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Tag: Healthcare

Physician, Heal Thyself!

Physician, Heal Thyself!

No, this isn’t about drugs or addiction or ODing, or any of those things. It is about frustration, though. Frustration with the medical profession. Frustration in trying to create sense where sense seems not to exist. Frustration that can lead to scenes such as in the image. Fall down on the floor, tear out your hair, rend your garments sort of frustration.

To be perfectly clear, this posting is based on a personal incident – drama is more like it – playing out now with certain elements of the medical profession. To protect both the innocent and the guilty, I’m not going to name any names. Now. But if I continue to be stymied, that decision might change. Watch this space.

If you’ve read my piece on The Biggest Shell Game in the World, which you should before reading on here, you know how I feel about the so-called “healthcare system” we have in this country. You’ll also see I elaborated on some specific actions that might help ease the growth in the cost of healthcare. That posting focuses on the macro dynamic of the system. This posting focuses on the micro dynamic, the one on the doctor level.

It’s no longer a laughing matter – it never was a joke – to say that much of the medical profession is still anchored, not just in the last century, but maybe even the one before it.

When I lived in Montana some dozen years ago, my physician – an author of the reputed Helena Heart Study, so no slouch – presented himself as advanced because he took his notes on a laptop. Why that should have been considered advanced when small computers had been in fairly wide business use for a quarter century already is a good question to ask, if you’re inclined to ask questions. Now, all the doctors I go to use laptops for their notetaking and recordkeeping. Of course, it is, at last count, 2017.

The one thing my Montana doctor did that really stood out was to communicate by email. Quick, easy, asynchronous. Email. One would think this also would be pretty standard now. That’s what I thought. I mean, I run a global business and communicate with clients all over the world at close to 100% by email. So picture my surprise to be out of Montana and in a southeastern state that also shall remain nameless (besides, I often reverse the “d” and the “i” in the name, which is embarrassing) and to find that email does not play a role in typical doctor-patient communication.

Does one even have to wonder why calling a doctor’s office often leads to more frustration, lengthy stays on hold listening to dreadful “hold” music and self-serving promotions, being asked, finally when you get past the official hold, “Can you hold, please?” (Okay, at that I’m tempted to fire back, what are my options here?)

Again, how can almost any organization in 2017 function without email? It’s not only a fast and easy means of communication, but it also can be used as a system of sending health information to patients and even, if one is allowed a bit of crassness, as a marketing device. But, no, this seems to be beyond the understanding of most doctors.

Then there are those doctors’ portals. Potentially great idea, completely mutilated, misused, and just plain not used, in execution and practice. First, they’re all clunky in that clunky way that special-purpose software (like used in lawyer and, yes, doctor offices) always is. I don’t know, maybe it’s me, but I’ve had a litany of problems with the portals of several doctors and healthcare groups. Sometimes I’d have to enter a new password each time I signed in. Sometimes things I’d want to see, like reports, are there. Sometimes not. One portal doesn’t even tell me my next appointment, which would seem pretty basic. I’ve yet to be able to get a prescription refill put through based on a request posted on a portal site. And, perhaps the biggest issue I’ve encountered, often doctors’ front offices don’t mind the sites, so sending a message to the office through the portal is like throwing a quarter down a deep well. “Pathetic” is too kind a word.

Okay, despite all that, that’s not my biggest problem nor the most immediate. Oh, no. I have a far bigger gripe, which we’ll get to now. The one that concerns the Health Insurance Portabliity and Accountabillity Act – HIPAA – and how doctors not only seem not to know much about its requirements but, worse, seem to think it exists to protect them and not the patient. Which is wrong.

I had one doctor earnestly tell me that there is a $50,000 fine attached to a single HIPAA violation. Well, he was part right. Fines can range from $100 to $50,000, or $1.5 million maximum per year for ongoing violations. What puzzled me then, and which irks me now, is that the implication was that the doctor had to protect himself against violations and resultant hefty fines. The point that was completely missed, even inverted, is that denying a patient access to his or her records in whatever way the patient deems suitable seems like a more sure route to a violation than just providing what it is the patient requests, in the form or via the means requested by the patient.

Now that doctor’s office will fax me things like test results. Some will even (horror!) email them. And then there are others, like another one of my doctors, who refuses to provide records or results in any form other than by mail, or picking it up in person. Never mind the inconvenience of the latter choice, I would defy anyone to show me how snail mail is any less prone to pilferage or misdelivery than a fax or email. I even maintain an encrypted email account for highly sensitive information. But all that is irrelevant. The Department of Health and Human Services (HHS), which oversees application of HIPAA, is clear on the subject: A provider should email, fax, or accommodate alternative delivery means as requested by the patient. Look it up. It’s right there, explicitly spelled out by HHS, in the department’s HIPAA FAQs.

That’s really the key issue: Patients have a right to see and receive their own records and results, and HIPAA exists to protect them, not the doctor or other provider. So if a patient wants his or her bloody records emailed or faxed to them, HHS says the provider should accommodate that request. But you’d never know that from the patchwork of restrictions, most of which make little to no sense anyway, that one encounters when requesting one’s records.

Of course, all this assumes that a patient has signed a statement authorizing release of information to the patient and whatever third-party designees, if any, that the patient might include in the release. Now here is a suggestion – a strong one: Why not include a check-off box with a line where the patient authorizes positively (by checking the box) transmittal of records via email or fax? Easy-peasy, and takes care of any misunderstanding. And while you’re at it, how about another line with a check-off box authorizing the same thing for any third-party designees? Two lines, and you can sleep better at night knowing the patient has asked for this and HHS says you should give it to them. And it’s in writing, no less.

All this leads to the source of my current distemperous mood toward doctors and things medical. It’s been four weeks – not hours, not days, not business days, but weeks – that I have been requesting the results of an MRI from a certain specialist. I requested that the doctor or his nurse-practitioner call me before I left on an extended trip so I could at least have a sense of what the MRI revealed. I was told, well, he probably won’t call you. He likes to do things in person.

Well, I like to do things in person, too, when that works. But in this case, it wasn’t even possible to get an appointment in less than a month or more. And I was clear that I was leaving the state and needed the information before I went.

Ha. Fat chance. Four weeks have gone by, I’ve lost count of the number of times I’ve called this doctor’s office, had my primary care physician’s office call him, even the insurance company called the office when I filed a grievance with them over this. And still I can’t get either the doctor or the nurse-practitioner (which would be fine) to speak with me and discuss the test results, much less actually get those results. Now if ever there is a HIPAA violation, it would seem this is it. It will take a formal complaint to HHS, but that is imminent. I now even have my attorney on the case.

The doctor might have his procedures, but there are two parties to the transaction, the other being the patient, and in this case this patient has different procedures. And HIPAA is on his side.

It’s bad enough having to deal with doctors and tests and health issues without having to be put under further stress and duress by providers and offices that just throw more roadblocks and obstacles in the patient’s path.

All this seems very 19th Century to me. Doctors hold themselves up as miniature deities and patients are just supposed to accept whatever inconveniences, incompetence, or affronts that the doctor and doctor’s minions subject them to. And there are others besides those discussed here. Let’s just save my rant on the prescription system for some other time, ‘kay?

If you’ve encountered any of these issues in dealing with doctors, I invite you to tell everyone about it in the comments. And if you have a different and more positive story to tell, by all means post that, too, in the comments. And if you question the premises on which this piece is based, well, fire away with that, too.

Meanwhile, I’m going to fax this piece off to a few doctors I know (I have to fax them since I don’t have their email addresses) and maybe shake a few trees. Or else things will just go on as they always do. And watch this space if I decide it’s necessary to start naming names.

Physician, heal thyself!

The Biggest Shell Game in the World

The Biggest Shell Game in the World

Healthcare has been all in the news these days with the U.S. Senate considering its version of whatever is to replace Obamacare. So it seems fitting to take a look at the intractable morass that is the American healthcare system. Which, as I see it, is better seen as the biggest shell game in the world, and as long as it is, resolving the issues surrounding it are likely to remain intractable.

You probably know what a shell game is. That’s the scam that sometimes crops up on city streets where the scammer, also known as a tosser, places a small ball or pea under one of three shells or cups, and then moves the shells or cups around on the table. The marks – people betting they can beat the tosser – have to guess which shell or cup contains the ball or pea. But of course the game is rigged, often with the ball or pea surreptitiously removed from the table altogether, so the marks lose their money. And that, of course, is the scammer’s objective. They’re not in the game for their health.

Now I don’t claim to be an expert on our healthcare system, but I’ve engaged with it enough and watched some of its inner machinations over the years to see how it resembles a classic shell game. You’ve probably seen it, too. How about those band aids that show up on the hospital bill for $8 (or whatever the current going rate is – a hospital in New Jersey charged a patient $8,200 for a band aid on a cut finger, plus $800 for a tetanus shot and a few other basic things). Or those $15 Tylenols, which can add into the hundreds of dollars during a typical hospital stay? And what about those nameless “specialists” who rush up to patients as they’re heading into the operating room so they touch the patient’s arm, crack a joke or two, and then send a sizable bill for hundreds or thousands of dollars for their “services.” And then there are those “itemized” hospital bills that can run pages long. Ever try checking one of those for “errors”?

I’ve done some research, too. For instance, the average cost of an MRI in the U.S. is $2,611. But price around to various hospitals and health centers, and you’ll find costs ranging from about $1,000 up to twice the national average (that’s what I found). Doing some number crunching, I determined the actual cost, depending on the rate of utilization and maintenance costs for any given installation, should be in the $250 – $500 range, which is close to what an MRI costs in Canada when paid for privately or with private insurance. The national average cost of a CT scan is $1,200, but the actual cost can range from $250 to $4,600. And during the discussion going on in the past week, I heard one person say they actually paid $9,000 for a CT scan. And that was after pricing around and driving something like 60 or 80 miles to get to it. What a deal!

The shell game doesn’t end there. A three-day hospital stay costs, on average, $30,000, and the average emergency-room visit runs $1,233. But I personally know of a case where someone was billed $6,300 for a four-hour visit where she spent most of that time sitting in a room by herself with a monitor draped around her neck. And that was 10 years ago. Yet, there are community health centers where one can be seen and treated for $20, or less. I’ve even had minor surgery at one of these centers, performed by a doctor, for $20. I can’t imagine what the same procedure would have cost had I gone to a hospital or private clinic.

Costs can also vary enormously, depending on whether one has insurance, the kind and terms of the insurance, is on Medicaid, pays cash, pays on time, or doesn’t pay at all. All these factors, which go to the heart of how our healthcare system is run and costs are assigned, guarantee these results. And the problems go beyond healthcare, reaching down into our educational system, where the outrageous costs of medical school cause medical students to run up enormous student-loan debt, often of a quarter of a million dollars and more. While eventually many of these medical graduates will earn significant salaries, the salaries for recent graduates and residents are a far cry from generous, falling in the range of $51,000 to $66,000 per year, before taxes, for an 80-hour work week. Taking that $51,000 figure, a new doctor working 48 weeks a year is averaging $13.28 an hour, less than many retail employees.

While the House, the Senate, the Administration, the Congressional Budget Office, and commentators on all sides of the current healthcare debate parse the finer points of the various bills and proposals on the table, the bigger issues seem to be lost in the cacophony. I can’t help but think that the special interests, the insurance companies and industry lobbyists, are given more consideration than the lowly patient. And whenever one hears the word “comprehensive,” it’s time to run for the exits since the fix is almost certainly in.

Perhaps the biggest issue of all concerns the near-complete divorce of healthcare costs from market forces. Healthcare providers, whether hospitals, private doctors, diagnostic labs, or clinics, are essentially businesses and, in aggregate, they form an enormous industry. In what other business or industry are costs not known, not set out in formal tariffs or schedules, and not subject to public scrutiny? Even airlines, for all their multitudinous fares and conditions, are forced to lay out their tariffs, and before customers buy tickets they know exactly how much they will cost.

While government regulates – to various degrees of effectiveness – the nature and quality of healthcare and medical practice, it does little to promote market forces. It is my contention that any healthcare provider should be required to post the rates or costs for any given procedure, action, or item. Even if there are different tariffs for different methods of payment, the consumer will at least have something to go on in deciding how and where to spend his or her healthcare dollar. And this will inevitably lead to price competition between providers and a brake on upwardly spiraling costs.

This divorce of healthcare costs from market forces also stems from how many Americans obtain their insurance, which is paid for or subsidized by their employers. There is no incentive for many Americans to price around (even if they could, given the price morass) and obtain the best bang for their buck. “Oh, the insurance will cover it,” is often the refrain. Now some insurance policies and plans do enforce certain limits on what providers within the plan can charge or be reimbursed for, and that helps control costs to some degree, but there is often a downside to the insured.

One downside is a limitation of choice, but the other side is the cost of administering these various insurance plans, approvals, billing, and so forth. In the U.S., 25% of healthcare spending goes to administrative costs. A full quarter of what we spend on healthcare. In our neighbor to the north, Canada, the administrative burden is half that – 12% – and most other countries have far lower administrative burdens than ours. Perhaps the only country that comes close to our burden is The Netherlands, with a 20% administrative burden.

While the U.S. often is criticized for lack of public support for healthcare, in fact our governments, federal, state, and local, spend more on healthcare than that spent by the governments of most other OECD countries. Overall per capita spending on healthcare puts the U.S. at the top of a list of 13 high-income countries – more than $9,000 per year, nearly three times the OECD average and more than double the next biggest spender, France – it is also near the top of the list of countries in public per capita spending on healthcare. Only Norway and The Netherlands spend more public funds on healthcare than the U.S., while Switzerland and Sweden rank just below the U.S. In fact, per capita public spending on healthcare in the U.S. is a third higher than in Canada.

What this indicates is that the U.S. does – and doesn’t – have a spending problem when it comes to healthcare. We’re certainly spending much more than what other countries are spending on healthcare overall, and even our public spending on healthcare exceeds what most other countries spend. But we’re not getting the results of some other countries in terms of total coverage of the population. And while it’s true that U.S. health results, measured in terms of life expectancy, infant mortality, and some other indicators, are below those of other countries even with our high outlays, there are mitigating factors influencing those results that are not as present in other countries.

By most standards, the quality of care in the U.S. is good, even excellent. And compared with other countries – including, again, our neighbor to the north – waiting times to see doctors, referrals to specialists, and to receive diagnostics and operations are significantly lower overall, though these can vary significantly from one area or region to another. While gaining access to the healthcare system can pose a challenge to many Americans, once that access is gained things tend to work pretty well, and better than in some countries with so-called universal coverage.

So where do we go from here? Okay, I have some ideas. These are my proposals, and while I can’t cite empirical data supporting their efficacy, I think they merit serious consideration and may allow us to gain control over this nationwide shell game:

● Introducing market forces by requiring all healthcare providers to develop, publicly post, and operate under specific costs and tariffs;

● Instituting public oversight of costs and charges of healthcare providers, including hospitals, clinics, private practitioners, and diagnostic labs, and allowing private suits and administrative processes challenging unreasonable or unsupportable costs;

● Encouraging individual initiative by expanding health savings plans where people can set aside a portion of their income to be applied to healthcare costs, and allowing them to roll over funds not expended from year-to-year;

● Encouraging employers to offer their employees allowances which employees can use to shop around and acquire their own insurance plans (often at lower cost than group policies), and further allowing tax deductions to cover insurance premiums and other healthcare costs;

● Allowing insurers to offer a variety of plans covering a range of services, and not requiring services that a given insured determines he or she is unlikely to need, such as mental health services or pregnancy coverage;

● Not restricting insurers to certain states but allowing them to operate across state lines;

● Taking steps to reduce the administrative burden and associated costs;

● Directing greater public funding toward community health centers and using these centers to provide health care, on sliding cost scales, especially to lower income and uninsured parties;

● Encouraging formation of healthcare cooperatives, both private and public, and allowing both insured and uninsured people to join them;

● Developing public policies and pressure to reduce the cost of medical education;

● Allowing write-offs of most or all debt or costs incurred by medical students in return for a certain period of service, at reduced salary levels, in rural and other under-served areas (as is done in some countries);

● Developing policies increasing the numbers of medical, nursing, and allied health students to address national shortages in these fields, applying the law of supply and demand to reduce costs and improve access;

● Applying both public and private initiatives to controlling the cost of pharmaceuticals;

● Instituting reasonable limits on medical malpractice claims to help contain the cost of malpractice insurance.

Again, I don’t claim to be an expert on healthcare, and I don’t claim to have all the answers. But I think these steps could go far toward expanding access to healthcare, controlling costs, and getting the runaway train of American healthcare back under control, without further straining public budgets. And it’s time we put a stop to the shell game inherent to the American healthcare system.

I welcome comments, criticisms, and other suggestions to what is said and proposed here. And please share this posting with your social networks and others who might have interest in the topic.

This piece also appears on Medium. Follow me there, and here, and if you like it please comment and share it.