Category: Uncategorized

Hidden Medication Costs

Jul 5, 2011• 19

By ANONYMOUS

Always covered by an employer health plan, I had never given a thought to prescription costs – my medications had been covered by moderate copays. This changed when I retired and enrolled in Medicare (and a Medicare Part D plan).

Just prior to retirement, my eyes suddenly began tear and swell so much that it impacted my vision. The eye doctor diagnosed an allergic reaction and prescribed prednisone drops to reduce the swelling and antihistamine drops to combat the reaction. The antihistamine drops required pre-approval by my employer’s PBM, which was granted. Per my employer plan I paid a relatively small copay for each prescription.

Three weeks later, on a follow-up visit, the doctor recommended that I continue the antihistamine drops for the duration of the allergy season. But I was running out and had to refill the prescription. Now I was on Medicare so I checked the cost of the drops on the website of my Part D provider. It was $279. Could this be?? Oh indeed it could — and I had a high deductible and would have to pay all of it!! Of course, if I continued to need the drops, the plan would eventually assume more of the expense – but even then the cost would be high – to the plan, even though not as much would come from my own pocket.Continue reading…

Bishops lack dignity

Jul 4, 2011

By Harris Meyer

The U.S. Conference of Catholic Bishops’ policy on physician-assisted suicide approved June 16 is the latest move by Roman Catholic leaders to intervene in Americans’ personal health care decisions.

The eight-page policy, which the bishops passed 191-1 at their annual spring meeting in Bellevue, Wa., is full of inaccurate and misleading statements about the Death with Dignity laws in Washington and Oregon and the policy positions of the laws’ supporters. It ignores 14 years of experience in Oregon and two years in Washington. The head of Compassion & Choices, the main group supporting those laws, rightly criticized the policy statement as “full of reckless, unsubstantiated accusations.”

The bishops’ statement warns that the voter-approved Death with Dignity laws — which allow terminally ill, mentally competent adult patients to receive medications from their doctor to end their lives – essentially legalize murder. And it makes the stunning claim that U.S. leaders of the Death with Dignity movement advocate ending the lives of people who have not sought help in dying.

“A society that devalues some people’s lives, by hastening and facilitating their deaths, will ultimately lose respect for their other rights and freedoms,” the bishops said. “Taking life in the name of compassion also invites a slippery slope toward ending the lives of people with non-terminal conditions.”

The new policy, “To Live Each Day with Dignity,” is the U.S. church’s first official policy on aid-in-dying, which also is legal in Montana under a 2009 Montana Supreme Court ruling. The policy follows increasingly aggressive efforts by the bishops to require Catholic health care facilities and providers to insert and maintain feeding and hydration tubes in terminally ill patients — even those who have written advance directives stating they don’t want them.

The bishops also have cracked down on Catholic hospitals that performed tube-tying operations for women who are not going to have more babies. Last year, a bishop expelled St. Charles Medical Center in Bend, Ore., a century-old hospital founded by nuns, from his diocese for refusing to stop performing tubal ligations. These policies matter because the bishops oversee more than 600 Catholic hospitals and the hundreds of Catholic nursing homes, assisted living centers, and hospices.Continue reading…

The HIT Hit: PPACA’s Health Insurance Tax

Jul 3, 2011• 3

By ROBERT F. GRABOYES

The 2010 health care law, the Patient Protection and Affordable Care Act (PPACA), hits small business with a barrage of inequities. Among the most egregious is the health insurance tax (HIT) launched by the law’s Section 9010. Ostensibly a tax on insurers, its real effect will be hundreds of billions of dollars of taxation on people who purchase coverage in the fully-insured market – mostly small business employers and employees and the self-employed. These are the people who usually generate around two-thirds of America’s new jobs.

In contrast, the HIT bypasses those who have coverage through self-insured plans – mostly big business, labor unions, and governments. Like PPACA’s essential health benefits and longstanding state benefit mandates, the HIT puts an anchor around the neck of small business while leaving larger organizations free to swim unburdened. And the anchor is a heavy one.

Over the first decade, the HIT will hit the fully-insured market with an estimated $87.4 billion tab, but that figure greatly understates the long-run financial impact. The tax is not implemented until the fourth year of the decade (2014) and is only fully implemented in 2018. The tax rises from $8 billion in 2014 to $14.3 billion in 2018 and in later years, even higher according to a complex (and at this point opaque) index, discussed below.

To put this in perspective, that $14.3 billion equals around 15 percent of the total small business expenditures on employee benefits in 2007. According to IRS data, proprietorships, partnerships, and corporations with up to $10 million in annual receipts deducted $96.8 billion that year for Employee Benefit Programs. An extra 15 percent or so constitutes an enormous blow to the ability of small businesses to compete against larger entities.

The HIT’s full magnitude will only become apparent in the second decade (2021-2030), when businesses and consumers experience 10 years of a premium-indexed, fully-implemented HIT. The second-decade cost is difficult to forecast, but may exceed $200 billion or even $300 billion. It all depends on how rapidly the law’s arcane index lifts the HIT beyond its $14.3 billion base in later years. There are two major sources of uncertainty in that index.Continue reading…

Never Say Never (Events)

Jul 2, 2011• 4

By BOB WACHTER

Earlier this month, the National Quality Forum released its revised list of “Serious Reportable Events in Healthcare, 2011,” with four new events added to the list. While the NQF no longer refers to this list as “Never Events,” it doesn’t really matter, since everyone else does. And this shorthand has helped make this list, which will soon mark its tenth anniversary, a dominant force in the patient safety field.

The NQF was founded in 1999 at the recommendation of Al Gore’s Presidential Advisory Commission on healthcare quality. For its founding chair, the organization selected Ken Kizer, a no-nonsense, seasoned physician-administrator who had just done a spectacular job of transforming the VA system from the subject of scathing articles and movies into a model of high-quality healthcare, a veritable star in patient safety galaxy.

Kizer’s original charge at NQF was to develop a Good Housekeeping seal-equivalent for quality measures (“NQF-endorsed measures”). But soon after he arrived, Kizer added another item to the NQF’s wish list: the creation of a list of medical errors and harm that might ultimately be the subject of a nationwide state-based reporting system. As Kizer said at the time,

This is intended to be a list of things that just should not happen in health care today. For example, operating on the wrong body part [or] a mother dying during childbirth. That’s such a rare event today that it’s generally viewed as something that just shouldn’t happen. Now, there’s probably going to be an occasion now and then when it happens and everything was done right, but it’s so infrequent that it means you have to investigate it every time it occurs. So “never” has quotes around it in this case. Now, wrong-site surgery is a different story—that should never happen. There’s no way that you should take off the right leg when you’re supposed to do the left one. So in this case, never really means never.

Unsurprisingly, the items on the list quickly became known as “Never Events.” Twenty-seven of them were announced in 2002, and the list was expanded and revised four years later. (This primer, written by my colleague Sumant Ranji for our patient safety website, AHRQ Patient Safety Network, is the best description of the list and some of its policy implications.)Continue reading…

Health Care Power Tools for Consumers

Jun 30, 2011• 2

By MARKUS FROMHERZ

Most people are getting their health insurance through their employer. That has been changing slowly, but with healthcare reform, many more people will be left to select their own plans without the pre-selection and help from their employer. What used to be a choice among 3-5 plans is soon to become a selection from dozens of health insurance companies each offering a dozen plans to choose from. And selecting an insurance plan is not like getting car insurance; family makeup, prior health issues, future healthcare needs, and affordability – they all matter. In other words, it’s very personal.

As in other insurance industries, there will be a number of options to help consumers, such as agents and brokers. Cost is one of the most important criteria, but the problem of predicting the impact of plan choices on out-of-pocket costs is much harder, since selecting a plan is such a personal choice. Our needs and therefore expenses also change over time, as we go through different life stages.

As in many industries, there is a lot of data one can harness to help with these decisions. One benefit we see emerging is the availability of personal power tools (similar to financial planning tools) that allow for detailed modeling of an individual or family’s situation. These tools predict likely health care needs and allow one to compare the detailed expenses given different insurance plans. Starting a family? Entering your fifties, with its slew of clinically advised exams? Dealing with the ups and downs of a chronic condition? Those factors can all be taken into account to provide detailed plan options and price comparisons to help choose the optimal health plan.

The Most Commonsensical And Hopeless Reform Idea Ever

Jun 30, 2011• 13

By MICHAEL MILLENSON

The way that Michael Long and Sandeep Green Vaswami want to change hospital care may well rank as both the most commonsensical and most hopeless health reform proposal ever. The real question is whether they can show the same tenacity in pursuing their goal as an elderly Jewish woman from Munster, Ind., who has invested nearly two decades in a similar effort.

What the two men are advocating is simple: hospitals should offer the same level of professional staffing and patient care on weekends as during the rest of the week. They should do this, the two men write in the Health Affairs blog, because trying to cram seven days of care into five leads to a cascade of problems that harm and even kill patients. It also costs a lot of money.

That’s the commonsense part. The hopeless part is that Long and Vaswami, both affiliated with the Institute for Healthcare Optimization, seem to believe that doctors, nurses and hospital execs will read their article and then spontaneously volunteer to work the weekend shift.

American hospitals are complex entities, but at heart they remain the doctor’s workshop, dependent upon the goodwill of physicians who admit and care for patients. Maintaining that goodwill requires treading carefully. For instance, telling a neurosurgeon, “You’re working Wednesday through Sunday this week” would rank high on the list of what a friend of mine calls a “career-limiting event.”

Long and Vaswami are aware they’re tampering with long-standing tradition, but as justification they offer a disturbing catalog of the effect of care controlled by the calendar.

To begin with, bunching scheduled admissions in midweek often overwhelms the staff, leading to “significant” increased risk of patient death or admission to the Intensive Care Unit. Filled beds force emergency rooms to discharge patients to “inappropriate care locations,” with the hospital relying on specialized teams to ride to the rescue “when patients deteriorate because of inadequate care.” At the same time, “medically appropriate transfers … may also be delayed or rejected.”

And that’s when hospitals are operating normally. Patients admitted over the weekend face an increased risk “because critical diagnostic or therapeutic modalities are not available,” while patients staying over the weekend experience “delays at best and deterioration in clinical condition at worst.”

The PHR School of Hard Knocks

Jun 29, 2011• 38

By MISSY KRASNER

By now everyone has seen the announcement last Friday that Google Health is being formally retired. Thanks to the several years I worked on Google Health, my phone was ringing off the hook Friday afternoon and emails were pouring in all weekend long.

Let me first start by saying that I am not going to comment on any specific company details. I think the broader question to ask anybody that has worked in health IT and consumer tech for the past 15 years is what have you learned from this experience. Or how about, is there a market for PHRs in the future? Given that I started looking at PHRs back in 2005 while I was working for David Brailer at the Office of the National Coordinator (ONC), here is what I would say I have learned:

1. Healthcare is paternalistic – consumers are blind to costs and data.
Let’s face it. Our current healthcare system is set up to be extremely paternalistic. Health plans, hospitals, and physician practices steward patient data on the patient’s behalf. Patients don’t know the costs of a simple outpatient procedure or inpatient stay. Because health care is not a true market-based commodity in this country, patients end up being lousy healthcare consumers. Unlike the banking, airline, and retail industries, this makes it much harder to convince a broad array of consumers to engage in a service that helps them organize, manage, and share their medical records online. The value proposition becomes even harder when consumers are not rewarded with industry aligned incentives for taking the time to manage their personal health data (e.g., discount on health insurance premiums, lower co-pays at doctor office visits, or something beyond a measly $50.00 benefit credit for signing up for a PHR at their place of employment).

Unheard Voices in the Emergency Room

Jun 29, 2011• 6

By NORA O’BRIEN-SURIC

Not too long ago I had the unique experience of needing the services of the emergency room of a major teaching hospital in New York City. (Don’t worry, I’m fine now.) During my thirty-four hours in the ER, I had the opportunity to observe the other patients crowded around on gurneys, in wheelchairs, or in chairs with canes and walkers resting nearby. The ER was overflowing (I was told later that their capacity is 35 and there were about 100 people waiting), and most of the people were older than 60. The doctors and nurses were incredibly busy and were doing their best to provide attention and comfort to everyone. Yet medical care wasn’t all some patients needed. The older people waiting alone needed an advocate. They needed someone to help them understand what the nurses and doctors were telling them and doing to them, someone to reassure them during the long wait to be seen by a doctor and/or to be admitted onto a hospital floor. More than several people were obviously very confused and agitated. They, like me, were waiting for hours, even days until they received care or were admitted to a room. But unlike me, they did not have family there to support them (my fiancé was with me), and they were not able to, or at least did not, verbalize their discomfort and need for food, water, or the bathroom.

After two nights, I was finally admitted to a cardiac surgery floor. I didn’t need cardiac surgery; it was just the only bed available. Every person who entered my room, from aides to meal servers, physical therapists, nurses, and doctors, was surprised to see someone under 60 on their floor. Each of them asked me, “What are you doing here?” I realized that they are so used to working with older people that someone obviously younger than 60 seemed out of place.

This whole episode got me thinking about the training hospital personnel receive in geriatrics. If everyone on the cardiac care unit expected to see a patient older than 60, and if most people in the ER were over 60, then shouldn’t all personnel receive training in geriatrics and care of the elderly? Yes, but this isn’t likely. Most medical schools do not have a geriatric curriculum or rotation, which is why the John A. Hartford Foundation provides grants to schools of medicine, nursing, and social work to help in developing more leaders and curriculum in geriatric education.

Interview with Alexandra Drane: Eliza loads for bear….

Jun 28, 2011• 2

By MATTHEW HOLT

Eliza is one of the more interesting Health 2.0 companies. It’s best known for making millions of automated (and very cute) phone calls on behalf of health insurers, employers and PBMs, but really they have a wealth of collected data that is received from and delivered to consumers over multiple channels to engage them in their health. We’ve featured them at Health 2.0 several times (and FD they’ve been a sponsor), one appearance resulted in them acquiring a fellow panel member (Sprigley) to enhance their web solutions. Like many companies that get to a decent size (somewhere between $25m & $50m in revenues) they faced the choice of getting bought or continuing on with organic growth–which they’ve done so far. Today they’ve made a third choice and taken on private equity money from Parthenon Capital.

What are they going to do with the cash? After all you might guess that there are other tools and services that health plans might be interested in. I interviewed Eliza’s President Alexandra Drane today to find out.

A Field of Dreams?

Jun 28, 2011

By VINCE KURAITIS

A study released last week by the Massachusetts Attorney Generalcontains surprising data to challenge two commonly held ACO (accountable care organization) ”Field of Dreams” assumptions. These assumptions relate to patient ”leakage” — out-of-network patient care and referrals.

1) Hospital administrators assume that tighter physician-hospital integration (e.g., through employment of physicians) will result in ”captive referrals” by physicians back to the mother-ship hospital.

2) Medicare administrators are assuming that Medicare Shared Savings ACOs will be able to coordinate patient care even without limitations on patients’ choice to go to providers outside of the ACO provider network.

Here’s the data that challenges the validity of BOTH of these assumptions:

Particularly for provider systems where hospitals and physicians are jointly at risk for the quality and cost of patients’ care, and have worked together to coordinate and improve care, we would expect to see physicians referring to their partner hospital more often. However, for the two physician-hospital provider systems in Massachusetts with the most years of experience managing referrals for HMO/POS patients under a global payment, one health insurer’s 2009 referral data shows that only 35-45% of adult inpatient care, as measured by revenue, goes to the partner hospital. That percentage can be even lower for providers with little to no experience managing where their patients receive specialist/hospital care, or under plan designs that do not require referrals. [emphasis added]

Continue reading…