to get Americans to take care of themselves in this way, but I’d rather spend my efforts trying to get us fit than to have to debate rationing rules. In the end, however, we may need to do both. What do you think?This post originally appeared on Dr. Val’s blog at

Thin workers woo investors?

I had an eye-opening conversation with Dr. Jim Hill
today.  He told me that Denver’s
Metro Mayors (Denver’s
metropolitan area is actually composed of 37 cities and towns!) are competing
with one another to see who can get their inhabitants the most fit and thin.

Why would they be so aggressive about fitness and good
health?  Because they say that large
corporations considering investing in Denver
(where they’d build factories or large office buildings) know that setting up
shop in areas where the population has a lower BMI means that health insurance
costs will be lower.

That’s right my friends.
Being thin can lure investors!  It
makes sense that a corporation seeking to avoid the skyrocketing costs of health
care would want to create facilities where new employees are likely to have
fewer medical issues.  And BMI is a good
surrogate marker for health… so there you have it.

Do you see this approach to wooing investors as a form of discrimination
or just good business sense?

Either way, I’m going to get on the treadmill later.

This post originally appeared on Dr. Val’s blog at

Nutrition standards for foods in schools

Congress recently directed the Centers for Disease Control
(CDC) to undertake a study in partnership with the Institute of Medicine (IOM).  The goal was to establish nutrition guidelines
for government-subsidized nutrition programs in schools nation-wide.  These guidelines are meant to help combat the
growing rates of overweight and obesity in US children.

The standards may surprise you in their restrictiveness – no
beverages with more than 5 calories/serving are permitted (excluding milk or
soy milk) unless the child is involved in rigorous physical activity for more
than 1 hour in duration (then they can have a sports drink such as Gatorade).  No items with more than 35% of calories from
total sugars are permitted, and all bread and cereal items must be whole grain.  There are also restrictions on fat and salt
levels in the food.  Artificially
sweetened drinks and caffeinated beverages are not recommended.  The IOM also calls for removal of all junk
food and soda machines, and replacement with fruit, milk, and healthy snack options.

Reading these guidelines I thought, “Wow, if kids really ate
this way we probably would make a big difference in obesity rates.”

And then I wondered… “But will these kids just go home and
eat a box of oreos and a liter of coke at the end of the school day?  Is it enough to have a healthy food
environment at school, but not at home?
What is the role of parents in this?”

What do you think?
Are the IOM’s recommendations likely to 1) be followed by all schools 2)
make a difference in childrens’ weights?
Is there anything else you’d recommend?This post originally appeared on Dr. Val’s blog at

Medical fraud – what to look out for

I was reading a news story about how medical fraud is becoming more frequent in Australia. They attribute this to the recent transition to electronic record keeping, which makes it easier to file fraudulent claims. Although these tactics are old news in the US, I think it’s worth a little summary (from the article) here – stay on the lookout for overcharges and fraud! The best way to protect yourself is to review your bills with vigilance. It’s sad that it has come to this…

Fraudulent tactics

Supply companies:

* Upcoding of items and services where, for example, a medical supplier may deliver to the patient a manually propelled wheelchair but bill the patient’s health fund for a more expensive, motorized wheelchair, or where a routine follow-up doctor’s office visit might be billed as an initial or comprehensive visit.

* Billing for medical services or items that are in excess of the patient’s actual needs. These might include a medical supply company delivering and billing for 30 wound care kits per week for a nursing home patient who only requires one change of dressings per day, or conducting daily medical office visits when monthly office visits are adequate.


* Duplicate claims, where a certain item or service is claimed twice. In this scheme, an exact copy of the claim need not be filed a second time. Rather, the provider usually changes part of the claim so the health insurer does not realize it is a duplicate.

* Unbundling, where bills are submitted in a fragmented fashion so as to maximize reimbursement for tests or procedures that are required to be billed together at a reduced cost.

* Kickbacks, when a healthcare provider or other person engages in an illegal kickback for the referral of a patient for healthcare services that may be paid for by Medicare.This post originally appeared on Dr. Val’s blog at

Informed consent & the animal guessing game

Growing up in Canada, my family spent a lot of time in the car. While my European friends would tell me how they could drive through 4 countries in a matter of hours, in Canada I couldn’t get part of the way through our smallest province in the same time period. Canadians have to travel long distances to get anywhere, which is part of the reason why they’re such a tolerant and patient lot.

So on these long drives (long before the days of portable entertainment devices) my family would have to think of ways to pass the time. Our favorite game was inspired by “20 questions.” We called it “the animal guessing game.”

It basically worked like this – you thought of the most unusual animal you knew of (perhaps something you’d seen on Animal Kingdom or in an animal encyclopedia) and the rest of the family would ask yes and no questions until they guessed what it was, or all agreed to being stumped.

Now, most of us would systematically narrow the field of possibilities by asking typical questions related to size, territory, habitat, skin type (fur, scale etc.) and so on. But my younger sister would always begin by asking the same question:

“Does it have fangs?”

At the time I thought she was hopelessly silly and incapable of systematic analysis. So few animals, after all, would fall into that category. Surely that wasn’t a good lead question.

But as I reflect on my sister’s perseverance on fangs, I realize that she was using an emotive hierarchy. To her, animals with fangs were so frightening, that she wanted to get it out of the way first thing – to be sure that we weren’t going to be spending time reviewing the life cycle and eating habits of animals with sharp teeth.

You know, it may seem funny, but I think that when it comes to matters of medicine some patients feel the way my sister did about the animal guessing game. They’re in unfamiliar territory, they are afraid of a real or perceived threat of a painful test or procedure, and they are internally focused on that threat to the exclusion of the big picture.

Doctors have the natural tendency to be removed from the emotional priorities of patients. We think that the patient is most interested in the evidence behind certain tests, the statistics, the technical aspects of a procedure – but sometimes as they try to comprehend the details of your informed consent, they really have one burning question:

Does it have fangs?

This post originally appeared on Dr. Val’s blog at

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