When Patients are Blind-Sided by Phantom Providers

By Maggie Mahar

Regular reader, author (108 Days), and patient advocate Lisa Lindell recently sent me a story that aired on her CBS television affiliate in Houston. It’s a tale I have heard before, but what is shocking is that no one has managed to find a solution to such a patently unfair wrinkle in our health care system.” Even strongman California Governor Arnold Schwarzenegger has not been able to the break the deadlock between doctors and insurers over whether surgeons have a right to charge $2,000 to $3,000 an hour—and whether the patient should be stuck with a bill that the insurer won’t pay.

The Score: Physicians 355; Insurers 59: Blood on the Senate Floor

By Maggie Mahar

Writing on Health Care Policy and Market Place Review over the week-end, Bob Laszewski called what happened in the Senate last week : “ the most amazing turn of events I have seen in 20 years of following health care policy in Washington, DC.”

It all began Tuesday, when the House voted 355 to 59 to block a pay cut for physicians. As regular readers know, Medicare is scheduled to slash physicians’ fees tomorrow (July 1) by an average of 10.6 percent across the board. Another 5 percent cut is scheduled for January 1, 2009. Some physicians have threatened that if legislators take an axe to their fees, they will stop taking Medicare patients

The Cream of Health Care Posts

This week, over at Disease Management Care Blog Jaan Sidorov hosts Honk Wonk Review, a compendium of the best health care posts of the past two weeks. Sidorov offers a tasty buffet, with links to all of the posts.

 Just a few highlights:

At Health Access Anthony Wright  is on the news as he  rails against private insurers who explicitly factor in gender (care to guess if males pay more or less?) and a past history of a caesarian section in their health insurance pricin . (Elizabeth Edwards also weighs in on this topic here.)

On InsureBlog, H.G. Stern reviews Fed Chairman Ben Bernanke’s pessimistic economic assessment of health care. “It costs a lot. It’s going to cost more. Information tech doesn’t hold a candle to growing demand paired with . . . ever pricier treatment options. And we are all going to pay for it.”

Julie Ferguson, of Worker’s Comp Insider fame, posts about I.T. behemoth Google’s foray into the electronic medical-personal-health record with links summarizing both the benefits and the problems.

To peruse the full menu go directly to Disease Management Care Blog.

Should Progressive Reformers Talk about Reining in the Cost of Care?

“It seems that John McCain may have stolen some of the fire that Democrats traditionally wield on health issues by making cost control his top priority, rather than universal coverage.” -Rob Cunningham, “Health Affairs” May/June 2008

Last week, the bold proposal for health care reform that Dr. Ezekiel Emanuel outlines in Healthcare, Guaranteed drew high praise from the American Prospect’s Ezra Klein. As Klein described it:

Emanuel’s Guaranteed Health Care Access Plan maps out “a total transformation of the system.  It does not build on the inefficiencies of the current structure, preserving them in amber for the next generation.” 

Rather than expanding on the dysfunctional system that we have today, Emanuel, who is the director of bioethics at NIH (and brother to politician Rahm Emanuel), is calling for structural reform. This is what makes his proposal both brave and fresh.

But Emanuel’s plan isn’t just exciting; it’s practical. As usual, Klein cuts to the heart of the matter: “the big deal, he explains is cost control. In health care, cost control is everything.”

The Buck-Eye Surgeon

If you’re feeling disillusioned about medicine—and physicians—take a look at the Buck-Eye Surgeon’s musing on week-end rounds here.   

I think you’ll enjoy it.

He also takes on the sticky question of specialists who are underpaid--and who might be overpaid--by dividing doctors into two groups: (1) The "Hit and Run Bandits" and (2) The "You Operate, You Own It Crew.”

Choosing Our Battles

The idea of “comparative-effectiveness” research has become a hot topic in health care circles. Conservatives are adamantly opposed to it—as are drug-makers, device-makers and even some physicians who have become involved in designing and profiting from new tests and procedures. They don’t want to see their products and services subjected to head-to-head comparisons with the less expensive rivals that they hope to replace. After all, they know that they might lose.  As medical research shows, often, what is “newest" isn’t best.  And with billions of dollars at stake, who wants to be a loser?

But if you think that any mention of comparative-effectiveness research pushes buttons, try talking about appraising the “cost-effectiveness” of medical products and procedures—i.e. asking whether the benefit justifies the price tag. For example, is it really worth paying $100,000 for a drug that will give the patient an extra six months of life?

Often, the two ideas are confused. Indeed, those who oppose health care reform argue that any attempt to set up a Comparative-Effectiveness Institute (as presidential candidate Barack Obama, among others, has suggested) inevitably puts us on a slippery slope headed straight toward making medical decisions based on “cost-effectiveness.”   Before long, the conservatives say, Medicare will be denying treatments simply because they are too pricey. 

Yet, is it such a terrible idea to take cost into consideration?  In a recent issue of the Annals of Internal Medicine, the American College of Physicians (ACP) argues that the United States needs to invest in a national entity that would generate information on both clinical comparative-effectiveness and cost-effectiveness. According to ACP, by failing to make such information available, we undermine efforts by payers, physicians, and patients to make effective, informed choices that optimize the value they receive for their health care dollars.

In the same issue of the Annals, health care economist Gail R. Wilensky, a senior fellow at Project Hope, disagrees, arguing that it is “vitally important to keep comparative clinical effectiveness analysis and cost-effectiveness analysis separate from each other.”  If you talk about “comparative-effectiveness” and “cost-effectiveness” in one sentence, you could doom both ideas.

What's Happening in...the Netherlands?

This post was written by Maggie Mahar and Niko Karvounis

Every now and then HealthBeat takes a look at health care systems in other countries So far we’ve tackled Germany and China. Next on our list was the Netherlands, but it turns out Health Affairs beat us to the punch. In May, Wynand van de Ven and Frederik T. Schut, two professors at Erasmus University in Rotterdam, authored an excellent profile of the Dutch health care.

Why should we care how they deliver health care in a tiny country most of us will never visit? Few European health care systems have garnered the kind of attention from Americans that the Dutch system has received.—especially from folks not known for their Euro-philia, including the Bush Administration. In the fall, the White House sent a delegation to the Netherlands to learn more about the Dutch system.  The Wall Street Journal also has praised the Dutch system for accomplishing “what many in the U.S. hunger to achieve: health insurance for everyone, coupled with a tighter lid on costs.”

What could make conservatives entertain the possibility that we might learn from Europeans? Under the Health Insurance Act of 2006, the Dutch have created a system of universal coverage delivered entirely through private insurers. In this, the Dutch plan is very much like the plan Dr. Ezekiel Emanuel proposes for the U.S.  in his new book Healthcare, Guaranteed. (We wrote about Emanuel’s plan here  and here), calling it a “fresh” proposal for reform.)

Consumers Have Choices

For those Americans uncomfortable with the idea of “Big Government” delivering their health care, the Dutch model is appealing. And Americans are bound to like the idea that consumers have many choices:  according to the Commonwealth Fund, there are 14 private insurance companies in the Netherlands and several related subsidiaries. This means that individuals can shop for insurance—a process made all the easier by a Dutch government web site “where consumers can compare all insurers with respect to price, services, consumer satisfaction, and supplemental insurance, and compare hospitals on different sets of performance indicators.” Thus, much to the delight of consumer-minded health care reformers, the Netherlands has essentially institutionalized comparison shopping.

Individuals also have the option of paying extra to beef up their benefits package. Van de Ven and Schut note that the Dutch can buy “supplementary insurance for benefits that are not included in the mandatory basic insurance, such as dental care for adults, physiotherapy, eyeglasses, alternative medicine, and cosmetic surgery.” More than 90 percent of the Dutch population takes advantage of this option –which suggests that the supplementary insurance is not too expensive for the vast majority of the population.  Van de Ven and Schut tell us that “most people [purchase their supplementary insurance] from the same insurer that provides their basic coverage.”

Do We Need to Ration End-of-Life Care? There Is a Better Way (Part II)

In the days and weeks before they die, fifteen to twenty percent of terminally ill cancer patients receive “palliative chemotherapy.” Their doctors do not expect chemo to cure them. Why then, do they receive it?

In “The Role of Chemotherapy at the End of Life: When Is Enough, Enough?", Drs. Sarah Elizabeth Harrington and Thomas J. Smith explain:  “Chemotherapy for metastatic solid tumors such as lung, breast, colon, or prostate cancer rarely if ever cures patients. The indication for such chemotherapy is to improve disease-free or overall survival, relieve symptoms, and improve quality of life.”

In the article, which appeared in the most recent issue of JAMA, Harrington and Smith tell the story of Mr.L., a 56-year old businessman who is determined to fight the lung cancer that has spread to his spine and brain. Even when his oncologist recommends that it is time for Mr. L. to shift over to hospice care, Mr. L. refuses.   

“You know my husband was extremely determined to remain positive, and he never was going to give in [to the fact] that this could eventually kill him,” his wife reports proudly. “It didn't really dawn on my husband that he was going to die until he was in the hospital with pneumonia, which was two weeks before he passed away.”

Near the very end of Mr. L’s life, the hospital staff called in a palliative care specialist to help Mr. L. face the fact that he was dying and to consider his options.

Chemotherapy had helped him during the first eight months after he was diagnosed, but during the last six months of his life, as his condition deteriorated, the medical staff felt that because the cancer had spread to his brain, “he was not making informed choices and had lost opportunities to do other  important things with his remaining time while pursuing further  chemotherapies and clinical trials.”

The palliative care specialist believed that he should have been called in sooner. Arguably, Mr. L. needed an oncologist like Dr. Peter Eisenberg, who I quote in part 1 of this post: “Most oncologists don’t talk about the important stuff. They just say, ‘In six to eight months, if this doesn’t work, we’ll try Plan B…”

By contrast, Eisenberg levels with his patients: “I ask them: ‘How do you want to spend the rest of your foreshortened life? Do you want to spend it hanging out with me and my staff [going through another round of chemo]—or do you have something else that you want to do?’”

Do We Need to Ration End-of-Life Care? There Is a Better Way (Part I)

A few weeks ago, I had just come home from work when I heard a soft knock at my apartment door.  I asked “who’s there?” and could barely hear a very small voice replying. 

I opened the door and saw a tiny woman: skeletally thin, bald-- just a few tufts of dark hair standing up on a bruised skull. Her dark eyes were enormous.  After a second of shock, I recognized her as my long-time neighbor, Anne.

I don’t know her well, but by instinct, I put my arms around her and tried to hold her.

She pulled back: “Please don’t,” she said, and she began to cry.  “I’m so very sick. I hurt everywhere. It hurts when you touch me. I even screamed at Alan on the street,” she said referring to her husband, “when he tried to pat my back.”

I knew that Anne had suffered from cancer some years ago, and recently, I had heard that it had come back. A neighbor had told me that she was staying with friends in New Jersey while undergoing another round of chemo.

Now she has come home. I believe that she has come home to die.

She has come to me because her husband isn’t home (they separated before the cancer came back), and she can’t get into her apartment. She has two keys for the two locks to her front door and isn’t able to figure out how to use them.

She is apologetic: “The chemo does things to your mind,” she says.

Then she adds, “I’m sorry, I can’t remember your name. But I know you wrote a wonderful book.”

I explain that the fact she doesn’t remember my name doesn’t matter. That she remembered the book is so very kind. “To me, that matters more,” I tell her.

I see the shadow of a smile. She has always been a very gracious woman, and at this moment, she realizes that, despite all of the pain, she still possesses the power to make others feel good.

When we get to her apartment, I open the locks. She won’t let me in—“The apartment is a mess,” she says. “And I just want to lie down.”

I understand that she wants to be alone. I persuade her to give me a piece of paper and write my phone number down, in case she needs something or someone during the night. 

I don’t expect to hear from her. And I didn’t.

But I do find out that her husband is coming every day to visit her and bring her things she needs. I still think she has come home to die.

And I also believe that the chemo that was supposed to help her may have done her more harm than good.  Of course, I don’t know for sure.

Health Care Spending: The Basics; How Much Do We Spend on Nursing Homes?

We know that as a nation, we invest well over $2 trillion each year in healthcare. But where exactly do our health care dollars go?  Where are they well-spent and where are they wasted?

In recent months I’ve been trying to answer those questions by looking at healthcare spending sector by sector, analyzing how much we spend on physicians’ services (here  and here);  on hospitals (here and here) ; and what share our health care dollars is eaten up by insurers’ “administrative costs and overhead.”

This post will take a hard look at spending on nursing homes.  As the chart below reveals, the nursing home sector accounts for roughly 6 percent, or $124.9 billion of the more than $2 trillion that we invest annually in healthcare. As always, the question is “Are we getting good value for our money?”  Given how vulnerable nursing home patients are, questions about quality deserve special attention.

Quality of Care

The news is almost as depressing as The Savages. (A powerful film, starring Philip Seymour Hoffman, Laura Linney, and Philip Bosco about a brother and sister who are faced with putting their father in a nursing home.)

Begin with a recent GAO report.  Last month the Government Accountability Office reported that when Congressional investigators double-checked nursing home reports from state inspectors, they found widespread “understatement of deficiencies,” including malnutrition, severe bedsores, overuse of prescription medications and abuse of nursing home residents.”

Health Wonk Review Is Up

Health Wonk Review, a compendium of some of the best health care blog posts of the past two weeks, is up at the ever-informative Health Affairs blog. Be sure to check it out.

Drug Addiction: Let Science Replace Ideology

This post was written by Maggie Mahar and Niko Karvounis

In 1986, Nancy Reagan made it clear that there is “no moral middle ground” when it comes to drug use. You either don’t take drugs—which means you are a “good” person—or you do take drugs, which means you are a “bad” person.”

The Reagan-era outlook on drug addiction has dominated our political culture for nearly three decades, though not without sharp criticism.  In March, for instance, the writers of "The Wire," the critically-acclaimed HBO series that brought the Realpolitik of Baltimore’s war on drugs to the small screen, made it clear what they thought of the Reagan approach: “what once began, perhaps, as a battle against dangerous substances, long ago transformed itself into a venal war on our underclass. Since declaring war on drugs nearly 40 years ago, we've been demonizing our most desperate citizens, isolating and incarcerating them and otherwise denying them a role in the American collective. All to no purpose. The prison population doubles and doubles again; the drugs remain.”

They’re right; we are not winning the war on drugs. But the question remains: what should we do now? Those who view illicit drug use as willful behavior believe that we have no choice but to jail those who choose to continue committing crimes. Others who argue that drug addiction is a disease that weakens the addict’s ability to choose argue that rather than stigmatizing the addict and punishing him, we must find new ways to “treat” the patient.

One could argue about who is right. But rather than engaging in yet another political argument about personal responsibility vs. society’s responsibility to help its poorest citizens, it might be helpful to take a look at what medical science has been learning about drug addiction over the past few decades.

The Silence Surrounding Diagnostic Errors; Part II

Sometimes physicians are overly confident; sometimes they narrow their hypothesis too early in the diagnostic process. Sometimes they rely too heavily on advanced diagnostic tests and accept the results too quickly. As I explained in part one of this post, these are some of the reasons why physicians misdiagnose their patients up to 15 percent of the time. Of all medical errors, misdiagnosis is the one that we talk about least—in part, because we don’t know what to do about it, in part because most doctors have no way of knowing how many diagnostic errors they make.

“Complacency” (i.e. the attitude that “nobody’s perfect”) also is a factor, reports Drs. Eta S. Berner and Mark L. Graber in the May issue of the American Journal of Medicine. “Complacency reflects tolerance for errors, and the belief that errors are inevitable,” they write, “combined with little understanding of how commonplace diagnostic errors are. Frequently, the complacent physician may think that the problem exists, but not in his own practice...”

Autopsies

It is crucial to recognize that physicians are not simply deceiving themselves: in our fragmented health care system many honestly don’t know when they have mis-diagnosed a patient. No one tells them—including the patient.

Sometimes a patient who isn’t getting better simply leaves the doctor and finds someone else. His original doctor may well assume that he was finally cured. Or the patient may be discharged from the hospital, relapse three months later, and go to a different ER where he discovers that his symptoms have returned because he was, in fact, misdiagnosed. The doctors who cared for him at the first hospital have no way of knowing; they think they cured him. In other cases, the patient gets better despite the wrong diagnosis. (It is surprising how often bodies heal themselves.) Meanwhile, both doctor and patient assume that the diagnosis was right and that the treatment “worked.”

In still other cases, the patient dies, and because everyone assumes that the diagnosis was correct, it is listed as the “cause of death”—when in fact, another condition killed the patient.

When giving talks to groups of physicians on diagnostic errors, Graber says that he frequently “asks whether they have made a diagnostic error in the past year. Typically, only 1% admit to having made such a mistake.”

Stories and Statistics— Why We Need Both

Lately, I’ve been thinking about the difference between stories and stats- those hard and fast numbers that give us “objective” information about everything from  the body politic to the human body.

Social scientists like data, perhaps because it makes social science seem more “scientific.”  They like to square things off and measure them. They like to count:  How many? How much? What do the polls say?  Percentages are impressive.

Try to tell a story, and a purist will remind you that “the plural of data is not anecdote.”

But what some social scientists—and some physicians—forget is that statistics measure only what can be counted. Many of the things that are most important, in medicine as in life, are immeasurable.   Stories are valuable because they can capture some of the messiness of reality, including the ambiguities and contradictions that make both human experience and the human mind/body just beyond comprehension. (Since we have only the mind with which understand the mind, ultimately investigation must end in a stand-off.)

I began thinking about the difference between stories and statistics this week end, while reading Dr. Chris Johnson’s blog. A pediatrician and former head of pediatric critical care at the Mayo Clinic, Johnson confides that he sees medicine as “complicated mish-mash of science, near-science, intuition, guesswork, and blind luck.”

And that, he explains, is why he has been thinking about “the enduring power of the anecdote in how we humans understand things. . .

Sapping VistA’s Soul

In the past I’ve spoken highly of VistA, the Veteran’s Administration computerized health records system—and with good reason. VistA has a lot going for it. In 2006, it won an “Innovations in American Government Award” from Harvard. Studies show that use of VistA has improved VA productivity by 6 percent a year since national implementation was achieved in 1999. In a time of sky rocketing health care costs, VA care has become 32 percent less expensive than it was in 1996 in part thanks to VistA. The computerized system also has helped the VA reach an amazing prescription accuracy rate of over 99.997 percent. And last—but certainly not least—VistA is a flexible program that allows for much independent tinkering in the name of improvement, both by techies outside of the VA and those within the administration.

Given all these pluses, you’d think that the government would be happily throwing its weight behind VistA and ensuring that the system is firmly institutionalized for the long-term. But in fact, just the opposite is happening. VistA is under attack; and it’s the federal government that’s leading the assault.

According to Dana Blankenhorn, a writer at ZDNet (a much-trafficked techie website),  VistA is dying “of starvation and neglect.” It’s demise comes in part from an unlikely source: the Department of Defense (DoD). In 2005, the DoD introduced it’s own computerized health records system, called AHLTA. The system was developed by Integic, a private firm that was acquired by defense giant Northrop Grumman a mere nine months before AHLTA’s formal roll-out.

So why would the DoD contract out the development of a health records system instead of co-opting VistA, which can be reworked for different contexts? It’s not because of it’s too difficult, that’s for sure. Blankenhorn quotes Phillip Longman, a senior fellow at the New America Foundation and an outspoken champion of the VA  noting that the government “could wire Walter Reed or Bethesda (the two biggest military hospitals) for VistA in an afternoon. Technically there’s no big problem....”

Yet still, the DoD created an entirely new system—one which has only limited interoperability with VistA. Longman, the author of The Best Care Anywhere: Why VA Health Care is Better Than Yours, explains just how bad things are: “I just gave 11 [speeches] to front line VA employees in the last few weeks, and I heard over and over again their frustration over not being able to get to the people at the [DoD] making the hand-offs [of patients between departments]. Not only can’t the computers talk to each other, they can’t get the Army doctor in Germany on the phone to answer a simple question.”

The Silence Surrounding Diagnostic Errors; Part I

This post was written by Maggie Mahar and Niko Karvounis

Despite all of the talk about medical errors and patient safety, almost no one likes to talk about diagnostic errors. Yet doctors misdiagnose patients more often than we would like to think. Sometimes they diagnose patients with illnesses they don’t have. Other times, the true condition is missed.  All in all, diagnostic errors account for 17 percent of adverse events in hospitals according to the “Harvard Medical Practice Study,” a landmark study that looks at medical errors.

Traditionally, these errors have not received much attention from researchers or the public.  This is understandable. Thinking about missed diagnosis and wrong diagnosis makes everyone—patients as well as doctors—queasy. Especially because there is no obvious solution.  But this past weekend the American Medical Informatics Association (AMIA) made a brave effort to spotlight the problem, holding its first-ever “Diagnostic Error in Medicine” conference. 

Hats off to Bob Wachter, Associate Chairman of the Department of Medicine at the University of California, San Francisco, and the keynote speaker at the conference. On Monday, Wachter shared some thoughts on diagnostic errors through his blog, “Wachter’s World.”

Wachter begins by pointing out that a misdiagnosis lacks the concentrated shock value that is needed to grab the public imagination. Diagnostic mistakes “often have complex causal pathways, take time to play out, and may not kill for hours [i.e., if a doctor misses myocardial infarction in a patient], days (missed meningitis) or even years (missed cancers).” In short, to understand diagnostic errors you need to pay attention for a longer period of time—not something that’s easy to do in today’s sound-bite driven culture.

Diagnostic errors just aren’t media friendly. When someone is prescribed the wrong medication and they die, the sequence of events is usually rapid enough that the story can be told soon after the tragedy occurs. But the consequences of a mistaken diagnosis are too diffuse to make a nice, punchy story. As Wachter puts it: “They don’t pack the same visceral wallop as wrong-site surgery.”

How the Mainstream Media Hypes Health Care

“False Hopes, Unwarranted Fears: The Trouble with Medical News Stories.” If you find the headline alarming, you should read the editorial, published just last week in PLoS Medicine. There, the journal’s editors summarize  what the Health News Review has discovered over the past two years while evaluating medical stories about new products and procedures throughout the mainstream media.

“It’s not a pretty picture,” says Gary Schwitzer, the University of Minnesota School of Journalism professor who publishes the online project.

In a video linked to the Health News Review website,  Schwitzer points out that “about 65% of the time” major news organization are not telling viewers and readers how “big the potential harms” of new treatments are–or “how small the potential benefits.”

Meanwhile, about three-quarters of the stories about a new product or procedure fail to talk about how much the idea costs.  “At a time when the U.S. is spending 16 percent of GDP on healthcare, I find this unfathomable,” says Schwitzer. “No one is asking: ‘How are we going to pay for it?’; ‘Who will have access to these things’?; ‘Who’s to say that we even need some of these things?  This is what we need to discuss.”

Ultimately, “these stories are painting a ‘kid in the candy-store’ picture of US health care,” Schwitzer charges, “whereby everything is made to look terrific, risk-free, and without a price tag. Nothing could be further from the truth.”

Health News Review is supported by a grant from the nonprofit Foundation for Informed Decision Making, which was founded in 1989 by Dr. Jack Wennberg and colleagues. Its mission is to assure “that people understand their choices and have the information they need to make sound decisions affecting their health and wellbeing.”

Eating My Words

How often have I said: “There is no Consumer Reports guide to healthcare—and with good reason"? Often I add that “rating refrigerators is a lot easier than measuring the quality of care provided by a hospital or doctor.”

Guess what?

Consumer Reports has just launched a new online "compare your hospital" tool  (Thanks to Gary Schwitzer, who reported this on Schwitzer Health News Blog over the week-end.)

And where did Consumer Reports get their information?  They’ve taken it from the Dartmouth research on treatment, overtreatment and outcomes that I cite so frequently.

I have always liked Consumer Reports--ever since I was a young bride buying my first air-conditioner. It didn’t let me down then, and, I’m glad to say, it hasn’t let me down now.