Medical Pricing Transparency via Non-Transparent Rule

copyright 2015 Daniel Ginsberg PhotographyHidden in a 700-page draft regulation to improve patient’s access to their electronic medical records is a proposal to require doctors, hospitals, and other healthcare providers to publicly reveal the prices they have negotiated with insurers. This rule, tied to the 21st Century Cures Act, would set the stage for eventually making prices publicly available. Although price transparency may be a good way to help lower medical costs, it’s ironic that there is a lack of transparency when it comes to the proposed rule. I challenge you to read the Title, Summary, or Actions section and realize that it includes such a major change (hint – in the PDF document it’s on page 7513 of the Federal Register under Price Information).

On the face of it, making prices readily available sounds like a no-brainer, but I think it’s more complicated than that, and there may be unforeseen consequences. The rule is long and complex, and I don’t have the few days it would probably take me to really understand it, but let me play devil’s advocate. Some of the comments posted say that medicine is the only industry that hides the cost. To a certain extent that’s true, but this rule could go beyond just saying the price consumers pay. If you go to a restaurant they won’t reveal how much they paid for the the ingredients. If you book through a 3rd party website, they don’t tell you how much, if any, they pay them for the referral. When you buy a car the dealer usually doesn’t tell you if the automobile manufacturer is giving them a rebate. From the point of view of a business, the consumer shouldn’t get to know their internal costs as that’s secret competitive information.

What mitigates that argument is that the price of healthcare has gotten out of control. Despite being better educated about the matter than most, when it comes to getting healthcare for their own family I suspect most physicians struggle to understand their bills just like everyone else.

When it comes to pay, doctors are a commodity. For a given surgical procedure or office visit of a certain complexity, they are paid the same amount as mandated by Medicare or Medicaid, as negotiated with insurance companies, or their list price for the unfortunate cash patient. Just like any profession, some doctors are better than others. If you want to hire a top lawyer or an A list actor, you have to pay top dollar.  But that’s not so with much of healthcare. The price doesn’t necessarily reflect the quality of the care.

Hospital systems mitigate that somewhat. They can negotiate higher prices with insurance companies and with large employers by demonstrating that they provide higher quality care and/or lower cost care, or because patient perceive them as providing superior care and they demand that that can get care from them. What will happen if the rule goes into affect and patients can easily compare prices? I don’t know, but potentially they might choose the lowest cost without regard to quality. That could lead to systems competing on price, cutting corners to do so, and ultimately lowering quality.

The lowest price might actually not be the path to cost savings. Imagine two surgeons. One of them charges $5,000 for a knee replacement, and operates on 60% of the patients seen for knee arthritis, treating the rest successfully with injections and physical therapy, which on average costs $1,000. The other charges $7,000, and operates on 50% of the patients seen and treats the rest successfully with the same conservative measures. Besides the physician fee, the hospital system charges $10,000 for the surgery. In this example, treating 100 patients would cost $940,000 for the first surgeon, and $900,000 for second. So even though the second surgeon charges 40% more than the first, on average the doctor ends up being cheaper when it comes to managing knee arthritis.

I’m inclined to support more transparency in healthcare pricing, but I don’t know how much of an impact it will have, and there may be unintended consequences.

Don’t expect to see published prices anytime soon. Even if the proposal goes forward, following a public comment period that ends May 3, it’s likely to be tied up in legal challenges for quite a while.

National Guideline Clearinghouse Goes Kaput

Although the practice of medicine has existed for thousands of years, it substantially improved with the implementation of the scientific method. Experiments and research studies improved diagnosis and treatment. Now so much information is published that no person can read everything unless, possibly, it’s limited to an extremely narrow subspecialty.  In addition, different studies can come up with opposing results, and it can be difficult to make sense of all the available information.

To remedy that, various groups have published guidelines to help clinicians decide what to do. For example, new guidelines for high blood pressure were recently published. The American Diabetes Association just updated their guidelines for Standards of Medical Care in Diabetes.

So how does one find out about existing guidelines, other than doing a web search or coming across it in a journal? Well in 1998 the National Guideline Clearinghouse was created. It formed a collection of guidelines that met minimum quality criteria. By June 2018 there were more than 2000 guidelines listed that could be searched by specialty. In July of 2018 all of that information became unavailable on the website because of federal government budget cuts.

The website was originally created by the Agency for Healthcare Research and Quality (AHRQ), in partnership with the American Medical Association (AMA) and the American Association of Health Plans (now America Health Insurance Plans).

In the last year of operation, the National Guideline Clearinghouse’s budget was about $1.2 million dollars. This is only about 1% of the money spent globally on developing guidelines, and an even much lower percentage of the cost of medical care. The guidelines can improve care and save money, but only if people can find them. Both my company’s electronic health record and my county medical society’s website have the National Clearinghouse Guidelines integrated to reach them with a click. I’m sure we’re not the only ones who routinely used it.

Perhaps a better repository can and will be built, but in the meantime I think the government should fund the National Guideline Clearinghouse and bring it back online.  This was not a case of trimming fat from the national budget, but a self-inflicted stroke where the government cut off the blood flow (money) to a portion of our collective brain. We’re the worse for it.

Fever – Hot Off the Press

Whether your mother taught you, or you learned it in medical school, chances are you’ve been told that 98.6° F (37° C) is the normal body temperature, and greater than 100.4° F (38° C) is a fever. It turns out it’s more complicated than that.

Those numbers came mainly from the work of Professor Carl Wunderlich. In 1870 he published an enormous study of over 1 million temperatures taken from about 25,000 patients. The thermometer he used was calibrated differently than modern thermometers, and he took temperatures in the axillae (armpit), which varies from oral (under the tongue) or tympanic (ear) measurements. He found that temperatures tended to be higher in the morning, and higher in women.A study published in JAMA in 1992 looked at patients 18 to 40-years-old who were hospitalized for a vaccine study. Prior to getting the vaccine, their temperatures were check 4 times a day for 2 ½ days. They found the upper limit of normal to be 98.9° F (37.2° C) in the early morning, and 99.9° F (37.7° C) overall.

A study that looked at 18,630 individuals from 20 to 98-years old showed women’s temperatures ran 0.3° F higher than men, and temperatures tended to decrease with age, with a 0.3° F difference between the youngest and the oldest.

An article published 13 August 2018 used an iPhone app called Feverprints. They looked at  11,458 oral temperatures recorded from 329 healthy adults and found an average normal temperature of 97.7° F, and that a fever started at 99.5° F.

I’ve often had patients tell me that a temperature we would normally consider within normal limits is high for them. That’s a good observation. There is a certain amount of normal variation in temperature by individual and time of day. It doesn’t necessarily mean it’s something that should be treated, but it may be a sign of infection and should be considered accordingly.

Drawing Lessons From a Disaster

Three days ago an engine explosion on Southwestern Airlines Flight 1380 caused a sudden cabin depressurization. Oxygen masks dropped as designed, but as reported by the New York Times, photos showed that many people had the mask over just their mouth, and not the nose and mouth as instructed. The conclusion? Passengers didn’t pay enough attention to safety instructions.

Although that is probably true, I don’t think reminding people to pay attention is really the answer.  As a physician, I have to re-certify in CPR every year. It’s not just the knowledge, it’s practicing it and getting muscle memory. Even with that, my skills surely deteriorate as I rarely have to do CPR now, and practice makes perfect. The key point is that passengers don’t get to practice. If you’ve ever taken a cruise, you know that shortly after you board, they have you actually go your assembly point and actually don a life vest. They don’t have you watch someone put on a vest, and they don’t point to where you should go.

As a medical student in the Air Force, I had the opportunity to take altitude chamber training. This is where you are in a chamber where the oxygen and pressure simulates being at high altitude, such as 25,000 feet. You then take off your oxygen mask to learn how you are affected by hypoxia (low oxygen). You are supposed to observe a few of the effects, then put your mask back on. I remember noticing some of the changes with curiosity, then someone tapping on my shoulder and telling me I had passed out. When I told him I hadn’t, he asked me who put my mask back on. At that point I realized that I had passed out, and it drove home the point of why they tell you to put the mask on yourself first, before helping your kids or anyone else. Otherwise you may pass out, then you are not in a position to help anyone else.

The article quoted a retired flight attendant as saying it didn’t matter that people didn’t have the mask over their nose as they could breath through the mouth. Although that’s true, that doesn’t mean they necessarily did. Many people breath through their nose most of the time, and in a high stress situation they may not necessarily realize that the mask is not covering their nose, or if they do, that they should breath through the mouth.  A better option might be to make the masks shaped more like a mask designed to cover the mouth and nose. You know, kind of oval shaped, not a circle.

It certainly not possible to put everyone who flies on commercial planes through altitude chamber training, but actually practicing putting on a mask would make people more proficient if they needed to do so in an emergency. On an airplane it may not be practical to do so because of the need to clean the masks, but in the terminal they could put booths where people could practice putting on masks, that could be cleaned and reused, and life jackets  to practice putting on, all while waiting for their flight. They could encourage participation by giving people who do so coupons for a snack or to be eligible to win a prize each flight.

Wasting Resources – A Day in the Life of Yours Truly

I’ve written before about some of the things that waste physicians time, and how trying to be a good steward of resources can be frustrating. As the saying goes, no good deed goes unpunished. So here are three such things I dealt with the day after April Fool’s Day.

I prescribed the diabetic medication alogliptin, the generic of Nesina, for one of my patients on a Medicare Advantage plan. I was told it wasn’t covered, but they would cover substitutes, including Januvia (sitagliptin). The cash price is a little over 4 times as much for Januvia! I don’t mind using Januvia from an efficacy point of view, but it was a waste of my time having to make the change, and tax payers are wasting money buying a more expensive drug. After any negotiated deals it may not be 4 times as expensive for the plan, but it’s hard to imagine it would be a cheaper option than what I prescribed.

I ordered a head MRI for one of my patients. A week ago I called Molina insurance after receiving a message that they required a peer to peer phone conversation with another physician. After 10 minutes on hold I left a message explaining why I had ordered the MRI (which I had already explained in my note and on the MRI request). As they still hadn’t approved it, I called back again today. I spent 3 minutes on hold, then 8 minutes talking to a staff member before she transferred me to a physician, then 3 minutes with him as he gathered the basic information then approved it. I did not give him any more information than I had provided in the first place. He said he didn’t have any information on why I had ordered the test or he would have approved it right away.

And the third thing? I can’t remember. No fooling!

As If I Have Nothing Better To Do

Ask most primary care physicians and they will probably tell you they waste a lot of time getting medications approved for their patients. I just dealt with this for one of my patients. He had been on it for four years, but they wanted some information from me. It seems they didn’t trust my judgement and wanted recent lab work to confirm he wasn’t taking too much, even though I had him on the lowest dose. The patient has insurance with Regence, and OptumRx manages the prescription benefit.

I called OptumRx and they first asked if I was a member or calling from a provider’s office. Well if they had separate numbers for each they wouldn’t have to waste time asking that question. Next they asked for my name and title. Then they asked for my NPI number. Once I gave it to them they looked up my name, so they could have skipped the question of my name and merely confirmed it after they had obtained it from the NPI number. Actually they should have already had my NPI number as it was attached to the prescription, that they paid for, and I’m sure is in their records already as they get that information when physicians apply to see (and bill) their patients.

Next they asked for the patient’s member ID number. I told them I didn’t have it, but I did have the reference number they gave when they asked for me to call. I was told they couldn’t use that information, so they asked for the patient’s name and date of birth. I gave it but the person couldn’t find the patient in their system. So she then asked for that reference number. After a while she said that patient wasn’t in the group she managed and she would have to pass me on to someone else.

The next person again asked some identifying information then wanted to know a test result the patient had, as well as the normal range for that test. I gave the three numbers and she said they would be in contact. Less than 30 minutes later it was approved, but that whole call took 9 minutes! That’s an incredible waste of my time just to give 3 numbers. They could have just asked my nurse to give the lab results to them over the phone or fax it to them and not have wasted my time at all. Besides the time I spent, there was also the time spent by a couple of staff members to get the message to me, and the subsequent fax confirming that it had been approved. We deal with lots of these things every day. If physicians were their paying customers, they’d be out of business with service like that.

Trying to Destroy Healthcare the Ostrich Way

Copyright: <a href='https://www.123rf.com/profile_andreykuzmin'>andreykuzmin / 123RF Stock Photo</a>Ostriches reportedly stick their heads in a hole if they see something they fear. If they can’t see it, then it must have gone away. President Trump, with most republicans lawmakers going along, is trying that same tactic on the public. Despite 7 years of promises, and multiple attempts, Republicans have been unsuccessful overturning the Affordable Care Act, otherwise know as ObamaCare. So Trump has been doing everything he can to destroy it, with the hopes that it will wither and die, then he can blame Democrats on it’s demise, claiming it was bad legislation. This despite not having a good alternative.

One of the efforts have been to keep people from signing up for coverage for next year. The Trump administration has cut the advertising budget by 90%, shortened the enrollment window, and will close the site on some Sundays for, “maintenance.” They figure that if people can’t see it, they will think it must not be there.

Well sign up just started. If you don’t otherwise have coverage, such as through work, sign up right away, while you still can.  You must sign up by 12/15/17. Don’t wait until the last minute as you might not be able to get on the site. Don’t be scared off by reports of premiums going up. Although true, subsidies also go up per the law, and it costs nothing to find out what it would cost for coverage. Go to healthcare.gov.

Regulators Asleep at the Wheel

Recently the Federal Railroad Administration and Federal Motor Carrier Safety Administration said they would no longer continue pursuing regulations requiring testing for sleep apnea in truck drivers and train engineers.

Sleep apnea is a condition where, in the most common form, the airway is partially blocked during sleep. This leads to daytime sleepiness, increasing the risk of accidents, plus is otherwise hazardous to patient’s health if untreated.  The National Transportation Board determined that a 2013 train derailment that killed 4 and injured 59 was a result of undiagnosed sleep apnea. According to the railroad Metro-North in the New York City suburbs, 11.6% of it’s train engineers have sleep apnea.

Screening involves an overnight sleep test.  We require our pilots to get tests for drug use. Why would we not want to test truck drivers and train engineers for a common problem that is just as dangerous? It’s part of President Donald Trump’s campaign to cut federal regulations. Although some regulations are excessive, this is not one of them. What’s next, repealing seat belt and motorcycle helmet laws?

Politicians Playing Doctor

Recently the British baby Charlie Gard has been in the news. Unfortunately he was born with a rare disorder called Infantile Onset Encephalomyopathic Mitochondrial DNA Depletion Syndrome. The parents of the 11-month-old boy have been in a court battle with the London Hospital caring for him since October. The hospital obtained a court order to remove the boy from life support as the doctors treating him said his condition was terminal and that treatment would just cause the boy additional distress.

The parents have held up hope for an experimental treatment with nucleosides a U.S. doctor has offered, even though he had not examined the patient. In fact no person or animal with Charlie’s condition had ever received the treatment. Reportedly 9 patients with a related disease had some improvement with the treatment.

President Trump weighed in:

Recently Republican House Congressmen Brad Wenstrup (Ohio) and Trent Franks (Arizona) said they would introduce a bill to give Charlie permanent residency in the United States so he can travel for the experimental therapy.

I sympathize with the parents. It’s awful to see your children with serious illness. However sometimes stopping care really is the best thing to do. The US doctor reportedly said a 10% improvement in strength was possible. But that’s the same as saying you can go from lifting 10 lbs to being able to lift 11 lbs. It’s just not going to make a significant difference.

I also believe in research studies. In fact close to 20 years ago I had a patient with a different neurological disorder who could not be removed from a ventilator. I received FDA approval to administer an experimental treatment. It may have helped – they did get off the ventilator, but they died not that much later. That drug had preliminary treatments in animals, then in humans.

If our politicians were really that concerned about the health of an infant in another country, maybe they would accept refugees from countries such as Syria, where innocent people have been in terrible conditions. Their chances of improvement would practically be guaranteed. Unfortunately for Charlie, that’s just not realistic.

Exploring Cuba – Part 2

In my prior post, I discussed a trip I made to Cuba in December. In this second part I will focus on some medical aspects.

When my patients ask about foreign travel where there may be health concerns, I usually direct them to the CDC site. It’s also where I go to check for my own travel, though I look at the more detailed Clinician view.  To start off it recommends typhoid vaccination.  You have a choice of the oral or injected. The oral is a live virus that is taken every other day for 4 doses, starting 12 days before potential exposure. It gives better immunity, but should not be taken by people with a suppressed immune system, such as those on steroids. The injected form is a non-live vaccine, a single injection taken at least 2 weeks before potential exposure. The injected form is harder to find, and even pharmacies that carry it may need to order it in advance. The injection is more expensive, and neither vaccine is usually covered by one’s health insurance. There are other vaccines recommended, but typhoid was the only one I needed.

Cuba has mosquitoes that may carry Dengue Fever, and more recently Zika. I chose to travel in December because it was outside hurricane season, it was the cooler time of the year, and there are less mosquitoes around that time. Cuba does a better job than many other countries controlling mosquitoes, but I was still cautious. Due to the cost, they don’t use insecticides to fumigate buildings, but rather burn oil, as can be seen in the photo above. We checked in to one place not long after they had done their weekly spray, and had to wait 30 minutes for smoke to stop poring out the window! I sprayed much of our clothes with permethrin spray, and applied DEET to exposed skin, especially in the evening when the mosquitoes are more apt to bite.  I texted PLAN to 855-255-5606 to get periodic updates from the CDC about Zika before the trip.

Food is generally safe to eat, but we avoided street food. The tap water is not safe, however. We mostly depended on bottled water and avoided ice except at a few restaurants and bars that filtered their own water. Bottled water is kind of pricey at times. The best deals are on large (3-4 liter bottles) that you can find sometimes in stores. They often cost the same price or less than a one liter bottle that is more readily found. I also brought along a SteriPEN which sterilizes water with ultraviolet light. I didn’t have enough experience to trust it completely to replace buying bottled water, but used it to sterilize water to rinse our toothbrushes, and would have used it if we didn’t have bottled water. I also recommend bringing Imodium, and an antibiotic from your physician for traveler’s diarrhea. I’d also bring some toilet paper. Many public toilets often didn’t have any, or  you’d get a small amount from an attendant after giving a tip.

Bring sunscreen. It’s not easy to find places that sell it in Cuba, and it’s expensive.

Months before my trip I tried to arrange to visit a hospital. It so happened that the fiancée of a Cuban in the travel industry who helped with some of the arrangements was an anesthesiology resident. He told me that he would love to show me his hospital, but that unfortunately the government required a 30-50 dollar payment, despite the fact that I said I would be bringing some medical supplies. He also said I would not be allowed to tour the medical school due to, “national security!” After I arrived we talked a number of times, and ultimately he could not get government approval for me to see his hospital, even though he said everyone at the hospital wanted me to come. He said the only exceptions they made were for those with an educational visa, coming to teach basically, and even then they needed at least 3 months notice.

Although I could not tour the hospital, I had some long conversations with that doctor and learned a lot about their system. All things considered, the Cuban doctors are apparently pretty good, but they are particularly hampered by old equipment and lack of medications and supplies. The anesthesiology resident showed me photos of anesthesia equipment they currently use that are from the 1980’s. He said they don’t have air scrubbers in the operating rooms, so sometimes everyone gets sleepy!  He told me about a colleague of his who was working with a nurse anesthetist. She let her go home early because she wasn’t feeling well. Later she had to intubate a pregnant patient. Unfortunately it didn’t go well and the patient suffered brain damage. During a subsequent investigation the government argued that had she not let the nurse anesthetist go home early, maybe the patient wouldn’t have died because she would have had additional help. She was sentenced to 12-15 years in prison, and even if she gets out after 5-7 years for good behavior, she won’t be allowed to be a doctor anymore! Because physicians are held responsible for a bad outcome, Jehovah’s Witness patients are told they can’t refuse blood if needed, though they do take measures to minimize the need. Doctors are paid poorly (the resident said after he finished he would make 80 CUC (about $80) a month), often less than taxi drivers. It’s very difficult for specialists to be allowed to leave the country, even on vacation, for fear they won’t come back. If they go on medical missions they are paid better than usual, but they only pay them the bare minimum while they are abroad to encourage them to return home after the mission. I was surprised to learn that they are fairly tolerant in terms of LBGT, in part due to Raúl Castro’s daughter, and they even have doctors who do sex reassignment surgery to change gender.

Many Cubans rely on natural formulations, such as herbs, they call ‘green medicine,’ due to cost or personal preference. The anesthesiologist told me that for a man to get a prescription for Viagra (sildenafil) he has to see his primary care doctor, a urologist, and a psychiatrist. Once they get a prescription, though, they are basically assured of getting it indefinitely. He said many patients research their condition and tell their doctors what prescription they want, and they often comply.

One of the most dangerous things in Cuba are the cars. They are famed for their old cars, many of which look fabulous, but they lack safety features, such as seat belts and airbags. In fact we were in a car accident. We hired a car and driver for 6 days through a contact in the travel industry in Havana. He was probably around 60-years-old, and reportedly one of their best drivers. He was very nice, funny, and knowledgeable, and arrived to pick us up in a pretty new Chinese car, a BYD (Build Your Dream). On the first day as we were driving, while my wife and daughter were sleeping in the back, the car started drifting to the left. I grabbed the steering wheel, noting the driver had fallen asleep. He quickly awakened, pulled the car to the side of the road, and got out to stretch. He came back in and apologized, saying he had gotten up early to pick the car up. The next day he said that actually he hadn’t slept well because he had witnessed a teenager, who was not paying attention listening to music, hit by a car the day before.

In the middle of the car trip I met with the doctor I mentioned above and told him about the incident. I wondered if he might have sleep apnea, though the driver had said he had never had such a problem.  He said that they don’t test for sleep apnea because they don’t have CPAP machines to treat it.

The rest of the road trip went fine until the final day. Once again my wife and daughter were sleeping in the backseat when the driver fell asleep again. This time he swerved too quickly for me to reach the wheel. We hit a guard rail, damaging the front end and side mirror and puncturing two tires. The driver said he did not know why he fell asleep and that he had been well rested. One theory I came up with is the possibility of carbon monoxide poisoning from a leak in the exhaust system. Our driver obtained another car and driver for us, who brought us back to Havana.

No one was serious injured, but my wife was seated behind the driver and her left elbow hurt immediately afterward. Back in Havana we went to a clinic that caters to foreign visitors. X-rays showed no fracture.  She was given a skinny piece of gauze to use for an arm sling (she had been using my belt up until that point). When it came time to leave they said we owed 100 CUC (about $100).

Boarding Pass

 

Cuba requires one to have medical insurance to visit the country, and they add $25 to the price of each airline ticket to cover it. Delta Airlines said to show the boarding pass if needed as proof of insurance. I showed the boarding pass, but they said it wasn’t good because it said AeroMexico on the top. I pointed out that below that is said that it was operated by Delta Airlines. They said they would have to investigate it. They gave no indication how long it would take, and given that it was the evening I didn’t think they would get an answer that night. I eventually gave up, paying the money so we could get her passport back and leave. I wrote Delta Airlines and explained the situation, sending them copies of the boarding pass and the medical bill. We were on something like their 4th commercial flight to Cuba, so I figured they would be eager to work out any glitches. I was wrong. Besides some email exchanges, they called twice at 7 am. When I pointed out the early hour I was told it was 10 am on the East coast. You would think an international airlines understood the concept of time zones! In any case, ultimately I was told we, “..must request a refund of the insurance premium directly with the Cuban insurance provider.” Really? They expect their customers to request a refund from the Cuban government?! All I was asking for was the approximately $100 I paid for the clinic. Not the taxi ride there and back, the medical costs after we got home, to say nothing of pain and suffering. Imagine someone of lesser means ended up needing much more care and being told the insurance they thought covered them didn’t. That might keep people from choosing to visit Cuba, at least on Delta Airlines.

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