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Sunday, September 21, 2014

Health Care Review Articles - September 21, 2014

After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know

By 

Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms. A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.
He was blindsided, though, by a bill of about $117,000 from an “assistant surgeon,” a Queens-based neurosurgeon whom Mr. Drier did not recall meeting.
“I thought I understood the risks,” Mr. Drier, who lives in New York City, said later. “But this was just so wrong — I had no choice and no negotiating power.”
In operating rooms and on hospital wards across the country, physicians and other health providers typically help one another in patient care. But in an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives.
The practice increases revenue for physicians and other health care workers at a time when insurers are cutting down reimbursement for many services. The surprise charges can be especially significant because, as in Mr. Drier’s case, they may involve out-of-network providers who bill 20 to 40 times the usual local rates and often collect the full amount, or a substantial portion.
“The notion is you can make end runs around price controls by increasing the number of things you do and bill for,” said Dr. Darshak Sanghavi, a health policy expert at the Brookings Institution until recently. This contributes to the nation’s $2.8 trillion in annual health costs.
Insurers, saying the surprise charges have proliferated, have filed lawsuits challenging them. In recent years, unexpected out-of-network charges have become the top complaint to the New York State agency that regulates insurance companies. Multiple state health insurance commissioners have tried to limit patients’ liability, but lobbying by the health care industry sometimes stymies their efforts.
“This has gotten really bad, and it’s wrong,” said James J. Donelon, the Republican insurance commissioner of Louisiana. “But when you try to address it as a policy maker, you run into a hornet’s nest of financial interests.”
http://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html?hp&action=click&pgtype=Homepage&version=LedeSum&module=first-column-region&region=top-news&WT.nav=top-news&_r=0

When Medicine Is Futile

By BARRON H. LERNER

MY father would have been thrilled to read “Dying in America,” a new report by the Institute of Medicine that argues that we subject dying patients to too many treatments, denying them a peaceful death. But he would have asked what took us so long. A physician from the late 1950s to the late 1990s, my dad grew increasingly angry at how patients died in this country, too often in hospitals and connected to machines and tubes he knew would not help them.
He placed some of the blame for the situation at the feet of bioethics and patients’ rights, two movements that I, as a young physician, had fiercely advocated. Doctors, he believed, had abrogated their duties in preventing — and, if necessary, thwarting — patients from pursuing inappropriate end-of-life interventions. We should heed my father’s advice. Physicians need to reclaim some of the turf they have ceded to patients and families.
My father was an unlikely proponent of what came to be known as the “medical futility” movement in the 1990s. He was an infectious disease specialist, trained to diagnose and cure complicated infections. For much of his early career, he did just that. It was a heady time. Thanks to penicillin and other antibiotics, my dad was able to cure once-fatal infections like tuberculosis.
But as his career progressed, he found himself increasingly consulted on different types of patients. Elderly, frequently from nursing homesand suffering from dementia or cancer, these patients would be admitted to his hospital with an infection, like pneumonia. Treating these infections, and the hospital-acquired ones that sometimes followed, did not make these people better. At best, the antibiotics preserved their poor quality of life. More often, they returned home without an infection but even sicker than when they had arrived. Even worse, many died on respirators in intensive care units, having been offered interventions that had no chance of working.

Website allows Canadians to check up on hospitals

Canadians can now easily see which hospitals have the highest death rates, the lowest infection rates, and how their regions compare with the national average in health measures like obesity and heart attacks.
The Canadian Institute of Health Information (CIHI) unveiled a website with the mountain of data it has been collecting on the health of Canadians. Users can browse the performance of hospitals and see statistics for their cities, regions, provinces and territories, as well as national averages.
The website is at yourhealthsystem.cihi.ca
The institute says one of its goals is to help health providers be more efficient and transparent by making their performance public.
“By releasing this information publicly, we hope to create a platform for hospitals, health regions, provinces and territories in Canada to learn from best results and identify best practices,” said Jeremy Veillard, vice-president of Research and Analysis at CIHI.
The site features a “top results” section with the best performers for other health authorities to identify and learn from, he said.
Making health data public has resulted in improvements in other countries. In 2005, the UK started publishing the death rates for heart surgery between individual hospitals. Ten years later, the number of adults dying during the operation fell 20 per cent.
CIHI did not say whether they will be releasing more detailed data in the future, but “will be meeting with national and provincial leaders next month to discuss priorities for future indicator development in Canada.”

Obamacare enrollment falls slightly to 7.3 million in August
By NOAM N. LEVEY
Enrollment in health plans offered through the Affordable Care Act dropped slightly through this year, falling from about 8 million this spring to 7.3 million in mid-August, the Obama administration announced Thursday.
The tally represents the first update the administration has provided since the April close of the open enrollment period.
It suggests that the vast majority of consumers who signed up for coverage this year stuck with it, contrary to warnings from critics of the health law that millions would stop paying their premiums.



Marilyn Tavenner, who as head of the federal Centers for Medicare and Medicaid Services oversees new insurance marketplaces created by the law, expressed satisfaction with the enrollment total.
"We are encouraged by the number of consumers who paid their premiums and continue to enroll," she told a congressional panel.
The decline since April also offers a warning, however. Because the law's long-term sustainability depends on millions more people signing up for health coverage in coming years, its supporters will have to reverse the erosion in coverage when the second sign-up period begins this fall.

The New Conservative Love Affair With Canada


You may remember your liberal friends threatening to move to Canada after George W. Bush was re-elected. But something surprising has happened in the last few years: Conservatives have fallen in love with Canada. The conservative journalist John Fund wrote in National Review this month that Canada is becoming “more American than America.” That’s the same John Fund who wrote a 1995 Wall Street Journal staff editorial calling Canada “an honorary member of the third world.” A lot can change in two decades.
In August, when Burger King announced its intention to acquire the Canadian coffee-and-doughnuts chain Tim Hortons and reincorporate up north, The Journal editorialized that the United States should focus on copying Canada’s attractive corporate tax policies, not on holding American companies captive. “Canada has become a far more business-friendly tax jurisdiction than the U.S.,” America’s leading conservative editorial page wrote. “The Burger King deal also signals the continuing success of Canada’s historic move toward open markets and economic growth.”
The libertarians Chris Edwards and Amity Shlaes (and Mr. Fund) have urged the United States to copy Canada’s tax-free savings accounts, which are substantially more flexible than I.R.A.s. Wonky conservative skeptics of comprehensive immigration reform, such as David Frum and Reihan Salam, like to point to Canada’s “points system,” which favors high-skilled immigrants and discourages family-based chain migration, as a model to imitate. All sorts of Republican politicians talk about Canada as a reliable partner for fossil-fuel-based energy, eager to extract oil from its tar sands and ship it to us through the Keystone pipeline if only we would let them.
But perhaps most of all, conservatives like Canada as an example of “expansionary austerity,” a country that grew its economy while slashing public spending and debt. Squeezed by high interest rates, a left-of-center government instituted big spending cuts in the 1990s; as a result, Canada’s level of public expenditure as a share of its economy has fallen to match America’s. Fred Barnes, the executive editor of The Weekly Standard, wrote several thousand words of praise for Canada’s fiscal restraint in 2011, under the headline “Lessons From Canada.”
“You can’t ignore the two groups that have ratings on economic freedom around the world,” Mr. Fund told me about his change of heart on Canada, referring to indexes published by the Heritage Foundation and the Fraser Institute, conservative think tanks in the United States and Canada, respectively. “Canada’s ratings continue to improve and U.S. ratings continue to slip.”
Indeed, Canada overtook the United States in Fraser’s rankings in 2005. Fraser calls Canada the freest country in the world among those with over 10 million residents; Heritage puts Canada second among large countries, behind Australia.
There’s a great deal of truth to the conservative praise for Canada. Its fiscal choices have shown how a country can maintain a strong social safety net while taxing and spending efficiently and encouraging private investment. Openness to trade and skilled immigration have made Canada an attractive place to invest; perhaps too attractive for some, given the dizzying way Chinese investment has driven up housing prices in Vancouver.
But there are two big caveats to the conservative case for Canada. First, the offsets. “The things conservatives love about Canada are closely linked to the things they hate most about Canada,” says Mr. Frum, a Canadian-American journalist. Canada’s light corporate taxes? Made possible, in part, by a value-added tax, imposed by a conservative government in 1991. Canada’s 1990s fiscal austerity? Made possible by top-down restraint of health care spending and a weak Canadian dollar.
Canada’s 1990s austerity was able to be expansionary because of an export boom that coincided with government spending cuts. The boom owed something to the North American Free Trade Agreement, which fits the conservative narrative. But a weak currency also favored exporters. In January 1995, the Canadian dollar stood at $0.71, down from $0.89 in November 1991, which prompted The Journal to mock the currency as the “northern peso.” But even as Canada’s broad economic metrics improved through the 1990s, the currency kept falling, hitting $0.65 in August 1998. Conservatives urging the United States to follow Canada’s fiscal example usually leave out the “weaken your currency” part of the plan.
And those spending cuts were partly achieved through reduced transfer payments to provinces for health care. Provinces turned around and cut payments in their provincially-run health care systems; as a result, health care spending fell to 8.6 percent of the Canadian economy in 1997 from 9.7 percent in 1992, according to the Organization for Economic Cooperation and Development. “If you want to do spending austerity, single payer is a powerful tool,” Mr. Frum said.
http://www.nytimes.com/2014/09/21/upshot/the-new-conservative-love-affair-with-canada.html?hpw&rref=upshot&action=click&pgtype=Homepage&version=HpHedThumbWell&module=well-region&region=bottom-well&WT.nav=bottom-well&abt=0002&abg=0


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