By NIRAN AL-AGBA, MD
A few weeks ago, I saw a young patient who was suffering from an ear infection. It was his fourth visit in eight weeks, as the infection had proven resistant to an escalating series of antibiotics prescribed so far. It was time to bring out a heavier hitter. I prescribed Ciprofloxacin, an antibiotic rarely used in pediatrics, yet effective for some drug-resistant pediatric infections.
The patient was on the state Medicaid insurance and required a so-called prior authorization, or PA, for Ciprofloxacin. Consisting of additional paperwork that physicians are required to fill out before pharmacists can fill prescriptions for certain drugs, PAs boil down to yet another cost-cutting measure implemented by insurers to stand between patients and certain costly drugs.
The PA process usually takes from 48-72 hours, and it’s not infrequent for requests to be denied, even when the physician has demonstrated an undeniable medical need for the drug in question.
In a beautiful community on the Olympic peninsula, just north of where I live and practice, it happened again; another private clinic sold to a large medical corporation.
Peninsula Children’s Clinic was a bustling pediatric office meeting the vital complex healthcare needs of children in Port Angeles, WA for the commercially insured as well as Medicaid patients. Why were they forced to close?
A phone call with their office manager six months ago foreshadowed the outcome, “we are losing a great deal of revenue seeing Medicaid patients making it difficult to survive.
Peninsula Children’s Clinic was unable to remain financially solvent, so they were purchased, like a horse on the auction block, by the Olympic Medical Center. Their website recently posted the following:
“Peninsula Children’s Clinic is now licensed as part of Olympic Medical Center. Patients seeking care at these hospital-based clinics may receive a separate billing for a facility-fee. This fee could result in higher out-of-pocket expenses for patients.
Patients should contact their insurance company to determine their coverage for hospital-based clinic facility charges.”
Hospital-based clinics tack on “facility fee” charges, which are separate from the bill for the doctors’ services, for the use of the room in which the patient was seen. One hospital administrator told me to think of it as “room rental.”
Facility fees bring in a considerable flow of cash and have the secondary benefit of incentivizing hospitals to buy independent practices because then the hospital can charge two to five times more. Buying independent practices, like Peninsula Children’s Clinic, expands the hospitals’ market share and allows greater leverage when negotiating reimbursements.
Besides state and higher-level health care expenditures, county level HCE are useful, integral really. For example, to promote the Triple Aim (the best care for the whole population at the lowest cost) you need per capita HCE. And knowing those costs at the county level would help a lot. However, county estimates generally don’t exist. They didn’t in Washington State until a client needed cost estimates for our 39 counties. To supply those estimates I used a regression approach resulting in this model:
percaphce = +0.1*percapinc + 247*pctage65 + 0.71*percapmedaid + 10.5*pctrural – 1349
Washington State Context
Before discussing model rationale and county HCE estimation, here’s some context about Washington State and its counties. You might view Washington as a microcosm of the nation. It has mountains, forests, deserts, rivers and lakes, vast rural areas, major cities, diverse populations and industries, and a varied climate. It is distinguished by active volcanoes and a coastal border. There is a wide range of political, social and economic clusters. In 2010 King County, where Seattle is located, median annual household income was about $67 thousand (the U.S. median was roughly $50 thousand) yet there are state counties where one in three children live in poverty. The total population is approximately 7 million with half of those people living in just three of the 39 counties.1 At the other end about a third of the counties have populations of 30 thousand or less.
An Aside about Seattle Weather
You may have been told that it rains all the time in Seattle. I live in Seattle and can tell you that’s a myth. Seattle’s average annual rainfall is less than New York City’s. However, during a good part of the non-summer months Seattle, and Puget Sound generally, is grey and cloudy. I once heard a story about the original settlers who landed in November, 1851, at Alki near present-day Seattle. The story is they were there for months before the weather finally cleared and they saw Mt. Rainier for the first time. I don’t know if that story is historically true, but as a Seattleite it’s believable. Regardless, Seattle is a summer paradise. Seattle summers, like most of Puget Sound, are characterized by pleasant sunny days, cool nights and no mosquitoes.
Background for the County HCE Estimates
Last year Empire Health Foundation of Spokane, Washington, asked me to estimate HCE for the 39 counties in the state. The purpose was for an upcoming meeting of policy types such as county commissioners, members of various health organizations, and other stake holders. A theme would be Donald Berwick’s Triple Aim, so cost estimates were wanted for benchmarks and context. The CMS2 Office of the Actuary had recently developed state HCE.3 If I could build a reasonable regression model on state-level data to predict state HCE, and there were similar variables at the county level, I could use the state model to estimate county HCE. That’s the approach I took. A caveat is my understanding was that acceptance—believability and reasonableness of the estimates to a lay audience—were as important as accuracy.
Next Tuesday, those of us registered in Massachusetts will have the opportunity to vote on “Question 2″ – prescribing medication to end life, otherwise known as physician-assisted suicide.
As described by the state secretary, “This proposed law would allow a physician licensed in Massachusetts to prescribe medication, at a terminally ill patient’s request, to end that patient’s life. To qualify, a patient would have to be an adult resident who (1) is medically determined to be mentally capable of making and communicating health care decisions; (2) has been diagnosed by attending and consulting physicians as having an incurable, irreversible disease that will, within reasonable medical judgment, cause death within six months; and (3) voluntarily expresses a wish to die and has made an informed decision.”
There are, of course, a number of other safeguards built in, such as the need to make the request twice, separated by 15 days, in the presence of witnesses. However, there could probably be stronger safeguards to protect individuals who are experiencing depression and anxiety, and might have preferable alternatives to physician-assisted death.
“I will give no deadly medicine to any one if asked, nor suggest any such counsel.” This is an excerpt from The Hippocratic Oath – the oath that guides my practice as a physician. On the November ballot, the Massachusetts Question 2 about physician assisted suicide, runs contrary to the foundation of medical practice. Since the 5th century BC when Hippocrates crafted the oath, the notion of Physician Assisted Suicide (PAS) has been debated in Western Society and repeatedly rejected as a violation of civilized behavior.
If adopted, MA Question 2 would legalize PAS for terminally ill patients who have fewer than six months to live. The assumptions underlying this question are erroneous. In 27 years as a primary care physician, I have never told a patient how long he or she has to live. An individual lifespan is scientifically impossible to predict with exactness. Time and time again, standards in medical literature that project survival for particular diagnoses are wrong. Today in my practice, I have numerous vibrant patients who have long outlived calculated life spans. This is not only for people with cancer, but diseases like multiple sclerosis, chronic obstructive pulmonary disease, kidney failure and heart failure. I never tell my patients how long they have to live. Why? Because the best prediction is based on old literature and past practice. New therapies combined with preventive and behavioral medicine change the true experience of each disease.
What motivates some people to elect PAS? Those who support Question 2 typically cite the patient’s right to self-determination and desire to avoid pain. But, the little we know from pre-death interviews in states such as Oregon, Montana and Washington shows otherwise. Some patients claim that it is their inability to do what they want to do that motivates their desire for death. Not wanting to burden loved ones can also motivate the choice to elect suicide. For my work as a physician, part of the job is helping patients and families to adjust to new circumstances. People who fear losing control of basic bodily functions can grow to realize that their humanity is about so much more than those acts. Despite new limitations, they can still fulfill significant roles in their communities and families. Furthermore, clinical depression is present in at least 25 percent of people with chronic illness. Depressed people think about suicide. Depression, however, is treatable. Question 2 does not mandate that the patient submit to evaluation and therapy for depression. Furthermore alleviating pain and suffering is the objective of all doctors. Some even specialize in hospice and palliative care.