I thought I understood health care. Then my Mom went into the ICU.
By Charles Ornstein, Published: February 28
Charles Ornstein is a senior reporter for ProPublica and the board president of the Association of Health Care Journalists.
My father, my sister and I sat in the near-empty Chinese restaurant, picking at our plates, unable to avoid the question that we’d gathered to discuss: When was it time to let Mom die?
It had been a grueling day at the hospital, watching — praying — for any sign that my mother would emerge from her coma. Three days earlier she’d been admitted for nausea; she had a nasty cough and was having trouble keeping food down. But while a nurse tried to insert a nasogastric tube, her heart stopped. She required CPR for nine minutes. Even before I flew into town, a ventilator was breathing for her, and intravenous medication was keeping her blood pressure steady. Hour after hour, my father, my sister and I tried talking to her, playing her favorite songs, encouraging her to squeeze our hands or open her eyes.
Doctors couldn’t tell us exactly what had gone wrong, but the prognosis was grim. They suggested that we consider removing her from the breathing machine. And so, that January evening, we drove to a nearby restaurant in suburban Detroit for an inevitable family meeting.
My father and sister looked to me for my thoughts. In our family, after all, I’m the go-to guy for all things medical. I’ve been a health-care reporter for 15 years: at the Dallas Morning News, the Los Angeles Times and now ProPublica. And since I have a relatively good grasp on America’s complex health-care system, I was the one to help my parents sign up for their Medicare drug plans, research new diagnoses and question doctors about their recommended treatments.
In this situation, like so many before, I was expected to have some answers. Yet none of my years of reporting had prepared me for this moment, this decision. In fact, I began to question some of my assumptions about the health-care system.
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Posted Feb. 26, 2013, at 4:30 p.m.
Accustomed as we are to thinking of hospitals as beneficent providers of lifesaving and often charitable care, it comes as a shock to learn how many are engaging in, not to put too fine a point on it, price gouging.
As Steven Brill shows in his cover story in this week’s Time magazine, nonprofit hospitals, even more than for-profit ones, chase 12 percent profit margins with eye-popping markups on everything from cardio stress tests to gauze pads.
The United States spends more per capita on health care, almost $9,000 a year, than any other country, yet it stands in the lowest quartile for life expectancy of developed countries. There is no doubt the U.S. health care system is plagued by warped incentives, overtreatment, poor quality of care and administrative waste. Part of the value of Brill’s report is that it exposes a problem easier to understand, if not easier to solve: plain old overcharging.
The good news is that health care economists know many ways to bring prices down. To begin, make them transparent. Providers of medical care charge widely varying amounts for the same services, even within a single geographic area. Brill’s reporting on hospital price lists — called “chargemasters” — explains why this happens.
Chargemasters contain laughably high prices that hospital administrators don’t even try to justify. (They don’t seem to know how they were set to begin with and argue that they’re misleading because insurance companies always negotiate lower ones). Yet people without insurance, or with too little insurance, often end up paying chargemaster prices. One woman described in the Time article was billed more than $6,500 for CT scans for which Medicare would have paid less than $1,000. Another patient was billed $24 apiece for five-cent niacin pills.
If health care payers — Medicare, Medicaid, insurance companies, public-employee health care plans — were to make public the prices that they pay, then maybe fees for services, equipment, facilities and medicines would fall. They could also reveal how much their beneficiaries pay out of pocket. Aetna and the state of New Hampshire have started doing this.
It is exactly this kind of transparency that will improve the health care system. Unfortunately, many contracts between hospitals and insurers contain gag clauses prohibiting the public release of pricing information. These gag clauses should be prohibited.
Cataloging Health Care's Excesses
By ALBERT R. HUNT | BLOOMBERG NEWS
WASHINGTON — The cover story in
Time magazine last week wasn’t the usual fare, like “Marco Rubio: Savior of the Republican Party.”
“Bitter Pill: Why Medical Bills Are Killing Us” is a serious, exhaustively reported piece about the problem the U.S. health care system has become. The article, by Steven Brill, has created unusual buzz in Washington; it spares no vested interest.
Nonprofit hospitals, the cornerstone of many communities, capriciously overcharge patients, sticking the powerless with exorbitant bills, while paying lavish salaries to their executives; drug companies, which charge humongous markups to American customers, rake in huge profits; trial lawyers, with the threat of legal action, add to the cost of defensive medicine; President Barack Obama’s Affordable Care Act does little to bend the cost curve, and while conservatives rail against
Medicare, the government-run insurance program is more efficient and customer-friendly than the private system.
None of this is new. Yet it resonates for several reasons: Mr. Brill documents the particulars more forcefully, and as health care spending approaches 20 percent of the U.S. economy, almost every American is affected and the debate is politically polarizing.
When asked to respond to these charges, most of the system’s stakeholders react in similar ways: Many of these criticisms are valid — except when it applies to us.
After several years of moderating costs, there are signs the rate of increase in Massachusetts health care prices — and insurance premiums — may soon start accelerating again, exceeding a heralded cost cap set by the state last year.
Three factors are threatening to push residents’ annual health care costs up faster than the state’s overall rate of economic growth:
First, health insurers in Massachusetts estimate the “medical cost trend” — an industry measure based on the price of services and the volume of doctor visits, procedures, and tests — will rise between 6 and 12 percent this year. That would be more than double the state’s anticipated rate of economic growth.
Second, organizers of new insurance-buying cooperatives, formed to enable small businesses to band together and negotiate discounts from health plans, say new federal rules will supersede Massachusetts regulations that qualify small businesses for discounts. That will probably drive up premiums for companies with fewer than 100 workers.
Finally, a string of hospital mergers — most recently, Beth Israel Deaconess Medical Center’s deal to acquire Jordan Hospital of Plymouth, as well as the proposed alliance of Partners HealthCare System with South Shore Hospital in Weymouth — raise the prospect that formerly independent community hospitals will have the clout to command higher medical reimbursements.
Reining in health expenses has been a top priority for Massachusetts officials, who view it as a pressing follow-up to the 2006 state law that created near-universal access to health insurance. Governor Deval Patrick last year signed legislation limiting the annual per-capita increase in health care costs to the state’s economic growth, projected to be 3.6 percent in 2013. The measure was applauded by business and consumer groups. Now, there is mounting skepticism about the chances of avoiding a higher increase.
Obama Asks Health Plans to Report Rising Rates
WASHINGTON — The Obama administration says it will require
health insurance companies to report all price increases, no matter how small, to the federal government so officials can monitor the impact of the new
health care law and insurers’ compliance with it.
Under current rules, the federal government requires insurers to report information on rate increases of 10 percent or more. New rules being issued by the administration will extend this requirement to all rate increases for all health plans sold to individuals, families and small businesses — a total of 60 million people.
Federal health officials said they needed the additional data to monitor trends in premiums as major provisions of the law take effect and more people buy insurance.
“The purpose of this policy is to identify patterns that could indicate market disruption, which could occur given the additional standards that apply” to insurance starting next year, the administration said in a justification of the rules adopted by Kathleen Sebelius, the secretary of health and human services.
Under the new law, Ms. Sebelius said, she is supposed to “monitor premium increases of health insurance coverage” inside and outside the regulated state-level markets known as insurance exchanges.
Consumer advocates welcomed the new reporting requirements, saying they would enhance the ability of insurance regulators and the public to scrutinize rate increases.
Insurers object to the requirements. The federal government “is creating a hugely burdensome and expensive reporting system” that duplicates what most states already require, the
Blue Cross and Blue Shield Association said.
The reporting requirements generally apply to rate increases sought after the beginning of next month.
A fierce debate has erupted over the impact of Mr. Obama’s health care law. Insurers and employers predict that it will drive up premiums, especially for healthy people under the age of 35. The White House disputes that prediction and says that many factors will lead to lower prices.
Experts Want More Studies of Diet’s Role for the Heart
This is a watershed moment in the field of nutrition, medical experts say. For the first time, researchers have shown that a diet can have an effect as powerful as drugs in preventing what really matters to patients — heart attacks, and strokes and deaths from cardiovascular disease.
The subjects were people at high risk of heart disease, and the diet was a Mediterranean one, high in olive oil or nuts.
The study, published last week in
The New England Journal of Medicine, is now shaking up the field of cardiovascular medicine, infusing it with optimism. Scientists are calling for similarly rigorous studies of other popular diets that are routinely recommended by cardiologists even though there is little solid evidence that they work.
“We don’t know what the best diet is,” said Dr. Michael Lauer, the director of the division of cardiovascular sciences at the National Heart, Lung and Blood Institute. “This is a great opportunity to come together and use power of the scientific method to get closer to the right answer.”
Other leading experts agreed.
“This is the start of where we need to go with nutritional clinical trials,” said Dr. Neil J. Stone, a professor of preventive cardiology at Northwestern University’s Feinberg School of Medicine and a former chairman of the American Heart Association’s nutrition committee.
The National Heart, Lung and Blood Institute is supporting a large clinical trial to see if fish oil and
vitamin D can prevent heart attacks and cardiovascular deaths. But while that is important, heart experts say it is time to also look at diets as a whole.
“We definitively need to test plausible diets, within the context of what is available and consumed in the U.S., that could lower the risk of heart disease,” said Alice H. Lichtenstein, a professor of nutrition science and policy at Tufts University and the lead author of the American Heart Association’s dietary guidelines.
Dr. Lawrence Appel, a professor of medicine at Johns Hopkins who was a member of the 2005 and 2010 United States dietary guidelines committees, said he was inspired by the Mediterranean diet study.
Mooching Off Medicaid
Conservatives like to say that their position is all about economic freedom, and hence making government’s role in general, and government spending in particular, as small as possible. And no doubt there are individual conservatives who really have such idealistic motives.
When it comes to conservatives with actual power, however, there’s an alternative, more cynical view of their motivations — namely, that it’s all about comforting the comfortable and afflicting the afflicted, about giving more to those who already have a lot. And if you want a strong piece of evidence in favor of that cynical view, look at the current state of play over Medicaid.
Some background: Medicaid, which provides health insurance to lower-income Americans, is a highly successful program that’s about to get bigger, because an expansion of Medicaid is one key piece of the Affordable Care Act, a k a Obamacare.
There is, however, a catch. Last year’s Supreme Court decision upholding Obamacare also opened a loophole that
lets states turn down the Medicaid expansion if they choose. And there has been a lot of tough talk from Republican governors about standing firm against the terrible, tyrannical notion of helping the uninsured.
Now, in the end most states will probably go along with the expansion because of the huge financial incentives: the federal government will pay the full cost of the expansion for the first three years, and the additional spending will benefit hospitals and doctors as well as patients. Still, some of the states grudgingly allowing the federal government to help their neediest citizens are placing a condition on this aid, insisting that it must be run through private insurance companies. And that tells you a lot about what conservative politicians really want.
Consider the case of Florida, whose governor, Rick Scott, made his personal fortune in the health industry. At one point, by the way, the company he built
pleaded guilty to criminal charges, and paid $1.7 billion in fines related to Medicare fraud. Anyway, Mr. Scott got elected as a fierce opponent of Obamacare, and
Florida participated in the suitasking the Supreme Court to declare the whole plan unconstitutional. Nonetheless, Mr. Scott recently shocked Tea Party activists by announcing his support for the Medicaid expansion.
Stubbing Out Cigarettes for Good
By RICHARD A. DAYNARD
BOSTON
PERHAPS no public official was as synonymous with the antismoking movement as
C. Everett Koop, who died last Monday at age 96. Dr. Koop, who worked tirelessly to turn America into “a smoke-free society,” did not live to see that goal reached. But the rest of us have the power to make it happen.
Fewer than one in five American adults smoke, a share that’s plunged by about half
since the 1960s — an achievement due, in some measure, to Dr. Koop’s antismoking crusade as surgeon general, from 1981 to 1989. Revelations in the 1990s about tobacco companies’ cover-up of smoking’s dangers also played a role. So have a host of other strategies that have included consumer taxes, minimum ages for cigarette purchases, restrictions on smoking in public spaces and programs to help people quit. Continuing on the same path, with some luck, we might be able reduce the smoking rate a little more.
But that would still leave us with a profound public health tragedy: cigarettes continue to kill
more than 400,000 Americans a year and cost untold billions in health care spending.
To its credit, the
Food and Drug Administration has tried more aggressive approaches, including a recent effort to require hard-hitting graphic warnings on cigarette packages. That proposal, already the rule in dozens of countries, has been held up in United States federal courts over concerns that the ads might infringe on cigarette manufacturers’ First Amendment rights. But even if implemented, more scare tactics would not go far enough.
What we need is an all-out push to reduce smoking rates to well below 10 percent. The notion is nothing new to tobacco-control advocates, many of whom gathered last week in Cambridge, Mass., for a
conference on the governance of tobacco, sponsored by Harvard with support from the World Health Organization.
But outside of such academic meetings and journals, little has been said about two possible approaches that could have an immediate impact.
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