Are you better off?

Changes are coming: For Good or Worse?

There are heady times for health care. Changes circumventing the Affordable Care Act are leaving people excited and confused at the same time. The overall goal of the Affordable Care Act is to expand access of care to people previously uninsured, under insured, and misrepresented. A paradox exists in this country where uninsured people receive too little care and insured people receive too much of it. Both ends of the spectrum have profound effects on patient outcomes and the financial stability of the system. On one end, uninsured people use the system the majority of the time when it’s too late. For example, a woman may have felt a lump in her breast 9 years ago and the lack of preventative services not afforded by having insurance caused an automastectomy to occur. At this point of time, what was once known as a benign tumor and could have been treated in a matter of hours has turned into a full blown malignant tumor that has most likely dispersed to the rest of the body, including areas of the brain, lungs, liver, kidneys and heart. At this point, the patient’s prognosis is much, much worse, and tax payers and beneficiaries will incur increased premiums as a result of her doctor’s trying to extend what little quality life she has left to live. Likewise, a patient with private insurance may demand more services be provided than deemed medically necessary. Consider a patient suffering migraines. She suffers intense bouts of pain and demands that all measures be taken to correct the problem. These measures include expensive laboratory tests such as a hormonal work-up, an MRI of the head, and sensitivity tests. What may have been diagnosed as stress induced migraines has blown out of proportion in terms of costs, patient safety, and necessity.

Are the changes coming for better or worse? One argument consists from an economic standpoint. Are all people entitled to health care? The answer to this question is an obvious yes. The not so obvious part of this answer is to what extent? As I argued in one of my first posts, the government has an inherent responsibility to protect its people. This is evidenced by proper public health measures that were instituted shortly after the scare of the bubonic plague. Every country in the free world except the U.S. has superseded government responsibly in health care by offering universal health coverage. In no other country but the U.S. has the plight towards universal health been charged with such adversarial clashing. Multiple attempts have been made to set up a one payer system, but governmental attempts have met strong opposition through strong political interest groups, such as the Labor Unions, AMA, and insurance agencies. The running joke for universal health care proponents is that we are one car accident or hooker manslaughter away from enactment. Even now, with the institution of the Affordable Care Act and its policies starting to have its most profound effect on our health system, the question often arises, are we doing more good or harm?

It is of my strong opinion that the Affordable Care Act is not the answer to our unsolved problem. The Act is definitely a step in the right direction, but for real progress to be made in this country, this country is going to have to endure a complete restructuring of the entire system. The ACA addresses issues of quality and access to care, but leads no sure promise of it actually seeing fruition. HMOs were government supported, and many areas of concern caused them to compromise the system by limiting care too much, and causing doctors to underdiagnose. What started out as a great turn of events eventually lead to the ship sinking again. How can things be done different so that our future is not so grim? The whole system needs to be remodeled. It’s apparent that the more we spend on health care does not have a profound on patient outcomes. In fact, spending more creates more issues related to fraud, embezzlement, providing sub-par services, and even scarier consequences. Consider this fact, each year there is about 100,000 hospital acquired infections (HAIs) that could have been preventable. These HAI’s equate to the same number of deaths. Also consider that last year Medicare experienced 100 billion in Fraud, some of it accidental, but most of it not. It’ll be interesting to see how the ACA has affected our system in the years to come, but will it be enough or is it just a temporary solution to a deeper, underlying problem?

The answer to the question of how the system needs to be overhauled is not an easy one. I do know however that it will take strong people to stand up against the doctors, insurance companies, and profit driven hospitals, and ultimately do what’s right for the people. History has generated some great ideas, but opposition from strong political groups has prevented their arrival into the market. For the rest of us watching as two ships pass in the night, fasten your seatbelt and enjoy the ride, because it’s going to get bumpy. 

One major concern leading to high health care costs

“It is difficult to rationalize the goals of a system that invests in the most sophisticated and expensive neonatal services to save premature, high-risk infants while cutting back on the relatively inexpensive and effective prenatal services that would have prevented many of those poor birth outcomes in the first place” (Sultz & Young, 2011).

Let that statement sink in for a minute. Do you understand that this is a major problem that is contributing to our outrageous cost of health care? Why is it we often spend hundreds of thousands of dollars to prolong end-of-life care by 2 weeks, 4 weeks, 6 months or even a 1 year? While recently watching a documentary on Medicare reimbursement, an older, 87-year- old gentleman, who had liver failure, kidney failure, and was on the verge of heart failure was asked by a physician if he wanted to initiate “DNR” orders or consider his other options. In the case that the patient’s respiratory status started to deteriorate, the hospital and its personnel would do whatever it took to keep this man alive, even if this meant spending hundreds of thousands of dollars to do so. The elderly man opted for the more expensive route. About a week after the discussion with the physician, the patient’s health status started to seriously deteriorate. He was then transferred to the ICU where he was kept alive on a respirator, given multiple expensive drugs to regulate his circulatory system and had specialized care from physicians and nursing staff. After about 3 months, the man passed away. The cost of his treatment? Well over $800,000. The worst part is that this man was delirious, had no form of conscious thought, and remained in a vegetative state in his last months. In school, we’re often inculcated that quality is better than quantity. These are the incidents that pervade our medical system that contribute to the high rising costs.

In David Goldhill’s book, “Catastrophic Care”, he blames a lot of wasteful medicine, such as in the example provided above, by society’s lack of knowledge that is often blocked by insurance companies serving as intermediaries. If one knew that the cost to keep himself alive would place an $800,000 financial burden on his family, do you think he would have wanted alternative options? These decisions are often difficult to make when family is making these decisions. I love my father, but I highly doubt my mother would want my father to live his last few months in agony, and better yet, I highly doubt she would consider the financial burden worth it. In fact, she may be more inclined to yank the plug than the physicians! Joking aside, my mother knows the piecemeal aspects of the health care system. She may be a little more educated than most when it comes to deciding what care should be delivered and what care should not be delivered.  Goldhill emphasizes that the reason consumers and health care industries are so out of sync with one another is because insurances serve as the intermediaries. Somehow, insurance companies (i.e. private and public) know how to better spend our money than we do. Granted, insurance companies can serve as a safety-net for some individuals, such as in the case of serious trauma resulting from a car accident, but who decides when and how to keep someone alive when costs far surpass the quality of life. Additionally, as provided by the opening statement, there is always a trade off of that price and other people’s health care. Interestingly enough, Goldhill states that, through basic principles of free enterprise, that these costs would significantly drop if insurances were taken out of the equation altogether.  An example of this was well illustrated in an article put out by the NYtimes last week.

The article, which can be found here: http://www.nytimes.com/2013/12/19/business/shake-up-at-big-co-pay-fund-raises-scrutiny-on-similar-charities.html describes the profound effect that Medicare has on keeping drug prices high. The investigator discovered that in a charity fund, which is used to help Medicare patient’s pay for out-of-pocket costs, drug companies were major contributors. The advantage the drug companies had were that by donating a small portion, they would ultimately receive a large portion.  Additionally, the article illustrated that a drug company, known as Questcor that sells a drug that was approved more than 60 years ago, has raised its price since then from $40 to more than $28,000/vial. The company only sells it at such a high rate because they know that Medicare will reimburse it. However, if insurance were not serving as a intermediary, the company would be forced to sell at a much lower rate. Consequently, if people decided that this lower rate, whatever it may be, did not meet its expectation (in this case extending life by a certain time frame), the drug company would be forced to come up with more creative alternatives or suffer the consequences of a failing market.

Lastly, the rate and growth of cost, with the addition of trying to control the ‘cost curve’ through budget cuts, has caused us, as consumers, to look at what exactly the reasons to our rising costs are. No one wants to be confronted with the idea that they’re behind the decision of potentially prematurely ending someone’s life, but when confronted with the cost, one might seriously consider the consequences or alternatives. For all extents and purposes, the lack of transparency of the health care system, as blocked mainly by its interest groups (other than consumers) has lead to these sky-rocketing costs. To be quite frank, the other interest groups want to keep it this way. The health care industry does not profit off of you being healthy, but has a perverse incentive to keep you sick. Even with Obamacare, better access to health care, through insurance markets, does not equate to better health. The whole system needs an overhaul. I would like to end this blog with a recent joke I read the other day:

Two New Russian businessmen encounter each other at the airport in Zurich. The first says, “That’s a nice tie.”

“Thank you,” responds the second man. “It’s an Hermes.”

“May I ask,” says the first, “how much did you pay for that tie?”

“A hundred and fifty dollars!” answers the second man proudly.

“You idiot!” says the first man. “I bought the exact same time, but for two hundred and fifty dollars!”……

I hope this joke doesn't overemphasize my point about cost and quality in health care, but to some extent there lays a hidden truth.

References

Goldhill, D. (2013). Catastrophi care: Why everything we think we know about health care is wrong. New York, NY: Vintage Books.

Pollack, A. (2013, December 18). Drug maker's donations to co-pay charity face scrutiny. Retrieved from http://www.nytimes.com/2013/12/19/business/shake-up-at-big-co-pay-fund-raises-scrutiny-on-similar-charities.html?pagewanted=1&_r=0

Sultz, H., & Young, K. (2011). Health care usa: Understanding its organization and delivery. (7th ed.). Sadbury, MA: Jones & Bartlett Learning

The Declaration of Independence should have said, Life, Liberty, and the Pursuit of Happiness... and health.

Without a doubt there is a huge moral dilemma when we talk about health. Does everybody have a right to health? This is a complex question that often causes me internal strife. The angel on my right shoulder tells me yes, everyone, when sick, should have the right to return to a state of well-being. The devil on my left shoulder tells me no, people make poor decisions purposefully, and those decisions should not be rewarded. Of course there are other reasons why people should have access to health care. For one, it does not benefit me, as a member of society, if I'm sick or if my neighbor is sick. From an economic perspective, he is less efficient, and if he gets me sick, he passes that effectiveness, or lack thereof, to me. What if, my neighbor cannot afford health care and I can? Am I still to suffer the potential consequences of my neighbors sickness because he or she cannot afford it?  According to Shi & Singh (2008) the sick individual is not held responsible for his or her sickness. In other words, being sick is recognized as the legitimate basis for society to exempt the individual from his or her social role obligations (pg. 56).  Thus, the answer to the question above  is an obvious no, therefore the government steps in and [sometimes] offers to pay for his or her cost of care, to my benefit. Or is it? At what cost does this affect MY health care?

From an economic standpoint, health is a private ownership. Similarly, outputs related to optimizing health status can come provided at a price. As American citizens, we are all too familiar with the fact that nothing is free, but this does not mean that things should not be offered at a just price. In a capitalistic market, 'just prices' are determined by the relationship between the supplier and consumer. When the consumer demands less, the cost goes down. The opposite is also true. However, there should be a caveat to this when it comes to our health. There are times when no matter the cost of care we will pay whatever to just feel better. This creates a kind of monopolistic advantage for the health care market. You may be wondering if the prices you pay for your care are justified or not? While the answer to that question is subjective, I can tell you that most hospitals (currently) are not profiting. In other words, the revenue they receive does not cover their expenses. So when you look at your explanation of benefits and you see that a large astronomical dollar amount and say JEEZ, this price is ridiculous, just remember, your hospital or provider has expenses too. Which brings me to my next point, does your neighbors inability to pay for care affect the prices YOU pay? Like you and I have bills to pay, so do providers. These bills can be fixed costs, variable costs (employees), technology costs (MRIs, CTs, X-rays, etc..), supplies, and many more. When your neighbor doesn't front the bill, the government can, and sometimes will pay for a portion of the bill. The portion of the bill that the government pays is MUCH less than what the hospital needs to cover its expenses. Therefore, the difference between the cost is shifted to people like you and me who have insurance. This means, instead of having a $100 copay for an appendectomy, we might have a $300 copay because of our neighbor.

Additionally, I would like to mention that these government programs determine the prices they pay based on complex formulas. Let's say you are an owner of a grocery store, and I am your customer (the government) I fill my grocery cart up to the top and tell you that I am not paying more than $100 dollars for this cart even though the actual cost of all goods is $250. As an owner you would probably be upset, but I would just laugh in your face and tell you to deal with it. This is pretty much how the government intervenes into our healthcare and affects the prices of those that are insured. This is confirmed when Dewar (2010) states that indigent care has been found to be directly financed by taxpayers and private charities and indirectly by shifting costs to those with insurance coverage. Interestingly enough, "over one-half of the uninsured state that they have no trouble getting the health care they need for free" (pg. 4). When you have this type of intervention by the government to help 'allocate' health care resources you create a market where capitalistic principles cannot be followed. The people that suffer the most are those that use their hard earned money to pay for these services. Prices are unfair for insured individuals partially because this public allocation offsets concepts of the Adam Smith's "Invisible Hand". Thus, even when you don't demand these services with your dollars, SOMEONE is, and in the end you are the one that suffers, speaking strictly in dollars.

Lastly, when you have a market with government intervention the market trends towards more Marxist views. The way our current system is setup right now promotes market failure. The government should take full responsibility for our health care or stay out of it completely. We cannot have both occur because the market will never correct itself then. If you think your costs are out of control now, just wait when in 2020, healthcare expenditure is expected to reach $5 Trillion opposed to our current $2.6 trillion.

References

Dewar, D. (2010). Essentials of Health Economics. Boston: Jones and Bartlett Publishers.

Singh, D. (2008). Delivering health care in america: A systems approach. (4th ed.). Sudbury, MA: Jones and Bartlett Publishers.

Primary Care Physician 'Did You Know' bullets

One problem with the primary care physician shortage is that these doctors are not fairly compensated when compared to their specialist counterparts. Often times, they do more work, see sicker patients, provide care in undeserved areas, and yet are still paid much less. Yet, it is believed that much of the work that PCPs provide is insignificant and often demeaning to their actual intended purpose.  Here are some some fact's that I found about concerns relating to the PCP shortage

Did you know:

• One projection estimates that by 2020 the shortage will balloon to 40,000 physicians.⁴ A more recent estimate suggests a gap of 52,000 primary care physicians by 2025.⁵ The problem particularly affects primary care for adults more so than for children.
• By 2016 the number of adult primary care physicians leaving practice will exceed the number entering,
•  A 50 percent increase inprimary care Medicare payments would be needed to greatly narrow theprimary care-specialty income gap
• There will be insufficient NPs and PAs to bridge the gap; the ratio of adult primary care clinicians
• One-fifth of primary care visits involve preventive care,¹⁵ most of which consists of cancer screening, counseling, and immunizations... An estimate that 60 percent of these preventive care services can be performed by nonclinicians suggests that 10 percent (60 percent times 17 percent) of clinicians’ time could be saved, which could translate into a 10 percent increase in primary care capacity
• Acute care consumes 46 percent of primary care physicians’ time. Registered nurses managing uncomplicated upper respiratory infections, using standing orders, provide care equal in quality to that offered by physicians;^27,28 also, patients are more satisfied with nurse-provided care.
• the patient-physician relationship is not alive and well. Seventy-eight percent of physicians believe that they provide compassionate care, but only 54 percent of patients agree.³⁸ Second, patient satisfaction with nurses or physical therapists for the care of minor acute illness and low back pain is greater than satisfaction with physicians for these conditions.^29,31,32 Third, patients who experience care from NPs and PAs are satisfied with their care

More information to come later. 

Reference

Bodenheimer, T., & Smith, M. (2013). Primary care: Proposed solutions to the physician shortage without training more physicians. HealthAffairs, 32(11), 1881-1886. doi: doi: 10.1377/hlthaff.2013.0234

Hospital's administrators need to be leaders

After reading an article by Forbes, many hospitals are not-profitable. This is quite disturbing especially when the average response from any recipient who receives their medical bill is, "Wow!" We often look at our EOB statements with disgust when we find that we received an EKG while in the E.R. and it cost us $90, or an I.V. that cost us close to $70. Why are these costs so high? What am I paying for? Well, in short, you're paying for the supply, labor, non-labor, capital, room & board, and probably other things that you didn't even think about. The article can be found here: http://www.forbes.com/2010/08/30/profitable-hospitals-hca-healthcare-business-mayo-clinic.html

One thing the article pointed out is that better quality = better patients, but as we all are often familiar, quality costs money. This doesn't mean we can't find quality at cheaper costs, but how much patience do we have when waiting for that quality? I equate this to the upcoming Playstation 4 making it's debut here in the next few days. I want a PS4, and I really don't want to wait for it to come down in price before I get it, though I know based on past experiences, when I've acquired a new technological system like this, I played the shit out of it for 1 week and let it sit on my shelf for about a year or so before giving it away to my brother. Even when knowing this, I will probably STILL rush out to buy this new console. Why? It's because I'm American, I want the biggest, baddest, best product on the market because it makes me feel good about myself. Do I need it? Hell no. I'm perfectly find with a PS3 or not even having it. I've lived my life this long without one, but it doesn't even matter to me. So what does this have to with the topic? There are obviously many of us that can live without these technological advances in the healthcare industry, but we still demand the biggest and the best, and we necessarily don't have a valid justification for it. In the end, people bitch and complain when they go to the hospital and their bill is through the roof, irregardless if they have medical insurance or not. You might be saying, well, the hospital doesn't have to purchase this high tech equipment, why don't they just purchase the bare minimum to provide the quality of care I need? This is because they must remain competitive in the market or else they will they face the fear is closing. Closing hospitals means less access for people like me and you that may need it one day.

Administrators of tomorrow's healthcare are faced with myriad struggles that affect the access, quality, and price of healthcare. Administrators need to take risks, analyze their markets, and provide accordingly. Additionally, they need to step up to the plate and put a firm foot down and implement policies that prevent the exploitation of healthcare technology. Do doctor's need to prescribe an MRI for a person that comes in complaining of a headache? No, but some still do. I find this to be outrageous. Additionally, people need to realize that the ER / hospital is not a place to get your 'check-up'. If you're sick, you need to see your PCP or go to the Urgent Care first. Contrary to popular belief, the ER is for emergencies, and a child with a fever of 102.0 degrees is not really emergent. Try giving your child an OTC treatment first, and if that doesn't work, schedule an appointment with your PCP, and see what he recommends. Stop wasting my healthcare dollars and everybody else's healthcare dollars at the expense of your stupidity / curiosity. I wish I could find the article, but I read earlier that something like 40% of ER admissions to in-patient wards do NOT increase a patient's quality of life. In other words, they can be treated as an outpatient basis and recover this way. To me, this is a little absurd. Doctor's are worried about being sued,, but guess what? Military medicine is the exception to this rule because active duty cannot sue active duty doctors. This means that doctor's treat in a conservative sense rather than aggressive, and it helps cut down on waste. The problem with healthcare is that hospitals are catered to try and please everybody, but this philosophy is equivalent to a person trying to obtain world peace. Sure, it's a great idea, but unrealistic. Administrators need to realize this, and start taking a stand against this type of abuse.

Does the Government belong in healthcare?

This is a highly debated issue. One argument is that healthcare involvement impedes capitalism and free-market reign. Government involvement also provides some sort of regulation, but how much regulation is too much regulation? Government helps prevent fraud, abuse, an inequity, but these problems still continue to exist. Below is my view on government involvement:

The question of whether government should be involved in healthcare is undoubtedly obvious. The government has a moral responsibility to protect its citizens and their health. To what extent the government involves themselves is a question of debate.  In an essay by John Bellers, a London philanthropist, titled Toward Improvement of Physick, he argued that “health of people was the responsibility of the state, whose task it was to establish and maintain hospitals and laboratories, erect a national health institute, and provide medical care for the sick” (Sultz & Young, 2011). Even people that disagree with government involvement would have a hard time arguing that public services provided to the indignant or severely sick individual does not protect their health, in some form, as well. In Parson’s social model of health, the sick individual is not held responsible for their health. Optimal health benefits all members of society by preventing the spread of disease (Shi and Singh, 2008). Government involvement is necessary to protect not only the health of the individual, but the health of society as well. Public health services have demonstrated this example by eradicating certain disease caused by contaminated waters, poor sewage, trash disposal, and much more.

As stated earlier, what, and how, the government intervenes is a complex issue. The medical model of health care is essentially a business model. Money cannot be made in the health care industry unless disease or poor health exists. Advancements in technology have spurred these costs out of control, making health care non-accessible to everybody.  According to Nichols (2012) government has a practical, necessary, and morally sound reason to be involved in health care markets. One interesting moral argument of government involvement illustrated by the author is clear when he states, “all of us could ultimately die from lack of timely care which we could get if we have good  health insurance, and we all could become too sick to work and then lose our health insurance… to refuse life-sustaining care as a matter of policy because of a cost that the society as a whole can afford to bear is a similar violation of the essence of the Covenant that Moses, Jesus, and Mohammed all taught their followers” (Nichols,2012, p.549). While not heavily religious, I must admit that without government oversight, the system of health care may succumb to this adverse principle. The author describes many economic rationales for government involvement in health care as well. For instance, “Government is usually necessary to effectively correct serious externalities, when costs or benefits borne or enjoyed by those who are not producing or cosuming the good or service directly. Pollution and education are classic examples here” (Nichols, 2012, p.550).

While many arguments exist for why government involvement is essential, the arguments against involvements should not go unnoticed. Although I agree that everyone should have access to some sort of health care, I do believe a way to prevent abuse should heavily be enforced. For example, there is an argument called moral hazard that states that when people have insurance, they are more likely to use it. Like any business, supply and demand exist in healthcare fields too. If, suddenly we open the doors to everyone, or everyone uses the system, we decrease the supply of staff thus reducing the quality of care. I’m not exactly sure how much quality I want to give up by providing care to individuals who may not necessarily need it

References

Nichols, L. (2012). Government intervention in health care is practical, necessary, and morally sound. Health Care Reform: Controversies in Ethics and Policy, 547-557.

Shi, L. and Singh, D. A. (2008). Delivering health care in America (4^th ed). Boston, MA: Jones and Bartlett

Sultz, H., & Young, K. (2011). Health care usa: Understanding its organization and delivery. (7th ed.). Sadbury, MA: Jones & Bartlett Learning

Welcome to my blog

Hello and welcome to my new blog, Healthcare News and Spotlight.

The intention of this blog is multifaceted. This is going to be a place where issues revolving around healthcare are addressed and analyzed. The healthcare industry is problematic, and as participating citizens, we must be involved with the issues circumventing the industry. The new focus of healthcare is reliant on the consumer. Healthcare affects all of us. Many of us live our day to day lives not even thinking about this industry and the impact it plays on our lives. The purpose of this blog is to get you, the consumer, interested and informed about the issues that have an impact on the cost, quality, and issues pertaining to access relevant to the industry. If you ask any layperson, you'd probably find a general consensus that everyone deserves access to care, but how that access is obtained is highly divisive. My goal is not to take a side, but rather inform. If you disagree with my opinion, you are entitled to that right, and I want to hear it. At the same time, please be aware that your opinions should be backed by some evidence if you want to attempted to persuade the audience, otherwise it may not seem credible.