Doc around the clock

If you’ve ever spent a weekend in the hospital, you couldn’t fail to notice how quiet it was. No surgeries, other than those that are urgent. Fewer tests being scheduled. Fewer staff in the building. The underlying mood that we’ve-all-throttled-back-because-it’s-the-weekend-and-we’ll-get-back-to-normal-on-Monday.

But what if hospitals were ramped up around the clock, instead of concentrating most of their activity during traditional hours? This concept is the focus of an intriguing opinion piece that appeared this past week in the New York Times. The author, Peter Orszag, may be familiar to readers as the previous director of the White House Office of Management and Budget.

It’s been well established that weekends aren’t an optimal time for patients to receive care, Orszag writes:

It’s never good to be hospitalized, but you really don’t want to be hospitalized on a weekend. There are fewer doctors around, and people admitted on Saturdays and Sundays fare relatively poorly.

One study in 2007 found, for example, that for every 1,000 patients suffering heart attacks who were admitted to the hospital on a weekend, there were 9 to 10 more deaths than in a comparable group of patients admitted on a weekday. The weekend patients were less likely to quickly receive the invasive procedures they needed – like coronary artery bypass grafts or cardiac catheterization.

If patient safety is one of the weekend hazards, cost and efficiency are the others. Orszag calls it the “the economics of a $750 billion-a-year industry letting its capacity sit idle a quarter or more of the time.”

“If hospitals were in constant use, costs would fall as expensive assets like operating rooms and imaging equipment were used more fully,” he writes. “And if the workflow at existing hospitals was spread more evenly over the entire week, patients could more often enjoy the privacy of a single-bed room.”

This isn’t just idle speculation. Orszag describes what’s happening at one institution, New York University Langone Medical Center, to provide more care on weekends. At Langone, magnetic resonance imaging and elective cardiac surgery are now available on weekends. The facility’s radiologists read medical imaging studies seven days a week. The cancer center provides some treatments during the weekend. Women planning to undergo an elective Caesarean delivery can now schedule it on a Saturday.

Information being tracked at NYU Langone has uncovered some hitherto-unnoticed issues with how the hospital deploys its resources, Orszag writes.

The dashboard data revealed, for instance, that on any given day a disproportionately small number of eligible patients were discharged before noon, so that many people were kept in the hospital longer than necessary. Further analysis revealed a key reason: several routine procedures that some patients need before leaving, like the insertion of central catheters, were not performed in the morning. The medical center has since begun to offer the procedures earlier, and the percentage of discharges before noon has increased significantly.

Reaction around the blogosphere to Orszag’s column has been, uh, interesting. Many people have seized on Orszag’s opening comments, which in essence said doctors should suck it up and work more weekends, as the equivalent of endorsing involuntary servitude. The response, at least from more than a few health care professionals, could probably be summed up by a blog commenter who said, “My first thought was, yeah, good luck with that.”

I can feel a twinge of sympathy. I’ve worked evenings, weekends and holidays my entire adult life. In the news industry it just comes with the territory and I’ve learned to live with it. This doesn’t mean I always like it, though, and I suspect most people would rather not work evenings and weekends if they can possibly help it. I don’t think this was Orszag’s main point, however.

It’s true there’s idle capacity in health care, particularly among hospitals, and that the normal 8-to-5 schedule doesn’t always match patient need. How many of us have wished we could make a doctor’s appointment in the evening so we wouldn’t have to take time off work? There’s a certain irony in telling consumers to call their doctor for non-urgent problems rather than seek expensive emergency-room care – yet giving them no other option if something crops up when the doctor’s office is closed for the day or for the weekend. There’s a certain irony in advising people to try to avoid being hospitalized on a weekend, yet ignoring the fact that illnesses and injuries don’t happen solely during daytime hours Monday through Friday.

Whether this is enough to justify a shakeup of the industry model is a whole ‘nother question, though. Do hospitals and clinics have the wherewithal to expand their hours into the weekend? How feasible is it, in terms of both workforce and financial resources? Would patients use a weekend service? Would it actually improve patient care and outcomes?

On the other hand, it should be troubling to all of us that patients who are hospitalized on a weekend might not receive the same level of care as on a weekday. And the many little overlooked inefficiencies in the system – such as having no one available to insert central catheters until after lunchtime – are frustrating and frankly make little sense, either for patient care or for the financial bottom line.

Maybe some discussion on these issues has been long overdue. Access to care on evenings and weekends isn’t a new problem that only recently sprang up. There has been a long-standing gap in how care is provided outside traditional hours, and solutions such as urgent care clinics and nurse hotlines, even when they do fill some of the need, are not the total answer. Critics might not like what Peter Orszag is saying but he’s nailed an issue that seems to merit further consideration.

Health care pricing: Murky, confusing, frustrating

You’re having dinner at a restaurant. You decide to order shrimp, listed on the menu at $15.95. The waitperson brings your entree, you enjoy a nice meal, then you ask for the bill and – surprise! – you’re charged $25.95, $10 more than the price you thought you’d be paying. When you ask for an explanation, you’re told: The chef who prepared your shrimp used a special saute pan that drove up the cost. Furthermore, the price on the menu didn’t include the higher-grade tableware and table linens on which you dined.

Restaurant customers would probably be outraged by this situation. Yet it occurs all the time with health care charges, particularly hospital bills.

Consider the story of Bill Rose, a temporarily uninsured salesman in Ohio, who broke his leg in a motorcycle accident. Rose negotiated a deal with the hospital: $8,260 for the surgery to fix his leg and a 30 percent discount in exchange for paying up front. But when he got the final bill, Kaiser Health News explains, he discovered he owed another $10,000:

One reason for the bigger bill was his surgeon’s decision to use a $7,500 bone graft product that is only used sometimes in such procedures, and was clearly not anticipated in the hospital’s estimate, according to documents provided by Rose.

Rose’s story shows the difficulties faced by consumers – especially the uninsured – when they try to shop for the best price or negotiate. More than 30 states, including Ohio, require hospitals to disclose at least some of their charges, according to the National Conference of State Legislatures. Congress included such a provision in the new health overhaul law and similar proposals are pending in the House. But many experts say these efforts don’t help much.

Paul Ginsburg, president of the Center for Studying Health System Change, a research organization in Washington, says published hospital charges are “useless for consumers.” One reason, as Rose discovered, is that hospital prices are moving targets, varying with patients’ needs and doctors’ treatment strategies.

There’s been a considerable national push toward what’s known as transparent pricing – in other words, being clear with consumers up front about what they’re going to be paying for and how much it’ll cost. As this article demonstrates, though, this is far easier said than done.

Even when consumers do their homework ahead of time, as Rose did, the final bill can still be a shocker. Critics can argue that Rose should have known the expensive bone graft product was a possibility, and that he either should have taken it into account in his cost estimate for the surgery or should have talked to the surgeon about using a cheaper product. This assumes a level of knowledge and foresight, however, that few consumers possess. When even the experts concede that health care pricing is confusing and opaque, it seems unreasonable to think the average person will be any better at figuring out how to navigate this maze and ask the right questions.

At a restaurant, of course, customers upset at being overcharged for their shrimp might simply decide not to go back. In health care, though, this often isn’t an option. And consumers who get walloped with a bill that’s way higher than the original quote usually have little recourse, other than to pay it or try to negotiate with the hospital.

Single pricing might make costs more transparent, the Kaiser Health News article suggests:

Price information could be made useful to consumers by requiring hospitals to publish prices for set diagnoses or procedures, rather than the charge lists of individual items, experts say. That way, there would be a single price for a gall bladder removal or a hip replacement.

“If the goal is for Americans to understand it,” and be able to compare prices, “then one number is the only way to go,” said Gerard Anderson, a health policy professor at Johns Hopkins University.

To be sure, health insurance has contributed to the problem by shielding consumers from the true cost of care and giving them a disincentive to be cost-conscious. I’m not convinced this is the only factor, though. Even people who are insured are often shocked at the size of their medical bills. Nor are they any less likely than the uninsured to be subject to complications, physician treatment preferences and other unexpected add-ons that can significantly inflate the final bill.

How can pricing information become more meaningful and more usable? There doesn’t seem to be an answer. When it comes to transparency, talk is cheap, but in a system as complex and intricate as health care, solutions are far from simple.

Photo: Wikimedia Commons

Fill out your disability form? That’ll be $25, please

If you can’t get by on the fees you collect for providing a service, start tacking on extra charges: $25 for the paperwork, $10 for the administrative overhead, $5 for copies of documents, another $25 for retrieval of said documents, etc. etc. etc.

Businesses and government do it all the time. Now the concept is being adopted by doctors as well. The practice doesn’t appear to be widespread, but according to a recent article in USA Today, it’s starting to look more and more attractive to physicians who can’t make ends meet on insurance reimbursement alone. From the article:

The extra payments include no-show fees of $30-$50 for missed appointments, widely varying charges for filling out health forms for school, work and athletic teams, and annual administrative fees of $30-$120 or more to simply be a patient in some practices, medical associations and doctors say.

"It’s not unlike the airlines," said William Jessee, president of the Medical Group Management Association, which generally advises against extra fees that may anger patients or run afoul of insurance contracts. "They’ve gone from all-inclusive to a la carte. That’s what you’re seeing with physicians."

Doctors who charge extra fees are in the minority, he said. Some have done it for years, but more are joining them because they say they need the fees to offset the rising costs of practicing medicine.

Is it fair or reasonable to charge extra? Or are services such as filling out forms and refilling prescriptions just part of the doctor’s cost of doing business?

An Atlanta mom has to fork over $10 every time the family pediatrician fills out a form, and she doesn’t like it. "It’s part of their job," she told USA Today.

Judging from the 800-some comments posted by readers in reaction to the story, there’s a lot of resentment over the concept. "Any doctor that tacks on fees will not be getting my business," one person wrote. "They are just greedy theives (sic). And on top of it they are whining greedy theives (sic)," fumed someone else.

Grousing aside, it’s valid for people to ask where the line should be drawn between the normal cost of doing business vs. uncompensated burden. A teacher who commented at USA Today wondered, "Should I be compensated extra for my student-teacher conferences? Or for having to fill out forms regarding a child’s poor behavior? What about the extra hassle of speaking on the phone with a parent who is worried about their child? Isn’t this all ‘administrative’ stuff?? Yes, but it comes with the territory."

From the physician’s point of view, though, it’s becoming increasingly difficult to stay solvent while managing the flood of unreimbursed paperwork. Dr. Toni Brayer lamented the situation in a guest post at Kevin, MD:

As a physician who has practiced for over 20 years, I can tell you that the demands of filling out forms for everything from work questions and school physicals to handicapped stickers and travel vouchers, dealing with insurance companies, reviewing tests ordered by other doctors, overseeing and coordinating patient care, talking with pharmacists, filling prescriptions and then redoing the work when a patient switches pharmacies, e-mailing and countless other tasks that are "free" make it near impossible to remain in private practice.

If health care was like other industries, it could simply raise its prices to cover the increased cost of doing business, or drop services that don’t pay for themselves. But health care doesn’t function like other businesses. For one thing, there’s limited room for negotiating reimbursement rates with third-party payers. In the case of Medicare, there’s no negotiation; providers either have to accept what Medicare is willing to pay them or opt out of Medicare altogether. For another, insurance contracts usually place restrictions on charging extra for services already deemed to be covered. In view of the fact that physicians only make money by seeing patients and/or doing procedures, administrative fees are one of the few viable options left for bringing in more revenue to subsidize their overhead costs.

I personally wouldn’t mind paying extra fees, as long as they were reasonable. (And I’m gonna add here that doctors aren’t alone in disliking all the forms they have to fill out on behalf of patients; most patients don’t like it either.) There are patients, though, who won’t be able to afford the extra fees – what then? And does it make sense to add more spending to a health care system that already consumes billions of dollars each year?

The irony in all of this is that it’s not doctors and patients who are the real problem. The real problem lies in how physicians are paid and how third-party payers set their reimbursement rates. If both these things could be changed, the burden for physician practices might be eased and administrative fees would no longer be necessary. As usual, though, doctors and patients are paying the price for the brokenness of the health care system, and until there’s a substantive fix, add-ons such as extra fees constitute little more than a Band-Aid.

Connecting the dots on health care spending

A couple of news releases caught my attention late last week.

Here’s one of them, from the Minnesota Department of Health, stating that health care spending in Minnesota rose from $33 billion in 2007 to $35 billion in 2008. You can read the full report here.

Among some of the statistics that stand out: Health care spending in the state amounted to an estimated $6,720 per person in 2008. Spending grew by 5.7 percent in 2008 and has more than doubled since 1998.

There’s a silver lining here, I guess. Compared to the rest of United States, health care spending in Minnesota is 6.2 percent less per capita. Also, a smaller portion of the Minnesota economy is spent on health care than in the U.S. as a whole. The not-so-good news, of course, is that per-capita spending is growing and also is consuming an increasing share of the economy.

A day later I came across this: “Patient survey: More health care is better, despite what experts say.”

It’s taken from a study that appears in the latest issue of Health Affairs, reporting on the results of focus groups, interviews and an online survey to measure American attitudes and beliefs about evidence-based health care. The findings? The authors sum them up:

We found many of these consumers’ beliefs, values, and knowledge to be at odds with what policymakers prescribe as evidence-based health care. Few consumers understood terms such as “medical evidence” or “quality guidelines.” Most believed that more care meant higher-quality, better care. The gaps in knowledge and misconceptions point to serious challenges in engaging consumers in evidence-based decisionmaking.

Why would it matter what consumers believe? Because, as the authors point out, “as the rise in health care costs continues to outstrip wages and growth in other sectors of the economy, it is critically important to increase the quality and value of health care.” And if consumers don’t understand or won’t accept evidence-based medicine, or if they don’t believe it’s relevant in making health care decisions, “the most ambitious goals of this movement may fail,” the authors write.

Is anyone connecting the dots here? I’d urge readers to check out both of the reports.

Update: Here’s an exploration of another aspect of this issue – consumer perceptions and expectations of what constitutes “needed care.”

Image: Wikimedia Commons

Paying what the doctor is worth

What’s the worth of an office visit to the doctor? $20? $50? $100?

A group of physicians, from Maine to California, recently tried something innovative: offering one day during which uninsured patients could make an appointment and pay what they felt they could afford for their care.

American Medical News describes how it went:

Overall, participating physicians said they learned that although patients valued the physician visit, they didn’t always put the value of care at its actual cost. Still, most valued it enough to pay something. Some patients paid nothing; some paid $100. Visits were as short as 10 minutes or as long as an hour.

None of the participating physicians collected enough money to make the concept financially viable over the long term, mainly because payments didn’t match a typical day’s collections from insurance and co-pays. Yet most say they want to do it again and enjoyed having one day free from insurance paperwork.

I’m not sure whether this is truly indicative of what patients think the doctor’s time is worth. For one thing, this involved people who were uninsured. For another, they were asked to pay what they could afford, not what they felt was the fair market value of an office visit.

Nevertheless, it raises some intriguing questions about consumer perceptions of what a medical visit should cost. Most of us in fact don’t really know what the going rate is supposed to be, because we’ve been shielded by our health insurance. We might have to fork over a $5, $10 or $25 co-pay (and maybe grumble about it) but the rest is more or less invisible and hence hard to weigh on the economic scale. Varying discounts, depending on who the payor is, have further muddied the waters.

It hasn’t helped that the prices aren’t exactly transparent, a la the McDonald’s menu posted above the customer counter. Small wonder, then, that many of us have a hard time assigning a reasonable value to a visit with the doctor.

I’ve heard people complain they were charged $85 or $100 for an office visit and only spent 10 minutes with the doctor. Then there are people who resent paying for tests if the results show there’s nothing wrong with them. People also often resent it when they have to see the doctor to receive a diagnosis they believe they could have figured out on their own. And they can get really upset if they feel they’re being “forced” to come in for no good reason, as a testy encounter between physician-blogger Rob Lamberts and a disgruntled patient illustrates all too well:

“You haven’t been in the office for over eighteen months. It was really time for you to come in,” I said, trying to remain calm as I spoke.

He sat for a moment, then responded with very little emotion: “I am doing fine. You could have just called in an order for labs and called in my prescriptions. I don’t know why I had to be seen.”

“You have hypertension and high cholesterol. These are serious medical problems, and if I am going to put my name on a prescription for you, I have to make sure everything is OK,” I responded, trying to hide my growing anger. “I am not a vending machine that you can call to get drugs.”

“I’ll come in if I am sick, but I am not sick right now.”

“My job is to make sure you don’t get sick in the first place!” I said, my volume rising slightly. “I don’t bring you in because I need the business; I’ve got plenty of patients to fill my schedule. Besides, how do I know if your blood pressure is OK?”

“I check my own blood pressure at home and it has been good. I can’t afford to come in to the doctor so much. I have a high-deductible plan. I had a stress test and a colonoscopy last year, and that’s enough spending for me,” he responded, his pitch and volume rising with mine.

“I have to say that I find this personally insulting,” I threw back. “You don’t think I am worth paying to see. You just want me to give you your medications, take the risk of adverse reactions, and basically work for free?”

Once the argument simmered down, what did this patient get out of his visit to Dr. Lamberts? A discussion about his medication and side effects. Some education about cardiac screening tests and the pros and cons of prostate cancer screening. Dr. Lamberts also changed his prescription to something cheaper, and sent him out of the office with a reminder to come back in six months.

Was it worth the cost of a visit? A lot of things that physicians do cannot be easily measured or quantified as a consumer commodity. It’s hard to put a price tag on the value of patient education, coaching and management of one’s health, especially when the payback might not be immediately visible.

The fact that we can’t always clearly define or pin down what we’re getting for our money doesn’t mean an office visit has little value, though. Not everything in health care can be measured in dollars and cents. If Dr. Lamberts’ patient was billed $100 or less for his doctor visit (no charge for the argument, it’s to be hoped) and came away with an assessment of his current health, some patient education and a plan for followup, I would say it was a pretty good deal.

Photo: Wikimedia Commons

The cost of ordinary care

There’s a Russian proverb: It’s not the sea that drowns you; it’s the puddle.

The American concept of health insurance is shaped by the belief that people need the greatest protection from catastrophic, costly illnesses and conditions. Everything else – in other words, most routine care – is affordable and should be borne by the consumer.

At one time this might have been the case. But I’m not sure how well it continues to hold true. This study, which was published a couple of months ago in the Health Affairs journal, explains some of the cost trends that have been taking place. (Access to the article is by subscription only; a summary of the key points can be found here.)

Broadly speaking, almost 20 percent of working-age Americans now spend 10 percent or more of their pre-tax income on health insurance premiums and medical care. From 2001 to 2006, the number of people in this bracket grew by about 1 percentage point each year. If you estimate that the median household income in rural west-central Minnesota is around $40,000, on average that’s $4,000 worth of annual medical expenses and insurance premiums – and that’s before taxes are figured into the equation. Some individual families obviously are paying considerably less than this if they’re healthy (and lucky enough not to get hit with an expensive illness or injury); others are paying way more.

The study points out that the burden of out-of-pocket health care costs has been growing especially rapidly among middle- and upper-middle-class households with private insurance.

Data were collected from a sampling of 28,000 people under age 65 for each of the years included in the study. Since the survey was conducted before the recession, it’s probably safe to assume there was little change in 2007-2009 in the cost burden being shouldered by many of these households.

There seems to be multiple contributing factors to this trend, starting with household income, especially in the bottom half of the median. Have wages kept up with the cost of living and what it takes to feed, clothe and house a family? Probably not. The other issue, though, is that health insurance premiums and the cost of medical care have been rising faster than the rate of inflation. Put them together and what you have is a widening gap. Efforts to plug the gap have consisted mainly of increasing what people are being asked to pay out of pocket. It’s not at all clear whether this strategy can be sustainable over the long term.

There’s also something else going on: the growing prevalence of pre-existing conditions. Families USA, a national consumer advocacy group for affordable health care, is releasing a report tomorrow that attempts to quantify how many Americans have an identifiable health condition that might previously have precluded them from being able to obtain health insurance. Among the preliminary findings: 57.2 million working-age Americans have some kind of pre-existing condition that potentially affects their ability to be insured.

This is not a direct proxy, of course, for health care costs, nor is it a measure of health care affordability. The point is, millions of Americans have some kind of serious and/or ongoing health issue either in their past or that they’re dealing with currently, and it comes with a cost – not just to the overall system but to these people’s individual finances as well.

This isn’t an argument in favor of scrapping the entire structure and philosophy underpinning the U.S. health insurance system. Most of us, unless we’re millionaires, cannot afford the cost of something catastrophic. Coverage for the major medical bills is, after all, why most people need health insurance. Many Americans cling to the belief, however, that all the rest of it, the so-called routine stuff, is somehow more affordable – even though the evidence is mounting that for a sizeable portion of the population, the cost of routine, ordinary care is no longer routine or ordinary.

Should health insurance do better at covering basic services for which people are most likely to require medical care? Perhaps, although this comes with a hefty price tag of its own. Do we need to rethink the concept of deductibles and copayments and how they’re applied? Would some system of capitation help even out expenses so they’re more manageable for a broader swath of consumers? Or should we concentrate instead on curbing health care inflation or paying livable wages so the cost of ordinary care doesn’t get pushed out of reach?

The day-to-day costs of routine care might not seem like a big deal but they have an insidious way of adding up. In the public discussion about health care costs, we can’t afford to continue ignoring this fact.

Photo: Wikimedia Commons

The price is right

If you needed to have an ultrasound or were prescribed an antidepressant, chances are you’d have no idea how much it would cost, nor would you know how to find the answer.

One of the criticisms of the American health care system is that consumers are shielded from the cost. When health insurance pays most of the bill, there’s really no incentive for people to know or care about the price of their care or to make cost-conscious decisions, hence the climbing expenses of the overall system – or so the argument goes.

This might have been true at one time for a significant percentage of consumers. But I don’t think this is any longer the case. Many of us have become highly aware of what we’re paying – not just in premiums but also in rising out-of-pocket expenses. One of the more recent studies, published just last month in Health Affairs, found that almost one in five of non-elderly Americans spent more than 10 percent of their pretax income on health care in 2006. Five years earlier, it was one in seven. These figures came from a survey of 28,000 people under age 65 and include both insurance premiums and direct medical costs.

Clearly a growing number of people are anything but insulated from the cost of their medical care. Just as clearly, it has made only a minimal dent in health care spending. There are some rather startling statistics contained in this report from the nonprofit Kaiser Family Foundation:

Expenditures in the United States on health care surpassed $2.3 trillion in 2008, more than three times the $714 billion spent in 1990, and over eight times the $253 billion spent in 1980… In 2008, U.S. health care spending was about $7,681 per resident  and accounted for 16.2% of the nation’s Gross Domestic Product; this is among the highest of all industrialized countries.

And hold your horses if you think Medicare and Medicaid are mostly to blame; according to the Kaiser Foundation’s report, spending by these two government programs actually has grown at a slower rate than spending by private insurance.

To be sure, we all need to be conscious of the cost of health care. And compared to even a few years ago, it has become a little easier to search out the price of a service or test. For instance, if you want to know the cost of a hospital procedure, the Minnesota Hospital Association’s price check site can tell you. The Center for Diagnostic Imaging, which operates a medical imaging center in Willmar, is working to develop a price list that tells patients up front what the cost of a CT scan or mammogram will be. A similar pricing initiative is in the works at Rice Memorial Hospital. And I recently ran across Leslie’s List, a free service that compiles information on low-cost testing, prescription drugs and medical services in the Chicago area.

It’s one thing, however, for consumers to know the cost of an office visit or a knee replacement. The real issue, it seems to me, is whether we’re able to use this information in a meaningful way – and I’m not convinced we are.

Networks, tiered pricing and group discounts have benefited insurers at the macro level, but they have obscured the true prices, making it difficult at the individual level for patients to “shop around” and accurately compare. What the provider charges is not what the consumer ultimately pays. Two people can receive the exact same service but one might pay substantially more out of pocket because he or she has a higher deductible or a lesser provider discount.

To a large extent, consumers also are captive to how care is provided. They might be able to choose a hospital or a service based on the total package, but beyond that, there’s very little room for negotiation.

Take, for instance, a knee replacement. Patients don’t get to pick the implant. They don’t get to pick the hospital’s cheapest operating room and OR team. They don’t get to cut corners by skipping the anesthesia, the pre-operative antibiotics or the post-operative rehabilitation. I suppose we could unbundle these costs and give people a menu of choices – first-class vs. coach care, perhaps – but would this be clinically wise? And are consumers equipped to make these kinds of decisions?

How many of us, really, are knowledgeable enough to know what we’re buying? More to the point, how many of us have the wherewithal to be able to define and search out the best health care buys? I frankly don’t know many people who’ll research prices at all the CT scanning facilities in a 50-mile radius and then pick the cheapest/best; most of the time they’ll simply go wherever their physician refers them. Maybe consumers behave somewhat differently in a city environment where there are more facilities to choose from; I’m not sure we can say the same for rural markets with comparatively fewer services.

It’s true that people are often more careful when they’re spending their own money. A $100 copayment to visit the emergency room tends to make us think twice about whether we really need to go to the ER. The introduction of $4 generics was a boon for many people struggling with the cost of prescription drugs.

But if we want to give consumers more control over their health care spending, we also have to accept that 1) they may not know how or be able to make the best decisions; and 2) there will inevitably be times when people can’t afford to be price-conscious. Patients have been known to forego care that’s actually necessary – skipping followup visits, not filling prescriptions – because of the cost, and then winding up sicker at greater overall cost to the system. Financial caution also can become moot when there’s a crisis that demands immediate care. Someone having a heart attack isn’t in a position to shop for the best cardiology bargain. Someone who has been diagnosed with cancer and needs an expensive chemotherapy drug that’s standard first-line treatment will probably opt for the drug, regardless of cost.

If we want to put the brakes on the escalation in health care spending, greater consumer attention to costs undoubtedly needs to be part of the solution. The operative word here, though, is “part.” People might make financial decisions based partly on cost but other things are important too: necessity, convenience, location, personal preference, value, quality, loyalty. A health care service that’s cheaper is not necessarily the better buy. Choosing on the basis of bargain pricing is not necessarily wise.

Here’s the thing: When we view health care as a consumer commodity, something to be bought and sold like a pair of shoes or a platter of ribs, we’re making a fundamental mistake. Health care isn’t a commodity like everything else in the marketplace (and I’m not sure I’d like a health care system that was); it’s a unique and vital service that stands apart. It bears no real comparison with any other industry, and it seems to me we’re misguided in trying to force a consumer model onto a service that defies easy placement in this particular box. By all means, let’s be more price-conscious – but let’s also recognize that the compare-the-costs-and-shop-around mentality has its limits. It’s only one piece in a much bigger and more complicated picture; it’s not The Answer.

Great expectations

When it comes to health care, we in the United States expect a lot. In many ways it’s not hard to see why. The U.S. is where the vast majority of medical innovations, the development of new drugs and medical devices, and the pursuit of important research takes place. We have access to top care at the top institutions. People are living longer and better lives because of it.

At what point, though, do we cross the line and begin to expect too much? Should we do everything possible just because it’s possible? Is "everything possible" invariably the better choice? These are questions I found myself asking after reading this intriguing essay, from the New York Times, about the need to start saying "no" in medicine:

Deep down, Americans tend to believe that more care is better care. We recoil from efforts to restrict care.

Managed care became loathed in the 1990s. The recent recommendation to reduce breast cancer screening set off a firestorm. On a personal level, anyone who has made a decision about his or her own care knows the nagging worry that comes from not choosing the most aggressive treatment.

This try-anything-and-everything instinct is ingrained in our culture, and it has some big benefits. But it also has big downsides, including the side effects and risks that come with unnecessary treatment.

I think all of us – providers, the media and consumers – have been complicit in perpetuating the belief that we should expect everything possible, and that if we’re not receiving it, it means we’re getting inadequate care. This happens even in the face of evidence that aggressive screening and treatment isn’t always medically useful and doesn’t necessarily lead to better outcomes for the patient. And you have only to look at the escalation of health care spending in this country to realize this attitude has gotten us into a heap of trouble.

Our great expectations aren’t the only thing contributing to rising health care costs, of course. But they’re surely one of the factors, and I suspect they will be one of the most difficult to change.

Unfortunately, it’s not easy to say no – and those who try to go against this cultural grain will probably lay themselves open to accusations of rationing, writes David Leonhardt, the author of the New York Times essay. Like dishing out bad-tasting medicine, however, it’s necessary, he writes:

From an economic perspective, health reform will fail if we can’t sometimes push back against the try-anything instinct. The new agencies will be hounded by accusations of rationing, and Medicare’s long-term budget deficit will grow.

So figuring out how we can say no may be the single toughest and most important task facing the people who will be in charge of carrying out reform. "Being able to say no," Dr. Alan Garber of Stanford says, "is the heart of the issue."

Read some of the 280-plus comments on the story to get a good look at why this is going to be so difficult. From one person: "Maybe you can say no… but not me." From someone else: "I want the same level of health care that I have always had, and I am willing to pay for it." "Crank up the death panels," one reader sarcastically advised.

Not everyone thinks this way. Studies have found that when patients are given all the information about risks and benefits of a given treatment, they often choose more carefully and are more willing to opt against it, especially if they perceive the risks are unacceptable or the benefit is minimal. When the Center for Healthcare Decisions, a California think tank, engaged the public in identifying priorities for how health care dollars should be spent, one of the things learned was that people are more ready to understand the tradeoffs than they’re given credit for.

I don’t think there’s going to be any delicate or diplomatic way to have this national conversation. It will probably expose a whole new Grand Canyon of disagreement over American health care. After all, not all of us draw the line in the exact same place; what’s reasonable to one person looks to someone else like rationing or government interference. Painful as it’s likely to be, however, it’s a conversation that’s long overdue.

Photo: Mount Everest. Courtesy of Wikimedia Commons

The technology boom

Raise your hand if you’ve never undergone a CT or MRI scan, never taken a statin to lower your cholesterol or never had a joint replacement. If your hand is still in the air after reading this, you’re either in a healthy minority or just haven’t caught up yet with the odds.

American health care is very good – a world leader, in fact – at developing and using technology. Just how prevalent our technologic interventions have become is demonstrated in a report recently issued by the National Center for Health Statistics, which takes a look at this technology boom by the numbers.

The findings are rather eye-opening. Take, for instance, the report’s summary of the growth of medical imaging over the past couple of decades:

Despite the significant costs of acquiring advanced imaging capability, the availability and use of imaging technologies in the United States has substantially increased since their introduction in the early 1980s. In 2006, there were more than 7,000 sites offering MRI, with an estimated 27 million MRI procedures performed. In 2007, more than 10,000 CT units were in operation at more than 7,600 hospital and nonhospital sites, and the availability of PET and other imaging modalities has been steadily increasing. The site of imaging services has diffused from hospital inpatient and outpatient settings to nonhospital settings such as physician offices or radiology centers. During the past decade, the number of freestanding diagnostic imaging centers owned by radiologists, other specialists, private investors, or for-profit companies has more than doubled.

The report found that from 1996 to 2007, the number of advanced imaging scans ordered during outpatient office visits tripled in number. In emergency rooms, the use of advanced imaging grew fivefold between 1996 and 2007 for patients under the age of 65 and quadrupled for patients 65 and older.

The number of joint replacement surgeries has grown substantially. At least one analysis estimates the demand for total hip replacements could grow by 175 percent in the next 20 years, while the demand for knee replacements could increase sixfold.

The rate of kidney transplantation increased 31 percent between 1997 and 2006. Liver transplants increased 42 percent during this same period. The use of assisted reproductive technology has risen, especially among women younger than 35. From 1988-1994 to 2003-2006, the use of statins to treat high cholesterol rose almost 10-fold, while the use of antidiabetic medications as a replacement for insulin rose by 50 percent.

None of this is necessarily bad. As the report points out, it’s “almost inconceivable to think about providing health care in today’s world without medical devices, machinery, tests, computers, prosthetics or drugs.” Joint replacement surgery has enabled countless people to remain mobile, independent and pain-free. Angioplasties and organ transplants save lives. Drug therapies have staved off illnesses that might otherwise have been fatal and allowed patients to return to normal life.

The flip side to this is that it costs money. A lot of money. Even interventions that are less costly can add up as they become more widely used. From the report:

Technologies applied to new populations and conditions generally come at a cost to individuals and to society as a whole. Technologies can be very expensive (e.g. heart transplants, chemotherapy) or very inexpensive (e.g. the Band-Aid). Total expenditures for a given technology, however, are determined by both use and cost; consequently, widely used inexpensive technologies can often have higher aggregate expenditures than rarely used expensive ones. Some new technologies can be cost-saving – for example, annual influenza vaccinations in high-risk children. Many technologies, however, contribute to increases in overall health care expenditures because they increase utilization (e.g. more doctor visits may be needed to monitor new drug therapies); they may be used on a larger number of patients; they may be more expensive than technologies they replace; or they may increase life expectancy in populations and thus their lifetime health care costs.

In one of the most telling sentences in the entire report, the authors point out: “In general, Americans – both providers and consumers – appear to be more willing and eager to adopt and use new technologies than people in other countries.”

This whole issue came to mind when I recently read a New York Times article about robotic surgery. It costs more per patient – $1,500 to $2,000 more. It’s not clear if the results are any better than more traditional surgery. But, as the article explains, hospitals and surgery centers are marketing it and patients are asking for “the robot,” in some cases walking away from surgeons who don’t do robotic surgery.

Readers chipped in with comments. Several said they’d had robotic surgery and couldn’t be happier with the results. Others were more skeptical. “Follow the money,” one person scoffed.

Last weekend my Sunday paper was accompanied by this article in Parade magazine: “Revealing the body’s deepest secrets.” It described several new forms of gee-whiz medical imaging technologies that are “transforming medicine.” One is the use of MRI for diagnosing heart attacks; another is a fiber-optic probe that can help detect oral cancer. To be fair, there could well be an appropriate niche for these technologies – but at what cost, not only in dollar terms but also in the ratcheting-up of people’s expectations? On some online message boards, I’ve seen people criticize their physician’s competence for not ordering a specialized test they felt they should have.

Finally, here’s yet another look at the issue, this time from Kaiser Health News, in an article titled “High-Tech Medicine Contributes to High-Cost Health Care”:

Just before Christmas, 41-year-old Michael Kelley decided he wanted a whole-body imaging exam, the heavily advertised service touted on television by celebrities like Oprah Winfrey. He didn’t smoke, wasn’t overweight, and didn’t have elevated cholesterol. “I’m pretty normal for a guy my age,” he said.

No matter. The electrical engineer scheduled a full-body X-ray computed tomography or CT scan at Virtual Physical, a radiology clinic located in a glass-enclosed office building on a busy commercial strip not far from the headquarters of the National Institutes of Health. The clinic’s name, plastered in large red letters on the building’s exterior, served as a billboard aimed at cars exiting the high-end shopping mall across the street.

About an hour after checking in, Kelley left the clinic clutching a manila envelope with high-resolution 3-dimensional images of most of his major body systems, including the insides of the major coronary arteries pumping blood to and from his heart. “They said I was fine, no plaque,” he said. Kelley paid $1,400 for a CT scan to confirm what he and his doctor already knew – he was perfectly healthy.

The rest of the article delves into some of the difficult issues surrounding the use of medical technology. When does the technology genuinely benefit patients and when does it reach the point of diminishing returns? Is “better” always the best thing? How should we weigh the potential benefit to the patient vs. the risk of harm?

The article concludes that in the long run, technology will probably help save money, but we’re not there yet:

When robotic doctors are able to perform micro-surgeries; when arm and leg replacements function as well if not better than the original parts; when pharmacology replaces more expensive treatments and therapies, the U.S. may actually be able to use technology to bend the cost curve of health care downward. Until that time comes, we’re stuck with ever-increasing costs and left to wonder whether the investment is greater than the payoff.

What’s remarkable about this whole discussion is that it’s happening on a wider, more public stage. Ten years ago, maybe even five years ago, I’m not sure the average person was ready to contemplate the down side of technology. More and more, however, these questions are being asked and debated – not just within policy circles but among the public. We might not have the answers, but the sheer fact that we’re willing to acknowledge it and talk about it is surely a sign of progress.

West Central Tribune photo by Anne Polta

Copayments, cost-cutting and contradictions

It’s long been the common belief that when consumers have to pay more out of pocket for their health care, they’ll make wiser, better decisions and money will be saved.

An interesting new study calls this into question, suggesting that when elderly patients have a higher copayment for outpatient care, they might be more likely to skip doctor visits and wind up needing hospital care that’s ultimately more expensive. The study appeared a couple of weeks ago in the New England Journal of Medicine.

It was a good-sized study, involving nearly 900,000 Medicare enrollees who were tracked from 2001 through 2006. Those who had their copayment raised for ambulatory care were matched against a control group whose copayment for outpatient care stayed the same. What the authors found was a little surprising: Medicare enrollees who saw their out-of-pocket costs for office visits go up were more likely to be hospitalized.

They wrote:

Over time, there was an increase in ambulatory visits in both the case and control plans. However, the increase was smaller in case plans than in control plans. In contrast, case plans had significant increases in annual inpatient days, annual inpatient admissions, and the probability of any use of inpatient care, as compared with control plans. Of the 18 case plans, 13 had declines in annual outpatient visits and 15 had increases in annual inpatient admissions, as compared with the concurrent trends in the matched control plans.

The authors also found this trend was magnified among Medicare enrollees who lived in areas with low income and low educational levels, enrollees who were black, and enrollees with high blood pressure, diabetes or a previous history of heart attack.

What’s going on here?

The copayment increases weren’t particularly large. They ranged from $5 to $10 more for a primary care visit and $5 to $15 more for an office visit to a specialist. The actual copayment for a primary care visit was $7.38 before the increase and $14.38 after the increase. For specialty care office visits, the mean co-payment rose from $12.66 to $22.05.

But if the intention was to reduce costs by having these elderly patients pay a larger out-of-pocket share, it may have backfired. The analysis found that among the plans that increased the copayment for ambulatory care, inpatient hospital expenses actually went up. There were 2.2 additional hospital admissions per 100 enrollees per year and 13.4 more inpatient days per 100 enrollees per year compared to the plans that didn’t increase their outpatient copayment. In fact, the savings from higher copayments for office visits were wiped out by increased hospital inpatient costs by a factor of 2 to 1, the study found.

The authors of the study speculated the higher amounts may have been enough of a barrier to discourage many of these enrollees, all of whom were over age 65, from seeing a doctor. Their conclusion: “Increasing copayments for ambulatory care among elderly Medicare beneficiaries may be a particularly ill-advised cost-containment strategy.”

It’s not clear if these same findings would apply to a younger, working-age population. The study noted elderly patients might be more sensitive to increased copayments because their incomes tend to be lower and they’re more likely to have chronic or multiple health problems. They could also be more likely to have additional copayments for prescription drugs, medical equipment and so on, leading to higher overall out-of-pocket health care expenses. The study also was unable to definitively connect the dots between fewer doctor visits and increased likelihood of hospitalization.

Nevertheless, this isn’t the first time concerns have been expressed about the unintended consequences of giving health care consumers more responsibility for the money they spend. In a paper issued for health insurance purchasers, the U.S. Agency for Healthcare Research and Quality cited the existing research and warned, “Patients who had to pay used care less often, but they tended to forego appropriate care as well as inappropriate care.”

Similar findings have been reported with HSAs, or health savings accounts. Although these have been touted for saving money and giving consumers more power, the large deductibles – often $3,000 or $5,000 per year – can cause some people to delay or skip necessary care, especially if they don’t have a lot of money banked in their account.

This study, conducted a few years ago for the Center on Budget and Policy Priorities, found that while HSAs helped lower health care costs for people who were more affluent, those who were less well off incurred higher costs and were more likely to delay primary care.

A few conclusions come to mind. First, asking consumers to pay more for their own health care doesn’t necessarily lead to lower overall costs. Second, giving consumers more responsibility for their health care spending is not a guarantee they’ll make wise choices or that they’ll even know what the right choice is supposed to be. Third, some segments of the population – namely those who are elderly and/or have lower incomes – seem to be more vulnerable to the effect of increased out-of-pocket expenses. And finally, what seems intuitively correct – in this case, the belief that it saves money to give people more financial skin in the game – is not always borne out by the facts.