Politics in healthcare - A day in the UVa ER

[Bill Glasheen]

Given the political discussions going on about Obamacare, I thought this very nice article about the ER of my former alma mater (and subsequent employer) was interesting. This is also the place where Ian got his medical education before heading north to Harvard/Beth Israel and then the left coast.

This is worth the read.

'24 hours in the ER' shows challenges of health system

- Bill

[Bill Glasheen]

For those who prefer to watch rather than to read a long article, there are a series of videos here showing the good, bad, and ugly of the health care debate.


Video: Dispatches from the front lines of the health care debate

If you aren't from the area, you might not appreciate the subtle clash of cultures here. UVa is in Charlottesville and Albemarle County - home of many Hollywood stars who want to get away from the left coast and around a multicultural, academic area in the bucolic valley of the mountains that Jefferson loved so much. However, UVa hospital is also a magnet for patients from surrounding rural counties. It's an intern and resident's dream. You want to see it all? Well it's here. You want human lab rats to develop new medical technologies? You'll find an appreciative crowd right here.

If you like listening to regional accents, you'll love these video clips. I could have picked out the counties before the various parties mentioned where they were from.

- Bill

[Bill Glasheen]

Patients like these help me develop software used to predict future costs as well as opportunities for better care. Like Pareto's 80/20 rule of economics, a handful in a population are responsible for most of the consumed care.

Chronic conditions crank up health costs

- Bill

[Dale Houser]

Take it for what it is worth, but this particular episode of HDNet World Reports had a great piece on Hospitals and Emergency Room crisies. http://www.hd.net/worldreport_epguide.html

It is episode 713 and available on iTunes if you don't get this channel and you're so inclined to buy it. The full title of the episode is: Emergency: Hospitals on the Brink; Russia's Jewel: Religion and Nationalism in Tatarstan; Acid Attacks: Juliette's Story.

[IJ]

Awww, good ole UVA. I recognize the floor plan, under construction the last time I was in there. If I recall an Indian psych resident with a thick accent was interviewing a farmer with a cowboy hat and a mouth full of chewing tobacco: "Telling me again what symptoms have you are?" The only response was a stare and "whhhhere you FROM?" The resident ordered the ER to give him a hefty dose of oral potassium and began to VERY slow write admit orders--which he tore up the moment the patient began vomiting in response. "Oops, I guess he'll have to go to medicine," he said with a grin. Good times.

"He lost the third [kidney]— donated by his wife — at age 48, because of a rare reaction to a dye that doctors used to view the blockages in his arteries."

How much would it really take to get docs to edit these pieces? Contrast nephropathy is the THIRD most common cause of renal failure in hospitalized patients and we would be quite scared to give contrast to someone with a single or transplant kidney.

And I must have missed the part where a baby with a seizure needs to see a cardiologist. Parts of story left out vs wherever did those rising costs come from?

These statements concern one person, believe it or not:

"During that time, her insurance will cover just one ER follow-up visit." ... "When she had a sinus infection last year that required surgery, "I was on the Internet, trying to figure out what was going on," Susan Herzog recalls. "I felt the onus was on me." ... "Despite her complaints about the HMO, she prefers private insurance because she fears a government-run plan would limit her choices."

" ... Her daughter has Type 1 diabetes, but Medicaid refused to pay for a state-of-the-art insulin pump. The premiums strained the family's budget, but Garrett added her daughter to her insurance plan for a year so she could get a pump."

Costs, again... the VAST majority of type one diabetes are treated without a pump and do well. Some with pumps do worse. There is, in fact, no reason to put a little girl on a pump when injected medicines will do the trick. I have met teenagers (not known for their great diabetes self care) with awful control on pumps and I've met a man who nearly died and required dialysis for complete kidney failure. He'd received his magic pump 2 days earlier and didn't notice that the insulin wasn't infusing. He'd been adequately controlled on injected medicines previously. Here again, another cost and expense without clear benefit.

[Bill Glasheen]

Since I did a lot of research using contrast agents in myocardial perfusion studies, I was wondering - what do they use for contrast nephropathy these days? (I know a few things they shouldn't use...)

Costs, again... the VAST majority of type one diabetes are treated without a pump and do well. Some with pumps do worse.

She wants deluxe. So she gets her kid on insurance long enough to get it paid for, and then gets off again. WTF???

Reminds me a bit of people who would get on the local news because "Blue Cross" wouldn't pay for an electric wheelchair. But by golly she was seen making it around town with little problem. If only she would lose a few hundred pounds... But BCBS had to keep tight-lipped and not respond to the media assault. Patient confidentiality, you know...

I think insulin pumps are a nice convenience when they work. But I agree that they are an expensive convenience therapy and definitely not a cure. I'd a lot rather see them working on Islet cell implants (from stem cells??), and/or therapy that stops autoimmune responses that may cause Type I diabetes in the first place.

- Bill

[IJ]

What are we using? Summary at least the last time I looked into this (and I'll have to refresh all this for an upcoming talk--presupposes we've already looked into ways to reduce the contrast load or at least space it out):

Standard:
1) Hydration with isotonic fluids. Awaiting more research on bicarbonate vs saline.
2) N-acetylcysteine. Bulk of data (at least, last metaanalysis in Annals) favors used; cheap, pretty safe.
3) substitution of low to isoosmolar contrast for high osmolar contrast appears effective in people with chronic kidney disease, particularly if diabetes is present

Nonstandard:
4) Invasive stuff like renal artery directed medications and preemptive dialysis have worked in high risk patients in some studies and aren't applied, generally.
5) theophylline produces a statistically significant and totally unimportant reduction in creatinine.

Caveats:
6) several of these measures, particularly hydration and acetylcysteine, produce a decrease in measured creatinine in many recipients, which makes one wonder if we are only diluting out a surrogate measure of true kidney function in a way that makes us less anxious and serves little purpose.
7) endpoints used are generally minimal creatinine increases and there are very few serious endpoints in trials so it's hard to know if this makes a lasting / clinically important difference
8) bicarb bolus and saline infusion are both supported by data but have not been compared head to head

[Glenn]

She wants deluxe. So she gets her kid on insurance long enough to get it paid for, and then gets off again. WTF???

Reminds me a bit of people who would get on the local news because "Blue Cross" wouldn't pay for an electric wheelchair.

Basic consumer economics, people want to feel like they are getting their money's worth. With insurance, people generally feel they are paying for nothing and that they should be getting something tangible in return. We pay a couple thousand dollars a year in premiums, yet we rarely get anywhere near that kind of return in services in any given year, particularly after deductables. Even with insurance, most years we pay out of pocket for everything health related, on top of the premiums. So yeah, when the need arises, I and my doctor should have some say in what I get for my money.

The bottom line is: Why should insurance companies be given special treatment? As with any other type of company, the customers should be able to demand a certain level of quality. Unfortunately because of the necessity of insurance, insurance companies do not feel they have to play that game anymore…and sadly, for the most part they are right.

Regarding this topic in general, for the most part we have been talking about extreme cases: The wealthy who can afford good health care versus the poor who cannot afford any but can get some level of health care under medicaid/care etc; and the media-worthy cases of possible attempts at abusing the system by insurance companies or people wanting certain care that they truly do not need. What is of more concern (to me at least) is the everyday working-class people who have been largely ignored in the health care reform debate. I know quite a few construction workers, mechanics, etc through their wives whom I worked with at Allstate. They are largely self-employed and often working 10+ hour days when the work is available, largely doing what they enjoy and living their version of the American Dream/Land of Opportunity. They will never be among the wealthy, even though they work way harder than the wealthy. They generally have a high need for insurance due to the nature of their jobs but cannot afford it, or at any rate what they can afford may not be enough to give them the level of care they would need to be able to return to work after a serious health issue, given the physical nature of their work. The solution: Their wives get employed by a corporation that offers decent family insurance. Works fine until the spouse is one of the millions laid off so far this year, and there were four I know in this situation who were laid off around the same time I was. So now they are out insurance. And if there are any pre-existing conditions for anyone in their family, then they are going to have a hard time getting the same level of coverage if they do get access to insurance again through another corporation.

Or my own case in point: I am going to be a very underpaid person for the next 3 or so years while trying to pursue my dreams of earning a PhD degree. Fortunately our insurance is through my wife’s job, so we did not lose anything when I was laid off from Allstate. But if my wife loses her job we will be a family of 5 without any insurance, unless she could get another comparable job, which seems unlikely in the current job market. And even then there are some existing conditions that are covered now, but likely would not be if a job change forces an insurance change.

This whole pre-existing condition mess brings up another problem with falling back on the “land of opportunity” slogan: How do you voluntarily change jobs to move onward and upward and pursue dreams if doing so means you would lose insurance coverage for an existing condition? We may be facing that decision after I get the PhD, assuming I do not get a job around here that would enable her to keep her current job and insurance.

Rather than focusing on the anomalies, we need to focus on fixing what has become the norm for far too many.

[Bill Glasheen]

The bottom line is: Why should insurance companies be given special treatment? As with any other type of company, the customers should be able to demand a certain level of quality. Unfortunately because of the necessity of insurance, insurance companies do not feel they have to play that game anymore…and sadly, for the most part they are right.

This IMO shows a misunderstanding of what insurance is all about. You purchase insurance to pool risk. You want to be prepared in the unlikely event that catastrophe strikes. For the average person, it's not (ever) about getting your money's worth in terms of financial return.

The distribution of paid amount (total cost) by individual in an insured population is identical to the wealth distribution Pareto observed in Italy a few centuries back. It follows the 80/20 rule. In other words, 20 percent of the people account for 80 percent of the health care costs. If you are a member of that 1 out of 5, that isn't good - unless of course you had a baby that year (which is a covered CONDITION). But then at least you don't have catastrophic bills. The remaining 80 percent should be thankful that they have reasonably good health, and were covered in case of...

If everyone gets back what they put into the system, then insurance won't work.

- Bill

[Glenn]

If everyone gets back what they put into the system, then insurance won't work.

Again that is focusing on an extreme situation. I wasn't advocating a free-for-all. Maybe I didn't word myself very well (I'm really tired right now), but my focus in the first section was on the related concepts of "I and my doctor should have some say in what I get for my money" and "customers should be able to demand a certain level of quality". Sure the basis for insurance is pooling risk, but that does not elevate insurance companies above there being a two-way interaction between producer and consumer. We pay a lot of money for a service and really have no say in the extent or quality of that service, and I cannot really go elsewhere if I am dis-satisfied with that service. That's a rather unique situation that goes against the foundations of capitalism (although unfortunately in some ways it is becoming more common).

[Bill Glasheen]

We pay a lot of money for a service

...because medical care is expensive. Doctors (not the insurance company) cost a lot. Hospitals (not the insurance companies) cost a lot. Medical equipment and supplies (not the insurance company) cost a lot.

FWIW... The same medical equipment used for people costs a fraction as much for animals. The same health care service delivered to a person costs a fraction as much for animals. Figure out why that is so. (Hint - It's a reform opportunity that I'm all for.)

and really have no say in the extent or quality of that service

It's up to the doctor to deliver quality care. And if it wasn't for people like me who measure care for a living (efficiency, process quality, and outcome), you'd probably have no idea whether or not you went to a doctor who delivers quality care.

and I cannot really go elsewhere if I am dis-satisfied with that service.

Yes you can. In virtually all insurance policies, you get to choose (at the very least) your primary care physicians. Many insurance policies now are "open access" which means you can go straight to a specialist if you so choose. You also usually have a choice of the hospital you go to, unless you got brought there unconscious and in an ambulance.

Insurance companies do not deliver care. They do the following:

• Pool risk so that you are protected against catastrophic events.
• Help you put money aside for healthcare.
• Bargain hard for the best price from MDs and hospitals. Newsflash - you'd NEVER get those prices by yourself on the open market.
• Monitor the doctors and hospitals in your network for efficiency and process quality, and either motivate or cull the bad actors.

It is true that insurance doesn't pay for everything. But if you want it badly enough, you can still pay for it out of pocket. Is that possible? Ask plastic surgeons who make a handsome living from direct-pay services. Some folks obviously are more motivated and capable of paying for medical services out-of-pocket than others.

Many also have options. If you have 2 working people who are covered by insurance on their jobs, you often have the option to do one family policy, the other, or even be double covered. And some people have options given to them by their employer (for instance an HMO vs. a PPO).

And if you aren't satisfied with your employer-based coverage, you can switch jobs in a good economy. (That was happening circa 1999). You can even go out on your own and buy the health insurance policy of your choosing. Good luck getting a good price on that!

- Bill

[Glenn]

and really have no say in the extent or quality of that service

It's up to the doctor to deliver quality care.

and I cannot really go elsewhere if I am dis-satisfied with that service

Yes you can. In virtually all insurance policies, you get to choose (at the very least) your primary care physicians. - Bill

I wasn't talking at all about doctors or quality of care, I'm talking about insurance companies and quality of their services.

And if you aren't satisfied with your employer-based coverage, you can switch jobs in a good economy. (That was happening circa 1999). You can even go out on your own and buy the health insurance policy of your choosing. Good luck getting a good price on that!

Exactly! Hence why I said I really cannot go elsewhere for insurance if disatisfied.

[IJ]

"I and my doctor should have some say in what I get for my money" and "customers should be able to demand a certain level of quality".

Here's a problem: your doctor may be stupid. See the Gawande article, or compare costs across the USA and the noncorrelation with quality. The quality and standardization is bad, and if I were insuring people (and I am, via tax and high premiums), I would be (wait, I guess I am!) FURIOUS that my monies is being totally wasted, for example:

On the latest diabetes drug with no outcome data at $100 a month instead of metformin, available for $10 for 90 days. (substitute hundreds of unneeded medications, particularly disturbing are overuse of GCSF and erythropoetin agents which can cost thousands of dollars a month and are overused and have been shown to increase mortality in some cases!)

On preventable complications of medical care.

On amputation and disability instead of preventing foot complications of diabetes.

On cardiac cath and stents (the best care I can get anywhere!) that have been shown no more effective than medical care.

On imaging for musculoskeletal back pain without "red flags" for serious conditions.

On BMT for breast cancer. On 15 gamma knife surgeries for someone who needs total brain irradiation (or morphine and a bed).

I could go on and on... we only get it right about HALF the time, on average, and in looking at the trial data for DVT prevention in the hospital, 14-21% of the patients were on therapy in the control groups / preintervention groups! Shockingly bad. There is no way to make healthcare insurance cheap when half of the money is wasted on stupid care, just like tickets would cost a lot more if half the planes were broken all the time. The summary is this: the idea that "a patient and their doctor" should decide how money is spent is based on a medical myth that an individual specialist can craft a magic personal regimen for each different patient and their pride in autonomy and craft justifies the fact it doesn't work. Imagine if gunsmiths tried to get insurance to pay for handsmithed guns with noninterchangeable parts that all differed from well known and objective standards for quality?!!?

"That's a rather unique situation that goes against the foundations of capitalism (although unfortunately in some ways it is becoming more common)."

Healthcare is a funny thing. Is there anything else that an illegal immigrant with no money can insist on? A snack at Burger King? A car? Lawn care? They can sometimes get good deals on schooling, but a lot of what's being discussed is limiting options for insurance. For example, denying preexisting conditions. Many insurers wouldn't consider my home because there was a pool and diving board (no longer). That won't change, although there are back up plans, eg insurance pools for high fire risk california homes. People feel they can insist on something like an electric wheelchair or insulin pump from insurance, but if the insurance they bought doesn't cover that (and with good reason, many only do in specific circumstances), then they bought the wrong insurance. It'd be nice if our insurance was more portable and not as tied to work, but reforming that won't make insurance hand out electric wheelchairs to people (some of whom need nothing more than some friggin exercise!)

[Gene DeMambro]

FWIW... The same medical equipment used for people costs a fraction as much for animals. The same health care service delivered to a person costs a fraction as much for animals. Figure out why that is so.

Because animals are generally considered property and any loss of that property is generally limited to replacement value. You might get a 5 or 6 figure award for malicious harm, but the vast majority of times any monetary award is limited replacing the animal. The recent pet food poisoning scandal is a good case study on that fact.

Also, who would pay the prices out of pocket for Fido or Fluffy that they pay for themselves? In general, medical care for pets or animals is worth less than for people, therefore it commands less of a price on the open market. Also, compare salaries for veternarians for people doctors:

From the US Dept. of Labor Bureau of Labor Statistics from 2006 for veternarians:

Median annual earnings of veterinarians were $71,990 in May 2006. The middle 50 percent earned between $56,450 and $94,880. The lowest 10 percent earned less than $43,530, and the highest 10 percent earned more than $133,150.

for physicians:

Earnings of physicians and surgeons are among the highest of any occupation. The Medical Group Management Association’s Physician Compensation and Production Survey, reports that median total compensation for physicians in 2005 varied by specialty, as shown in table 2. Total compensation for physicians reflects the amount reported as direct compensation for tax purposes, plus all voluntary salary reductions. Salary, bonus and incentive payments, research stipends, honoraria, and distribution of profits were included in total compensation.

Table 2. Median compensation for physicians, 2005.
Specialty Less than two years in specialty Over one year in specialty
Anesthesiology $259,948 $321,686
Surgery: General $228,839 $282,504
Obstetrics/gynecology: General $203,270 $247,348
Psychiatry: General $173,922 $180,000
Internal medicine: General $141,912 $166,420
Pediatrics: General $132,953 $161,331
Family practice (w/o obstetrics) $137,119 $156,010

(NOTE) Source: Medical Group Management Association, Physician Compensation and Production Report, 2005.

Even the highest paid vet barely reaches the lowest paid people doctor.

So if your point is that veternarians enjoy a level of protection from malpractice, you are correct. That's because animals are worth far less than people are, and good luck trying to sell malpractice reform on that fact.

Gene

[Bill Glasheen]

Not just services, Gene, but supplies as well. You pay so much more for the same item if it's going to be used for human medical care. Device makers have liability issues as well.

And if you hadn't noticed, I'd just as soon see a good chunk of those lawyers put out of business. Maybe we can have managed legal care where we pay lawyers a capitated fee rather than a percent of booty extracted. Works for me! After all, I want my doctor (who has this valuable life in his hands) earning a LOT more than a trial lawyer who only has paper in his hands. And after all, paper is worth far less than animals, right? Let's put doctors at the top of the income order, followed by vets and then lawyers at the bottom. Yea, that's the ticket!

- Bill