V.A. Seeks to Redirect Billions of Dollars Into Private Care – NY Times

Whatever could go wrong with this proposal? Everything. A long time goal of the Koch Brothers and the Libertarian right wing,  the Trump administration seems bent on carrying out this ill advised plan. If you are a vet, and value the notion of being supported for your health costs in the future, you better come out against this now. The proposal shifts money from a low cost federal government model to a high cost, low value private world of care where you will be milked for your savings. This is a recipe for disaster. What might be done to fix the situation? Shift money from military spending to the V.A. It would cost far less. One less fighter would add billions to the V.A. now. No new taxes needed. But I’m not a vet. Ultimately, it’s not my battle. It’s yours. I’ll remind you of a quote from a Republican operative, Grover Nordquist”,”

“Our goal is to shrink government to the size where we can drown it in a bathtub. “

 

The Deteriorating Administrative Efficiency Of The U.S. Health Care System – PNHP

As we start 2019, I thought I would bring in some fundamental issues that we have been facing and continue to face, both in Jefferson County and nationwide. In reading through a variety of articles recently, I came across a couple of articles that pretty clearly identify the state of healthcare in the US.

The first is an old study, but one that has been updated and used frequently in presentations. Lest start with the original study first.

The Physician’s for a National Health Program published a 1991 study from the Harvard School of Medicine that validates what many of us, the critics of modern hospital management, have been instinctively feeling all along. The situation, updated in a more recent slide deck, here, gives the current situation.

The problems of hospital administration are endemic. You can hear it every time there is a hospital commissioner meeting each month. Only good news is presented. Bad news is couched in doublespeak if it’s ever raised at all.  No mention of the medical bankruptcy rates in Jefferson County (they are on the rise). Never raise issues that are problems or concerns or face being ostracized by your peers. From executive suites of hospital management making vastly more money than the surrounding towns they serve, to the rubber stamps of hospital commissioners that simply are uninformed and  like staying that way, or aren’t willing to challenge anything of a controversial nature, to medical professionals who cosy up to the administration to make themselves feel better about their positions of authority and stop any change agents ending up as hospital commissioners. It all feeds the continuation of a system that is fundamentally out of control on costs. It’s not just JHC it’s the whole broken system.

Here’s the underlying data sets of one aspect of our current, deeply broken system.

The 1991 study found that “the spending on hospital administration is 117% higher than Canada and accounts for about half the total difference in healthcare spending between the two nations…If healthcare in the United States had been as efficient as Canada’s between $69 to $83 Billion dollars would have been saved. ” It has only gotten much worse since then.

Enough to pay for healthcare for all Americans without cutting the beloved military budget that so many Americans feel is beyond questioning, even as it consumes more than half of all governmental expenditures.

It goes on to state: “Recent health policies with the avowed goal of improving the efficiency of care have imposed substantial new bureaucratic costs and burdens.”

There are other issues at work beyond this, such as pharmaceutical costs, etc, but this goes to the core of this leg of the stool. Perhaps the stool should have three legs, For Profit Insurance Companies, Pharmaceutical companies, and hospital administration. But read it yourself and draw your own conclusions.

“CONCLUSIONS: The administration structure of the United States healthcare system is increasingly inefficient as compared to that of Canada’s national healthcare program. Recent health policies with the avowed goal of improving efficiency of care have imposed significant new bureaucratic costs and burdens.”

http://www.pnhp.org/publications/NEJM5_2_91.htm

The data has been updated through 2014 with data from the Department of Labor Statistics. It only got vastly worse since 1991. What happened between then and now? Well, computer use exploded. Is that the problem? During this time we also had both Democratic and Republican Presidents and Congress. And we had an explosion of medical insurance growth.

growth of physicians and admin

This recent study covers updated information related to hospital administration costs.

Medical Spending Differences in the United States and Canada: The Role of Prices,

Procedures, and Administrative Expenses

Abstract

The United States far outspends Canada on health care, but the sources of additional spending are unclear. We evaluated the importance of incomes, administration, and medical interventions in this difference. Pooling various sources, we calculated medical personnel incomes, administrative expenses, and procedure volume and intensity for the United States and Canada. We found that Canada spent $1,589 per capita less on physicians and hospitals in 2002. Administration accounted for the largest share of this difference (39%), followed by incomes (31%), and more intensive provision of medical services (14%). Whether this additional spending is wasteful or warranted is unknown.

The United States spends nearly twice as much per capita on health care as Canada: $7,290 per person in the United States in 2007 compared with $3,895 per person in Canada (aOrganisation for Economic Co-operation and Development [OECD] 2009a).

Despite this higher spending, however, U.S. health indicators continue to lag behind those of Canada. In 2006, infant mortality was 6.7 per 1,000 live births in the United States, compared to 5.0 per 1,000 in Canada. In the same year, life expectancy at birth was 78.1 years in the United States and 80.7 years in Canada (OECD 2009a)

…Some studies stress administrative expenses; estimates suggest that U.S. administrative costs are 46% to 71% higher than Canada’s (Aaron 2003; Woolhandler, Campbell, and Himmelstein 2003). Other studies propose that higher prices paid for services are the primary driver of greater spending (Anderson et al. 2003). Pharmaceutical costs are higher for branded drugs (Danzon 1992; Graham and Robson 2000), and physicians earn more in the United States as well (Newhouse 1992). Still other studies have examined the volume and intensity of health care services received.

another study, from Princeton

http://www.princeton.edu/~ota/disk1/1994/9417/941705.PDF

Hopefully, if you have interest in this issue, you can look through these studies and come to your own conclusions. Some critics state that we won’t get better healthcare by having single payer or some other blanket coverage. I’m unclear, given the current system and it’s documented bad outcomes compared to other countries, how this is possible.

But it seems increasingly like only those who can afford healthcare get it and an increasingly large share of Americans can’t afford coverage, or get coverage and become impoverished by being taken to court to pay for services that they never could afford in the first place. By the way, both here in Jefferson County and nationwide, medical bankruptcies are on the rise. They are unheard of in all other industrialized countries.

If you are worried about this state of affairs and want to do something about it, there will be an election for Matt Ready’s seat this year.

More reports explore crowdfunding of dubious treatments – Consumer Health Digest

Disturbing news that it appears the market for dubious or outright fraudulent cures is now in friends asking friends to fund those treatments.

Two recent reports add to the literature on the use of crowdfunding platforms to support the pursuit of unproven treatments for serious health problems:

  • One research team looked at the largest crowdfunding platform (GoFundMe) and three other well-trafficked sites that permit medical crowdfunding (YouCaring, CrowdRise, and Fund Razr). The search terms they used were related to (a) homeopathy or naturopathy for cancer, (b) hyperbaric oxygen therapy (HBOT) for brain injury, (c) stem cell therapy for brain injury, and (d) spinal cord injury, and (e) long-term antibiotic therapy for “chronic Lyme disease”—all of which the researchers considered poorly supported and/or potentially dangerous. The study found that from Nov 1, 2015 through December 11, 2017, 1,059 campaigns had sought a total of $27.25 million and raised nearly $6.8 million. GoFundMe hosted 98% of the campaigns, YouCaring had 2%, and the others had none that met the researchers’ inclusion criteria. [Vox F and others. Medical crowdfunding for scientifically unsupported or potentially dangerous treatments. JAMA 320:1705-1706, 2018]
  • Another research team searched GoFundMe in June 2018 for campaigns that included the words “cancer” and variations on the word “homeopathy.” They found 220 unique campaigns with all but eight located in the United States and Canada. The campaigns, which mentioned 26 unproven interventions, requested nearly US $5.8 million and garnered pledges of more than $1.4 million. In addition to homeopathy, the most common methods were dietary changes such as juicing and organic foods (39% of campaigns). The other methods for which funding was sought by at least 10% of the campaigns were: (a) dietary supplements and herbal remedies, (b) vitamin C infusions, and (c) oxygen, ozone, and hyperbaric treatments. Unsubstantiated claims for the treatments sought were made in 29% of the campaigns. Among those seeking the treatments: (a) 38% wanted to try every available treatment and use it in addition to standard treatment; (b) 29% chose to forgo standard treatment because of fear of adverse effects or doubts about effectiveness, and (c) 31% could not pursue standard treatment for financial or medical reasons. At least 28% had died after their campaign began. [Snyder J, Caulfield T. Patients’ crowdfunding campaigns for alternative cancer treatments. Lancet Oncology. DOI:https://doi.org/10.1016/S1470-2045(18)30950-1, 2019]

Past issues of Consumer Health Digest have summarized the findings of studies of crowdfunding that involved cancer patients in the UKclaims that stem cell treatments were being offered through research studies, and claims that stem cell treatments had been proven effective.

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What A French Doctor’s Office Taught Me about Health Care – New York Times

I have found in my conversations with Americans that very few have any understanding of how bad American health care is compared to other industrialized countries. While it’s true that we have great medical professionals, the actual cost to deliver that care is much higher than other similar countries, the outcomes are much worse. Here is a ground level view of a real patient who fled America because of her inability to afford care, and what she found in France.

Taking Surprise Medical Bills to Court – NY Times

With a growing number of people being sent to collections here in Jefferson County by JHC, this article points out a very interesting issue of whether the “contract” between a patient (especially one coming into an E.R.) and the hospital is a legal and binding contract for billing purposes. Can you have a binding agreement if the client/consumer doesn’t know the price they are paying when they sign the consent agreement?

 

What if the Placebo Effect isn’t a trick? NY Times

The NY Times has a fascinating article on the latest research into the Placebo Effect. The Times does a good job of outlining the history of the Effect, including the beginning of modern science’s interest in it, with none other than Benjamin Franklin in the mix. The latest research helps paint a picture that if correct, could help us understand the interconnection between faith healing, eastern medicine, therapeutic touch, and western medicine. It also holds out the possibility of even making our drugs more effective. Read on…

 

Why Doctors Hate their Computers – New Yorker

Atul Gawande is one of the best writers today, writing on the subject of healthcare, end of life issues and modern medicine in general. You likely have heard him on NPR. Finally, he tackles the aggravation and lost promise of  electronic medical record systems (EMR).

EMRs have been viewed as a panacea by the medical community, primarily by politicians and government administrators lured by the promises of centralized control of medicine with rising costs of patient care, along with lawyers who are seeking to minimize risk of lawsuits. Add to that  hospital administrators, many of whom have never had to fill in a screen of medical data in their lives.

From the medical practitioners I’ve talked to about EMRs they are frustrated with the level of work they have had to do to keep up and the difficulty of finding useful information in the systems. Some patients have lost their lives due to EMRs, as specialized practitioners enter data that is not easily found, and when a patient is admitted to an ER room, often these instructions are lost to the ER techs. Or, to be more precise, they can’t take the time to find them in the mountains of screens. Yes, because of EMRs patients that otherwise may have lived are dead. Gawande alludes to this issue in his article.

Once, physicians could dictate and have the dictation sent to India overnight for translation. They’d have it the next morning. Or they wrote notes that were good enough and ended up in charts where they could be found quickly.

We are now in the worse of all worlds. EMRs are not automated enough to actually save practitioners time. Because of the use of EMRs, the expectations that medical providers can do the work faster and better mean that funding agencies drive providers to work faster and see more patients. A PA I know would spend two hours after seeing over 25 patients a day, before finishing the work of  filling out her EMR records. She was not reimbursed for this effort and she said it affected her home life as well. It’s a story I’m hearing from many practitioners.  At some point in the future dictation will be perfected and finding data that’s critical to patient care in an emergency will be easy to do. Until then, providers will continue to burn out and leave the system, just at a time when we need them more than ever.

We encounter, in Gawande’s article, an administrator who claims that the EMRs are not for the doctors but for the patients. While it’s true that patients use these systems a lot, (myself included) the results that most of us get are simply lab results and some easy to understand notes from our providers. That someone would think that the patient is the focus of all of this is misguided and shows a lack of understanding of systems.  The patient could just have easily have been given this information without the vast back end systems that affect every moment of provider time.  Think I’m wrong? It’s the backbone of every app you run on your smart phones. They are small and customer/consumer focused. We create these systems all the time. Requirements? Just listen to the customer. No need for thousands of hours of input meetings and lawyers.

It’s time to demand better EMR systems, focused on the needs of the providers and patients, not the hospital administrators, the lawyers, government and private insurers and the like. It can be done.

With all that said, Gawande’s article is the best thing I’ve read yet that gives a clear lay of the land of the frustration that physicians are feeling about EMRs. Take a read.

https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers/amp