Medicine Has Become the Great Patient Handoff
— Patients pay the price for our fragmented healthcare system
by
Americans have become the commodity in their own healthcare system. A patient has gone from being a person who has a relationship with a physician to a sheep that is herded through, with the corporate medical world making money off them with every move. Gone are the days when a physician would do rounds in the hospital in the morning, see patients in the office, follow them into the nursing home, and do home visits as they came to the end of their journey.
"Care" has now become a fragmented web of hospitalists, intensivists, and mid-level care that only remotely reflects the relationships that were the bedrock of the American medical system just 20 years ago.
What is the most substantial impact of this fragmented care? No one provider is the sole caregiver with total responsibility. Medicine has become the great handoff, with no one seeing the whole picture of the person in front of them. Patients have become a conglomeration of body systems and body parts to be fixed or addressed in a fragmented fashion, reminiscent of an assembly line.
Pretend for a moment you're a patient and you go to the emergency room for an acute issue. There, staff need only to verify that you will not expire within 24 hours, and out you go. If the risk is too high, then they hand you off to the hospitalist who will admit you, but if your condition worsens, there is often another handoff to an intensivist who manages the ICU. If more than one or two organ systems are affected then subspecialists will come and pore over the computer (rarely over the human) to see if the numbers in the electronic medical record are within their wheelhouse.
Gone are the days when the ER doc would come up to the ICU the next day to chat with the primary physician about how their other patients are doing and confirm the ultimate diagnoses. Gone are the days when the primary physician would see patients though their entire hospital course and remain responsible for them on discharge.
Technical advances -- while aimed at bettering diagnosis, treatment, and healing -- have simultaneously distanced doctors from physicians in other specialties who were once so closely linked. When X-rays and CT scans were all on film, physicians used to walk into the radiology department every day (imagine this!) where I worked, and pull the films on their patients from the day prior. Here, doctors of all specialties would often corner our radiology physicians to discuss the case, pore over films together, and both would then see the nuances of the patient from both the outside and the inside. The pathologist likewise was a few feet further down a hallway, where questions about biopsy specimens could be discussed. Should we do a different study? Is there a limitation of this stain on the results of the test? Questions and dialog were woven together with the patient at the core.
Nursing home care was also under the purview of the primary physician, who would do rounds and take phone calls, write orders, and talk with the family. Now, many nursing home facilities have no on-site provider, and for some, the facility's medical director is in another state altogether. A separate corporate system has sprouted like a weed, and has taken over as the remote "medical director of record" for nursing homes where there are too few staff, and where "standing orders" are an automated way of caring for any particular problem that may arise so as to minimize any thought or analysis of the problem.
We have paid a heavy price for medicine that is at once "at your finger tips" as well as broken and fragmented. Proponents will point to "best practice advisories" and "metrics" that our electronic medical records blip across the screen with dizzying speed. It does not matter if you know that Mrs. Smith's emotional eating is driven by her grief for her son's addiction problem and her 14-year-old cat who she recently put down. All that matters is you put her on the approved diabetes medications and her hemoglobin a1c is at target.
We no longer have a system that values attention to the person. We have a system that values a database that can be mined for profit and publication. Electronic medical record systems were built not for patient care but for billing and mitigating legal risk. Moreover, the young providers of today know nothing of generating orders in their mind and then putting them to paper. The computer provides (often inaccurate) proposals at each click for dosing, drug options, and diagnostic testing. It took years to get our own system to stop giving lactation warnings for my 90-year-old female patients. When ransomware hits a medical system, providers must scramble to learn how to generate orders and doses without a computer to prompt them.
Often in medicine there is an invisible pendulum that swings in wide arcs. It has an eerie resonance to the story by Edgar Allen Poe, with the patient at the edge of the blade. Our automation and convenience has come at a price. As our nation grapples with obesity, depression, anxiety, and addiction, we must seek to reconnect with people in our care. We must resist the urge to "click the box" and remember to look up at the person.
Unfortunately, the drivers of the corporate medical system are no longer the physicians. We are at the mercy of federal and state bureaucracies overlapped with big data companies and the pharmaceutical industry. They are all present with you in the doctor's office, manifested in the sound of the endless clicking, reflected in the light of the computer screen. Every day I miss the paper chart, the simple folder that never stood between me and the patient, that not once told me how to make someone better, and simply allowed me to practice the art of medicine.
Kathleen A. Hallinan, MD, MPH, is Internal Medicine Specialist in Corning, New York, and a Diplomate of the American Board of Obesity Medicine.
The Corporate Plan to Murder Medicare Runs Through Medicare Advantage
In 2003, George W Bush set up the destruction and privatization of Medicare. The end of "real Medicare" is getting closer every day, and Congress and Medicare's administrators are doing nothing.
Last Friday the Centers for Medicare Services (CMS) announced a 14.5% increase in Medicare Part B premiums, raising the monthly payments by the lowest-income Medicare recipients from $148.50 a month to $170.10 a month next year.
Congress must stop these for-profit parasites who are steadily draining "real" Medicare of funds and resources while producing billions in profits and often outright stolen funds for the insurance industry.
If you're trying to live on the bottom rung of Social Security (about $365/month), that's consequential. People with Medigap policies are also seeing their policy price rises announced this month.
Two months ago I wrote about the Medicare Advantage Scam and how it can screw consumers. This price hike, though, raises the larger issue of what's happening to Medicare itself and whether the entire system may be out of business in a few years, in part because our government is being robbed blind by all these so-called "Advantage" plans.
It all began with George W. Bush, who'd spent most of his life openly and proudly campaigning to privatize Medicare and Social Security.
In 2003 Congress and the Bush administration rolled out a privatization option, allowing private for-profit insurance companies to sell policies branded as "Medicare Advantage" to gullible seniors who think they're buying the actual Medicare Parts A and B. As a result, today companies eager to rip off seniors are flooding the market, particularly with TV advertising.
As I note in considerable detail in The Hidden History of American Healthcare: Why Sickness Bankrupts You and Makes Others Insanely Rich, Medicare Advantage is hurting traditional Medicare, because that system is paying the insurance companies, in most cases, far more than it would be paying to simply cover the costs of its regular Medicare recipients.
Medicare Advantage is also one of the most effective ways that insurance companies can kill a real "Medicare for All" system, since so many people who think they're on Medicare are actually on these privatized plans instead.
Nearly from its beginning, Medicare allowed private companies to offer plans that essentially compete with it, but they were an obscure corner of the market and didn't really take off until the Bush administration and Congress rolled out the Medicare Modernization Act of 2003.
This was the GOP's (and a few corporate-owned Democrats') big chance to finally privatize Medicare, albeit one customer at a time.
That law legalized a brand known as "Medicare Advantage" under the Medicare Part C provision and a year later it phased in what are known as risk-adjusted large-batch payments to insurance companies offering Advantage plans.
Medicare Advantage plans are not government-provided Medicare. They're private health insurance most often offered by the big for-profit insurance companies (although some nonprofits participate, particularly the larger HMOs), and the rules they must live by are considerably looser than those for Medicare.
Even more consequential, they don't get reimbursed directly on a person-by-person, procedure-by-procedure basis. Instead, every year, Advantage providers submit a bill to the federal government based on the aggregate risk score of all their customers and, practically speaking, are paid in a massive lump sum for all of their customers.
The higher their risk score, the larger the payment. Profit-seeking insurance companies, being the predators that they are, have found a number of ways to raise their risk scores without raising their expenses.
For example, many Medicare Advantage plans promote an "annual home visit" by a nurse or physician's assistant as a "benefit" of the plan. What the companies are doing, though, is trying to upcode (raise their payments from Medicare) customers to make them seem sicker than they are.
"Heart failure," for example, can be a severe and expensive condition to treat . . . or a barely perceptible tic on an EKG that represents little or no threat to a person for years or even decades. Depression is similarly variable; if it lasts less than two weeks, there's no reimbursement; if it lasts longer than two weeks, it's called a "major depressive episode" and rapidly jacks up a risk score — and thus the payments to the insurance company, even if it provides no services.
The home health visits are so profitable that an entire industry has sprung up of companies that send nurses out on behalf of the smaller insurance companies.
In summer 2014, the Center for Public Integrity (CPI) published an in-depth investigative report titled Why Medicare Advantage Costs Taxpayers Billions More Than It Should.
They found, among other things, that one of the most common scams companies were running involved that very scoring of their customers as being sicker than they actually were, so that their reimbursements were way above the cost of caring for those people.
Here are a few quotes and summaries (in my words) from the report:
"Risk scores of Medicare Advantage patients rose sharply in plans in at least 1,000 counties nationwide between 2007 and 2011, boosting taxpayer costs by more than $36 billion over estimated costs for caring for patients in standard Medicare."
"In more than 200 of these counties, the cost of some Medicare Advantage plans was at least 25 percent higher than the cost of providing standard Medicare coverage."
The report documents how risk scores rose twice as fast for people who joined a Medicare Advantage health plan as for those who didn't.
Patients, the report lays out, never know how their health is rated because neither the health plan nor Medicare shares risk scores with them — and the process itself is so arcane and secretive that it remains unfathomable to many health professionals.
"By 2009, government officials were estimating that just over 15 percent of total Medicare Advantage payments were inaccurate, about $12 billion that year."
Based on its own sampling of data from health plans, the report shows how CMS has estimated that "faulty" risk scores triggered nearly $70 billion in what officials deemed "improper" payments to Medicare Advantage plans from 2008 through 2013.
CMS decided, according to the report, not to chase after overcharges from 2008 through 2010 even though the agency estimated through sampling that it made more than $32 billion in "improper" payments to insurance companies offering Medicare Advantage plans over those three years. CMS did not explain its reasoning.
The report documents how Medicare expects to pay the health plans more than $150 billion in 2014, the year the study was published.
Companies are almost never nailed for these overcharges, and when they are, they usually pay back pennies on the dollar.
For example, when the Office of Inspector General, Health and Human Services (which oversees Medicare), audited six out of the hundreds of plans on the market in 2007, they found that just those six companies "had been overpaid by an estimated $650 million" for that one year. As the Center for Public Integrity states, "CMS settled five of the six audits for a total repayment of just over $1.3 million."
The Centers for Medicare and Medicaid Services also, in 2012, decided to audit only 30 plans a year going forward. As CPI noted, "At that rate, it would take CMS more than 15 years to review the hundreds of Medicare Advantage contracts now in force." And that's 15 years to audit just one year's activity!
Things haven't improved since that 2014 investigative report from CPI. In September 2019, Senator Sherrod Brown of Ohio and five Democratic colleagues sent a letter to President Donald Trump's CMS Administrator, Seema Verma.
"The recent HHS Payment Accuracy Report exposes that taxpayers have overpaid Medicare Advantage plans more than $30 billion dollars over the last three years," Brown wrote, wanting to know if the government was going to try to recover any of that essentially stolen money.
Meanwhile, during the four years of the Trump administration, CMS went out of their way to illegally promote Medicare Advantage plans.
A February 2020 report in the New York Times stated, "Under President Trump, some critics contend, the Centers for Medicare and Medicaid Services, which administers Medicare, has become a cheerleader for Advantage plans at the expense of original Medicare."
The National Bureau of Economic Research (NBER) compared Medicare Advantage with traditional Medicare and found the Advantage programs to be mind-bogglingly profitable: "MA insurer revenues are 30 percent higher than their healthcare spending. Healthcare spending for enrollees in MA is 25 percent lower than for enrollees in [traditional Medicare] in the same county and [with the same] risk score."
In other words, they are paid more and deliver less, keeping the balance as their profit. And it is hundreds of billions of dollars.
At the same time, Medicare Advantage often screws its customers. According to the NBER study, people with Medicare Advantage got 15 percent fewer colon cancer screening tests, 24 percent fewer diagnostic tests, and 38 percent fewer flu shots.
Today the industry is so entrenched and massively profitable it can buy off members of Congress with the loose change it finds in the couch.
Meanwhile, changes CMS made to the Medicare website during the Trump administration now direct people who want to sign up for Medicare, instead, to a page to sign up for private Medicare Advantage plans.
If they can move more than half of Americans off traditional Medicare and onto these corporate plans, it'll provide the political cover to kill off Medicare altogether—and they're nearly there right now.
While much of the media focus on Medicare's price increase has been around a single Alzheimer's drug, the simple reality is that without the Medicare Advantage scam the Medicare system would be in great shape right now.
Congress must stop these for-profit parasites who are steadily draining "real" Medicare of funds and resources while producing billions in profits and often outright stolen funds for the insurance industry.
This article was first published on The Hartmann Report.
Letter to the editor: Maine marketplace makes health care coverage harder to get
The new website, coverme.gov, is tough to navigate, and customer service representatives aren’t trained to provide help.
The new website, coverme.gov, is tough to navigate, and customer service representatives aren’t trained to provide help.
The state of Maine has opted out of the national affordable health care coverage program and created its own affordable health care coverage system. Using the website, called coverme.gov, to enroll is a disastrous proposition. In my opinion, what is worse is that there is absolutely no knowledgeable help available to correct any incorrect information that is auto-populated by their system.
In my experience, customer service representatives are untrained individuals, working out of their homes, without supervision. They find it necessary to email supervisors while you are on the phone with them to get answers to the most basic questions. Most of the time, the answers don’t come. And these representatives for a Maine health care coverage system are not located in the state of Maine.
Additionally, if you call the medical insurance company in Maine with the hope of their being able to correct inaccurate applicant information, you are told there’s nothing they can do – they have to use the information given to them by coverme.gov.
I am sure there will be many people who want health care coverage who won’t be able to get it, simply because they won’t be able to navigate this new, woefully inadequate system. It is a shameful situation.
Susan Bisbing
Cumberland
Editor's Note:
I know how to solve the problem outlined in the preceding letter to the editor.
- SPC
Patients Get Stranded Out of Network as Insurer-Hospital Contract Talks Fall Apart
by Andy Miller - Kaiser Health News - November 18, 2021
In September, when Shelly Azzopardi went to Wellstar Kennestone Hospital with abdominal pain, she didn’t worry about her insurance.
Doctors said she had a case of appendicitis. But she also tested positive at the hospital in Marietta, Georgia, for covid-19. Physicians decided not to do surgery and treated her with antibiotics and painkillers. Azzopardi, 47, went home after a couple of days in the hospital, feeling better.
But in October, the appendix pain again flared. Her husband took her to the same hospital, where surgery was performed successfully. This time, though, she ran into a snag with her insurance.
Azzopardi has UnitedHealthcare coverage, and as of Oct. 3, Wellstar Health System was no longer in the giant insurer’s network, after the two sides did not agree on a new contract.
Wellstar dominates the Cobb County area where Azzopardi and her husband live. She has applied to UnitedHealthcare for a “continuity of care” waiver, which would extend her previous in-network coverage for the treatment of an ongoing condition for the October hospital visit and surgery. If it doesn’t work out, she could owe thousands of dollars. “I don’t know where it stands,” Azzopardi said.
On a larger level, the severed contract between a hospital system and health insurer reflects tensions that have been growing nationally this year. In the past, even when contract negotiations became publicly antagonistic, they typically would be resolved before the deadline for termination.
Now health care consultants and industry officials say an increasing number of contracts end without a deal. Even if they are eventually resolved, those terminations throw tens of thousands of patients into the difficult position of choosing between much higher out-of-pocket costs or leaving a trusted physician and hospital.
The Wellstar vs. UnitedHealthcare situation — and an even bigger dispute looming in metro Atlanta involving Anthem Blue Cross and Blue Shield — come at a tricky time, during open enrollment season when many employers have already picked their insurance offerings and many consumers must choose their health plan.
“We are seeing more insurers terminate contracts without a deal, and this is both a national and local trend,” said Beth Spoto, a Georgia-based health care consultant with Spoto & Associates. From the insurers’ point of view, she said, it’s a hardball tactic to lower payment rates to medical providers for services.
“Health systems are getting quite large, so you are dealing with hundreds of millions of dollars,” she said. “The fighting is getting pretty tough.”
Recent contract terminations involving big insurers include UnitedHealthcare vs. Montefiore Health System in New York, and Anthem vs. Dignity Health in California. Each conflict was eventually resolved, though Montefiore took several months to settle.
Hospitals are reporting higher tensions in negotiations with health insurers, said Molly Smith, an American Hospital Association vice president. She said contract talks often are not conducted by local executives of the insurer, which might allow for more collaboration, but are directed instead by company headquarters.
Just in the Atlanta area, other out-of-network situations involving insurance heavyweights UnitedHealthcare and Anthem have occurred in the past couple of years. Northside Hospital’s Gwinnett County facilities were out of network for UnitedHealthcare members for five months, while Northeast Georgia Health System in Gainesville left Anthem’s lineup for three months.
In the most recent dispute, Wellstar said it wants UHC to pay reimbursements similar to those it gets from other insurers. UnitedHealthcare, based in Minnesota, counters that Wellstar wants “egregious” rate hikes that the insurer said would amount to 37% over three years.
“Both sides said the other is just out for money,” Azzopardi said. The impasse, she said, “is cruel to the patients who have done nothing wrong.”
The open enrollment quandary has Emilie Cousineau of Smyrna, Georgia, wondering whether to stay with UnitedHealthcare or switch to Anthem, which she said would cost her more for the upcoming benefits year in her employer plan.
Cousineau canceled a Wellstar well-check appointment recently because suddenly it was out of network. “Right now, it’s an inconvenience.” But her doctor as well as her kids’ pediatrician are Wellstar physicians. “I’m picky about my health care,” she said.
Uncertainty over covid and rising hospital labor costs are fueling the disruptions, consultants said.
Health insurers recorded sky-high profits last year as people avoided medical care because of fears about covid. This year, profits have been lower but still healthy. For hospitals, the pandemic brought mixed results. Some richer, bigger health systems racked up huge surpluses, helped by covid relief funds, while many safety-net and rural hospitals fought hard to break even.
Cole Manbeck, a spokesperson for UnitedHealthcare, said affordability of health care is of prime importance to consumers and employers. They expect the insurer to help contain costs, which requires maintaining fair and competitive agreements with hospitals and doctors in its network, he said.
Insurers also point out that health care systems have enhanced their bargaining clout by acquiring additional hospitals and doctor practices. The tough negotiations extend to physician group contracts, said Dave Smith with the health care consulting firm Kearny Street Management. Insurers, he said, “are trying to drive health care costs down, and are doing it on the backs of physicians and hospitals.”
Factoring into the fray are payment delays involving insurers Anthem and UnitedHealthcare. Hospitals are dealing with a spike in retroactive claim denials by UnitedHealthcare for emergency department care, the AHA’s Smith said.
KHN also recently reported that Anthem Blue Cross is behind on billions of dollars in payments owed to hospitals and doctors because of onerous new reimbursement rules, computer problems and mishandled claims, according to hospital officials in multiple states.
Tom Mee, CEO of North Country Healthcare in New Hampshire, said the outstanding claims owed to his system by Anthem rose $250,000 in one quarter to reach $1 million.
Indianapolis-based Anthem said the contract rifts and the claims issue are not related. Both it and UnitedHealthcare noted that the large majority of contracts are renewed without public attention.
Employers, meanwhile, don’t like these network disruptions, said Ash Shehata, a health care consultant with KPMG. But, he added, employers also don’t want to subsidize the rate increases.
“When times are good, and everybody is doing well, generally you don’t see these negotiation issues,” he said. “As long as the environment remains unpredictable, we’ll see some unpredictable negotiations.”
Contract terminations harm hospitals more than insurers, said Nathan Kaufman of Kaufman Strategic Advisors. For example, UnitedHealthcare and Anthem, which operate in several states, “can take a hit in one state,” he said, because they’re diversified and insurers still receive premium payments for members after a contract with a hospital lapses.
“On day one, the hospitals start feeling increased financial stress,” Kaufman said. “They experience this financial jolt.”
The Atlanta market is facing another such contract disruption. Anthem has alerted consumers that Northside Hospital and its facilities may not be part of its network come Jan. 1. While the Wellstar vs. UnitedHealthcare tug-of-war involves an estimated 80,000 consumers, the Northside contract could affect four or five times that many, according to Northside officials.
“Anthem’s timing is very unfavorable to our patients,” said Lee Echols, a Northside spokesperson. “It’s hard to understand. We’re still in a pandemic, and this is the open enrollment period for health care policyholders. Many people are returning to their physicians and hospitals for deferred care, and Anthem’s threats make that process really challenging.”
But Anthem spokesperson Christina Gaines said that the company is fighting to curb health care costs, and that Northside is one of the most expensive systems in Georgia.
The showdown has consumers such as Carol Lander of Sandy Springs, Georgia, concerned and confused.
She has been an Anthem member for years and has used nearby Northside facilities and doctors. She’s now shopping for other plans to see if they include Northside in their networks. One insurance plan has her doctor but not her sons’ physician.
“It’s so frustrating,” said Lander. “This is a huge deal in this area.”
Good morning. We’re looking at the ways Biden’s social policy bill will change health care.
by Margot Sanger-Katz - NYT -November 18,2021
A health care home renovation
News coverage of health care in the Democrats’ big social spending bill has focused on policies that got cut: things like broad limits on prescription drug prices and dental benefits for those on Medicare. But the bill, as it stands, still includes a lot of changes that would expand health coverage, broaden benefits and lower costs across the age spectrum. |
The changes aren’t a major reconsideration of the health care system in the U.S., as Medicare for all would be. Instead, Democrats in Congress have crafted smaller solutions to gaps in the current system. |
“They’re all sort of small slices,” said Christine Eibner, a senior economist at the RAND Corporation. “We have a whole bunch of little niches that need to be filled.” |
Because the bill is still being negotiated by Congress, details could change — or the legislation might fail altogether. But the current package represents a particular vision for how to overhaul the system. |
During the 2020 presidential primary, I described the Democratic Party’s health care debate as a metaphorical fight over home construction options. Some candidates, like Bernie Sanders, saw the weird old house of the U.S. health care system as a tear-down; others, like Joe Biden, viewed it as a fixer-upper. The authors of the Build Back Better Act are aiming for a renovation. |
Here’s what the bill’s health care proposals would offer different groups. |
Seniors |
If the current bill passes, the more than 25 million Medicare patients with hearing loss could get coverage for hearing aids. An overhaul of drug benefits would also reduce what patients pay for medicines, including a monthly $35 cap for insulin and an annual drug spending limit of $2,000. Around 2.5 million Medicare patients pay more than that now, and the ones who do can face huge bills for lifesaving treatments. |
The legislation would for the first time allow Medicare to regulate the price of prescription drugs, which could drive down pharmacy costs for some patients. The details of that plan were heavily negotiated and remain the subject of intense lobbying. But the current version still represents a significant change in how Medicare pays for drugs. |
Another part of the bill would expand funding for home health care. That could help some of the 800,000 older and disabled Americans on waiting lists to get care in their community instead of in nursing homes. |
Working-age adults |
The bill would fix a longstanding hole in the Affordable Care Act by offering an affordable health insurance option to poor adults in 12 states that have not adopted expanded Medicaid programs. The bill would give those people access to free Obamacare plans, with additional benefits that would eliminate most co-payments and offer additional services. |
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People who buy their own health insurance would be able to keep collecting tax credits that were created by President Biden’s pandemic stimulus bill in March. Those subsidies lower the price of health insurance for almost everyone who buys their own plan. Adults with low incomes would be able to sign up for free plans, and those with higher incomes could keep new financial assistance that didn’t exist in Obamacare’s first decade. |
Those increases were aimed at concerns among researchers and Democratic lawmakers that the Affordable Care Act had not made insurance affordable enough. Combined with a big enrollment push, the changes prompted 2.8 million more Americans to sign up for insurance this year. |
New rules in the bill would limit how much pharmaceutical companies can increase drug prices each year. That could help lower premiums and co-payments for the two-thirds of Americans with private health insurance. (Though, as Politico recently reported, pharmaceutical companies are lobbying hard to weaken this proposal.) |
Children |
The bill would permanently extend the Children’s Health Insurance Program, which provides inexpensive health benefits to nearly 10 million children from lower-income families. |
It would also make a technical change to Medicaid that experts say would help children keep their health insurance for longer. The change requires that children be allowed to keep the insurance for a year after being signed up, even if their family’s income changes. Frequent eligibility checks in certain states had contributed to loss of coverage for more than a million children in recent years. |
The Bottom Line |
The sum of these parts is much smaller than the tear-downers might have preferred. America’s health coverage system remains fragmented. Some groups, such as undocumented immigrants, remain left out. Other people may still struggle to afford coverage or may lack insurance for benefits such as dental care. Price regulations won’t take a huge bite out of pharmaceutical industry profits. And some of the key coverage expansions will expire after 2025 if Congress doesn’t renew them. |
But, for a legislative package that is not primarily about health care and faces monetary constraints, Democrats have targeted many cracks in the system. They aim to protect key groups of uninsured Americans and address missing benefits in existing programs, at least for a while. |
“It’s a short-term big deal,” said Cynthia Cox, the director of the Program on the A.C.A. at the Kaiser Family Foundation. “What we are going to see is almost every American citizen will be eligible for affordable health insurance, but only for the next three or so years.”
https://messaging-custom-newsletters.nytimes.com/template/oakv2?
Planning for Surgery? You Might Not Need All Those Tests Beforehand.
Cardiac stress tests, X-rays and other medical tests may not provide useful information before operations, and they could cause harm.
by Jane E. Brofy - NYT - November 15, 2021
Let’s say you’re scheduled for a common and relatively low-risk operation, like a cataract removal, hernia repair or a hip or knee replacement. It’s normal to feel anxious about any upcoming surgery.
But what if one of the presurgical tests your doctor orders — for example, a chest X-ray or cardiac stress test — turns up something unexpected, like a suspicious nodule or a mild heart abnormality? Now you have even more reason to worry, and your surgery will likely be delayed until further tests assure the doctor it would be safe to operate.
Experts say that presurgical testing is often unjustified for many common operations. Many of these tests are a waste of time and money, a growing body of research shows, and the tests themselves can sometimes result in complications.
For more than two decades, experts in various medical specialties, including cardiology, ophthalmology and anesthesiology, have issued guidelines directed at reducing preoperative tests that rarely provide findings relevant to a patient’s surgical risk. Yet practicing doctors often do not follow this advice. Guidelines published in 2002, for example, from the American College of Cardiology, the American Heart Association and the American Society of Anesthesiologists resulted in almost no change in doctors’ presurgical orders nearly a decade later, according to a report in JAMA Internal Medicine. The only exception was a decline in the use of electrocardiograms, or EKGs, a noninvasive test that checks heart function at rest.
Sometimes a preoperative test of questionable value results in unanticipated complications, as happened to a man in his 50s scheduled for repair of a very painful hernia. Two Colorado doctors reported in 2014 that the man’s lab tests and physical exam were normal. But a chest X-ray, ordered because he had a history of mild asthma, suggested he had a nodule on a lung.
Doctors delayed the surgery until he got a CT scan, which did not confirm a lung nodule but did find one on an adrenal gland. Again, doctors postponed surgery to allow for further work-up of the adrenal nodule, which was ultimately found to be benign. The man finally had his hernia repaired after six additional months of debilitating pain and repeated anxiety over incidental test findings suggesting he could have cancer.
However, doctors are making some headway. In 2019 in JAMA Internal Medicine, Dr. John N. Mafi, an internist at the David Geffen School of Medicine at the University of California, Los Angeles, and his colleagues described an effort to reduce “low-value preoperative care” for patients about to have cataract surgery. New guidelines were issued, and a specially trained quality improvement nurse advised the surgeons about the new recommended protocol. The result, as assessed in a controlled clinical trial of 1,054 patients, was a dramatic decline in preoperative testing, a significant projected cost saving after the first year and “no measurable adverse effects” on the patients’ surgery, he said.
Cardiac stress tests show over-testing persists.
Perhaps most problematic among common preoperative procedures is a cardiac stress test, which assesses blood flow to the heart while patients exercise. Dr. Alana E. Sigmund, an internal medicine physician at the Hospital for Special Surgery in New York who has studied physicians’ responses to preoperative guidelines, said in an interview, “Cardiac stress testing is over-ordered. If there’s no indication of a heart problem, like shortness of breath, there’s no reason to do this test prior to surgery.”
The latest guidelines, which the American College of Cardiology and American Heart Association issued in 2014, advise that a cardiac stress test before surgery is generally not recommended for patients lacking symptoms suggestive of heart disease. The guidelines leave the decision to test up to the doctor, and you might think it’s better to rule out a possible heart problem before surgery. But existing evidence shows no health or lifesaving benefit from a preoperative stress test when the patient lacks cardiac symptoms or has fewer than two major risk factors for having a heart attack, like high blood pressure and smoking, especially when the prospective surgery itself is low-risk.
Yet despite these guidelines and a national campaign called Choosing Wisely, aimed at curbing unnecessary tests and procedures, a recent study by Dr. Daniel S. Rubin and his colleagues at the University of Chicago found that many doctors persist in ordering preoperative stress tests among patients at very low risk for cardiac complications. The study, published in JAMA Cardiology in January, looked at more than 800,000 patients having a hip or knee replaced, which is usually considered a low-risk surgery. It found that nearly half the patients who were given a preoperative stress test had no cardiac risk factors that might justify its use. Furthermore, the stress test did not lessen the risk of suffering a heart attack or cardiac arrest during or immediately after surgery, even among patients with one or more cardiac risk factors.
In fact, the stress test might have been counterproductive. For reasons Dr. Rubin could not explain, patients without risk factors who were given a cardiac stress test had double the surgical complication rate experienced by comparable patients who did not have one.
Whatever the explanation for that finding, testing itself is not free of risk, as noted by Dr. Ravi Chopra, a resident in neurology at Washington University School of Medicine. In JAMA Internal Medicine in October, Dr. Chopra and his colleagues described a 72-year-old patient with no known cardiovascular disease or cardiac symptoms who was given a stress test before a hip replacement. The test showed a mild heart abnormality, prompting a catheterization that resulted in damage to two blood vessels that then had to be surgically repaired.
“Testing can cause harm,” Dr. Chopra said. “We need to think hard about whom we’re testing. There should be a really good reason.”
What patients can do.
Experts suggest you’d be wise to ask whether the prescribed tests would reveal anything relevant to your surgical risk that the doctor could not determine by asking you a few questions during a routine physical. For example, answering a simple question like, “Do you get out of breath climbing a flight of stairs or walking four city blocks?” might provide a quick assessment of whether you might be having heart symptoms.
Dr. Mafi added that “it’s hard to change physician behavior with guidelines,” especially when doctors fear being sued if something goes wrong that might have been prevented by a presurgical test. He suggested that patients can help by questioning what a particular test might show and whether it’s really needed. Also helpful, he said, is to choose a doctor “who’s thoughtful, takes time to listen and is judicious about testing. You don’t have to order 100 tests if just one test will do.”
Jane Brody is the Personal Health columnist, a position she has held since 1976. She has written more than a dozen books including the best sellers “Jane Brody’s Nutrition Book” and “Jane Brody’s Good Food Book.”
https://www.nytimes.com/2021/11/15/well/live/surgery-medical-tests.html
At Mass General Brigham, when is enough enough?
State must step in to stop hospital system’s $2.4b expansion
by Douglas S. Brown - Commonwealth Magazine - November 5, 2021
ON AUGUST 19, 2003, I stood in the operating room of Brigham and Women’s Hospital in Boston. My wife was lying supine on a table in front of me and the obstetrician was pulling and tugging at her insides in a manner that exceeded my comfort level. I was running the state Medicaid program at the time, and even though my agency paid for about 30,000 births that year, I had never witnessed one.
In medical terms, the birth of my daughter was uneventful. But not for me. I was uneasy and scared. As it turned out, the physician was a master and performed the caesarean section flawlessly.
Brigham and Women’s Hospital is part of what is now known as Mass General Brigham, the largest integrated health care system in Massachusetts. The care provided in this system is outstanding and the physicians and nurses are among the best in the business. The system seems to have it all: not one, but two world class hospitals; the largest physician network in the state; the highest payment rates; and the most money.
But there is one thing it does not seem to have — enough. The system is now embarking on a $2.4 billion expansion strategy that, if not stopped by state regulators, will threaten the fabric of the fragile health care ecosystem in Massachusetts. And the result will be felt most acutely by those most in need.
A brief primer on hospital finances will help explain why. Hospitals have three primary sources of revenue: Medicare, Medicaid, and commercial insurance. Medicare is the federal insurance program that pays for medical care primarily for those 65 and older. Most hospitals come close to breaking even on Medicare. Medicaid is the joint federal-state insurance program that pays for the medical care of low-income families, disabled individuals, and some seniors. Most hospitals lose their shirts on Medicaid; it pays approximately 65 percent of the cost to provide care to these populations.
If Medicare and Medicaid were the only sources of revenue, virtually all hospitals would be out of business. That brings us to commercial insurance, the third and most profitable source of revenue. This is the insurance that employers purchase to cover the medical care of their employees. It is the only area where hospitals have the ability to negotiate their rates. What they must do is negotiate rates that are at least high enough to make up for the losses from the two government payers. Most hospitals in this state do it just enough to about break even; the median statewide operating margin for hospitals last year was 1.3 percent.
How well a hospital does financially, therefore, is largely a function of how much commercial insurance business it has and how high its rates are for that business. And its rates are determined by its negotiating power. How does a hospital increase its negotiating power? By becoming as big as possible and having hospitals and doctors in its network that patients want to see. If an insurance company cannot do without you in their network, you have a huge advantage in negotiating rates with them.
Mass General Brigham has shrewdly pursued this strategy for decades. Brigham and Women’s Hospital has inpatient rates that are about 30 percent higher than most of its competitors (the gap is even larger on the outpatient side). But there is no material difference in the type of services being offered. Its competitors are all academic medical centers, delivering the same high quality, complex and cutting-edge care.
This bargaining advantage has allowed Mass General Brigham to completely dominate the market in Massachusetts. Its hospital revenues, at over $7 billion, are more than two times those of its next largest competitor. Revenues from its employed physician group are an additional $2.7 billion, more than three times those of the next in line. Its total net assets are now over $10 billion, which is greater than the combined net assets of all six of its next largest Massachusetts-based competitors, including Beth Israel Lahey, UMass Memorial Health, Baystate Health, Wellforce (which includes Tufts Medical Center), Dana-Farber Cancer Institute, and Boston Medical Center.
So why is this bad? Why shouldn’t market dynamics and competition be allowed to play out like in other sectors of the economy? There are many reasons, but the first is that if you are trying to control costs in health care, expansion of the largest, most dominant and most expensive system in the state does not help. It has the opposite effect.
And the state desperately wants to control costs. It passed a law in 2012, known as chapter 224, to try to do just that. But while well intended, it missed the mark. The reason is that it focused only on limiting cost growth and not on the underlying price disparity that exists between providers. As a result, it baked into law the huge advantage that Mass General Brigham already had. And Mass General Brigham has prospered as a result.
But there is a bigger reason why the bargaining advantage of Mass General Brigham is bad for society. It’s equity. This is a zero-sum game. There is only so much profitable commercial business to go around. As Mass General Brigham uses its market power to acquire more of that commercial volume, it is taking this market share from other hospitals who tend to serve higher percentages of Medicaid members and other low-income populations. These other hospitals rely on the substantially lower commercial volume they have to help cover their losses on Medicaid. When they lose even a small amount of that commercial business, it destabilizes them and hurts the vulnerable constituencies they serve. That’s exactly what has played out.
Community hospitals in particular are sucking wind right now. The aggregate operating margin for all community hospitals in the state last year was a negative number and the lowest it has been in five years. This summer the Boston Herald reported that 28 safety net hospitals in Massachusetts are on “life support” and are being pushed to the brink of closure or program cuts. And this is after receiving federal and state COVID relief funding to help. Their latest troubles have been caused largely by COVID, to be sure. But that’s exactly the point. These hospitals operate on such a slim margin that any unanticipated environmental event can push them over the edge.
But there is something else at play that needs to be addressed directly. It is not just that the populations most severely impacted by these market dynamics are from poor neighborhoods. It is that they are also disproportionately communities of color.
State Sen. Barry Finegold of Andover represents the city of Lawrence, where more than 85 percent of the population is from a minority community. On a debate in the Senate earlier this year, he noted that Lawrence General Hospital gets a commercial payment rate of $100 for a basic chest X-ray, but Massachusetts General Hospital gets $180 for that same chest X-ray. He called this disparity and others like it “a manifestation of systemic racism in the insurance industry.”
To be clear, there are no racial motives behind Mass General Brigham’s market strategy. On the contrary, the hospital system employs some of the nation’s leading experts on health equity and diversity and has made meaningful contributions to the field. The system recently announced a $50 million investment in mental health and community healthy equity.
While significant and laudable, this investment pales in comparison to the hundreds of millions of dollars Mass General Brigham is investing toward expanding access for already well served affluent communities. And if these expansion strategies worsen existing racial disparities, Mass General Brigham must answer for them, no matter how much good it may be doing elsewhere.
That brings us to Mass General Brigham’s current expansion proposal. The $2.4 billion spending plan appears to be the biggest ever proposed in the history of Massachusetts health care.
While Mass General Brigham did not plan it this way, the timing could not be worse for vulnerable providers and populations. We are in the midst of the worst world-wide pandemic in a century. Safety net hospitals are as vulnerable as they have ever been. And we are now facing in health care the worst workforce shortage crisis in decades. And yet, this is the time Mass General Brigham is planning to double down on its market dominance and add significantly more capacity. Really?
The most glaring example of the deleterious effects of this strategy can be seen by looking at the hospital system’s plans to place a facility in Worcester County. It is hoping to build a 62,000-square-foot facility in Westborough at the intersection of Routes 9 and 495 that will effectively serve as a mini-hospital. The proposal calls for a multidisciplinary outpatient clinic that will have primary care, 11 different subspecialty services, imaging, surgery, and behavioral health.
It is hard to escape the conclusion that Mass General Brigham chose this site specifically to “cherry pick” the profitable commercial business and leave the care for Worcester County’s low-income patients to everyone else. Westborough residents have a median income in the top 20 percent of the state and most of these residents are commercially insured. Westborough also has a very low percentage of Medicaid patients and these patients could not get to the proposed site anyway because it is not accessible by public transportation. Perhaps even more troubling is the fact that fewer than 2 percent of Westborough residents are Black and fewer than 1.4 percent are Hispanic. (The comparison for the state as a whole is 9 percent Black and 12.4 percent Hispanic. For Worcester it is 13.3 percent Black and 21.9 percent Hispanic.)
Picking off this commercial business in central Massachusetts will be destabilizing to providers in the region and the patients they serve. This is especially so for UMass Memorial Health, the largest safety net system in central Massachusetts and the system where I work.
But why should anyone cry for UMass Memorial? It is a $3 billion system. Can’t it take care of itself? The answer has to do with the level of the playing field. Competition only works if it is fair. And this is not.
The numbers tell the story. First is the payer mix. Commercial business makes up about 30 percent of the revenue of the average hospital in Massachusetts. That is about what it is for UMass Memorial. Mass General Brigham is at 40 percent. This difference is massive. For example, if UMass Memorial could trade just 5 percent of its Medicaid business for commercial volume, getting halfway to Mass General Brigham’s mix, it would result in an extra $50 million to the bottom line.
Then there is the rate advantage of Mass General Brigham. If UMass Memorial got paid the same inpatient rates as Mass General Brigham, it would result in an additional $200 million per year to the bottom line.
So Mass General Brigham has 10 times the net assets, much more high-paying business, and much higher rates for the business it has. But that’s not all. UMass Memorial is a private, non-profit organization, just like Mass General Brigham. But the state has imposed two specific obligations on it that it has not imposed on Mass General Brigham. Both are designed to serve the public interest. The first obligation is to serve as the safety net for the region and to take care of the most vulnerable patients. This is reflected in UMass Memorial’s Medicaid payer mix, which at 25 percent is more than double that of Mass General Brigham. The second obligation is to financially support the T.H. Chan School of Medicine, the state’s only public medical school.
UMass Memorial takes on these important responsibilities with pride. But how can government impose such a weight on its shoulders, bake into law certain unfair advantages for Mass General Brigham, and then expect UMass Memorial to out-compete Mass General Brigham for commercial share? It can’t. And this same inherent unfairness, to varying degrees, plays out with virtually every other hospital in the Commonwealth.
We cannot blame Mass General Brigham’s leaders for this situation. Most health care leaders in their shoes would do the same thing: maximize their advantages within the rules and take what they can to further the interests of their organization and its patients. It is up to our government to fix this.
Health care is not like making widgets. It is intimate and personal and part of the ingredient of living a good life. For this reason, we care a lot about it and we ask our government officials to play an outsized role in helping to guide the system and protect all of us. That is especially true in Massachusetts where we have chosen to treat health care as a right effectively guaranteed to all citizens.
We care deeply in this state about the greater good. Doing so has paid huge dividends. Massachusetts is routinely listed as among the best states in the nation for health and health care. This civic-mindedness also resulted in our state having one of the highest COVID vaccination rates in the country, undoubtedly saving thousands of lives.
But maintaining this high perch requires a not-so-invisible-hand balancing all of the interests at play. Private interests, including even the convenience of some Westborough residents, must at times have to give way to the public good. We have reached that point with Mass General Brigham.
Our health care ecosystem is at a crossroads, much like that little girl who came into the world before my eyes in a Brigham and Woman’s operating room. My daughter is off to college next year, and is filled with hope and expectation, but uncertain of what her future has in store. So, too, the people of Massachusetts, who envision a health care system that delivers high quality, equitable care to all.
There are several government actors with the tools to stop Mass General Brigham’s expansion and pull us back from the brink. Will they act? Who will be the heroes in this drama? Who will be its ostriches? As a society, will we lean in to make the hard decisions necessary to preserve our fragile system? Or will we shrug? Only time will tell.
Douglas S. Brown is president of community hospitals and chief administrative officer at UMass Memorial Health in Worcester. Prior to coming to UMass Memorial, he spent 10 years in public service in Massachusetts, including as its Medicaid director.
White House to invest $1.5 billion to attract more doctors to underserved communities
The money will be able to support nearly 23,000 providers through two national medical programs
by Akilah Johnson and Danielle Douglas-Gabriel - Washington Post - November 22, 2021
The Biden administration on Monday announced $1.5 billion in funding to help eliminate the shortage of doctors and nurses in underserved communities by providing scholarships and repaying the student loans of providers who work in medically needy areas.
The pandemic has highlighted what has long been a barrier to accessing quality medical care in rural areas and communities of color: provider shortages. The lack of primary care physicians hindered testing, treating and educating patients about the coronavirus and the vaccines, and now growing staff shortages in hospitals are aggravating an already inadequate health care infrastructure.
“Our nation must invest in a health care workforce that looks like America and provide access to equitable health care for all Americans,” Vice President Harris said at a briefing Monday. “There is more work to be done, but I believe we are headed in the right direction.”
The money, made available through the American Rescue Plan, will be able to support nearly 23,000 providers through the National Health Service Corps and Nurse Corps, according to the White House.
There are more than 16,000 clinicians caring for millions of patients through the National Health Service Corps, which was founded in 1972 in response to dwindling numbers of primary care physicians. They work in areas with limited access to health care and, during the pandemic, thousands served in community health centers and hospitals across the country, administering coronavirus tests, caring for infected patients, and putting shots in arms.
National Health Service Corps funding supports four loan repayment programs for medical, dental and mental health professionals. In exchange for two to three years of work at an approved site, participants can receive up to $100,000 in loan forgiveness, depending on the line of service. Scholarships are also available for students willing to commit a minimum of two years in exchange for a full year of funding.
Participation and funding have increased over the years, but demand in some programs has outpaced the money available to support them. An audit released in June by the Government Accountability Office found 43 percent of the more than 11,100 providers who applied to programs did not receive funding in fiscal 2020. While some applicants were simply ineligible, others were rejected because the limited funds are prioritized for those serving in areas with the most severe shortages.
The funding, according to a White House official, is in response to recommendations from the White House Covid-19 Health Equity Task Force to invest in a representative health workforce and increase equitable access.
According to the Association of American Medical Colleges, about 17 percent of doctors in the United States are Asian, 6 percent are Latino, 5 percent are Black and less than 1 percent are American Indian and Alaska Native.
Medical school student loan debt, which averages more than $200,000, is often a barrier to pursing graduate studies in health care, which the National Health Service Corp helps offset through the scholarships and loan repayments. More than 25 percent of the physicians in the group are Black and Latino.
Luis Padilla, an alumnus and the director of the National Health Service Corps, called the program “life-changing.” He said, “This is particularly true for clinicians of color and those from underserved communities who otherwise might not be able to become primary care doctors, nurses, dentists and behavioral health providers.”
He added, “Because of these programs, they can help ensure that patients in these underserved communities see themselves in the clinicians who care and provide them care.”
https://www.washingtonpost.com/education/2021/11/22/white-house-doctors-forgiveness-scholarships/?
