Health care - Hospital's point of view. . .

[gmattson]

I enjoy watching House on TV Last night, where the hospital administrator and her role in keeping the hospital running efficiently while keeping the budget under control, was featured.

Her 'face off' with the medical insurance company was most interesting and the story line gave the audience an insider's look at another side of the health care business/industry.

Wondering if our resident experts in the health care business happened to catch the show and if so, would they comment on the accuracy of the story line.

[Bill Glasheen]

George

I saw the show. Very interesting character development show for House's boss.

Mostly the show is accurate.

The one-line crack that the CEO made in the restaurant though (about defending being a rich bastard or something like that) would NEVER happen. That's when the show's author showed his bias. No CEO in his right mind would make a comment that would come back to haunt him later. These men get paid the big bucks because they're the brightest of the bright and they're good at what they do. Their every word is scrutinized by all parties. An anti-insurance press is more than eager to take any insurance company executive to the public gas chamber. I saw it happen in Virginia where a young Gilmore (then attorney general) raked the state BCBS plan over the coals for a bargaining practice that the federal government also does with Medicare. He (Gilmore) was a populist, and got elected governor by drawing attention to himself with his populist agenda. His true colors showed however when put in charge of the RNC. He didn't last very long.

Look at it this way, George. You buy insurance and it costs a fortune, right? The biggest reason why it costs a fortune is because medicine is complicated and it is very expensive. The biggest reason you want to be insured is because you have cut-throat deal-makers out there who will see to it that you don't pay "charges." No insurance? The provider takes you to the cleaners with whatever he wants to charge, and a court of law will make you responsible for it. Got an 800-pound gorilla insurance company in your corner? They'll bring volume to these hospitals, and demand a very thin margin in return. At the end of the day, you win.

I've been involved in doing analyses of situations where a provider group (in this case, a large OB/GYN group) threatened to walk and the Blue plan I worked for called their bluff. They stayed out of the network for all of a month. All their patients subsequently started jumping over to competing provider groups, and we noted an uptick in the detection of breast cancer and cervical cancer from the "new patient visits" that ensued. Ultimately this "quality" OB/GYN group came crawling back and took the original deal they were offered. They had to. THIS is the more likely scenario.

I feel the pain of the very good hospital that demanded higher payment BECAUSE they were good. For what it's worth, some really good doctor groups demand this as well. And sometimes they really are that good and they really will get a better price because the insurance company's customers demand that this group stay in the network. In this way the consumer and the quality provider can also win.

Moral of the story?

1) Don't let your insurance lapse.

2) Be good.

3) Hire a pit bull to do your negotiations.

As for the corrupt pharmacy tech, she deserved everything she got. And if that b1tch tried that blackmail stuff on me, I'd rather lose my job than bow to her sociopathic behavior. (House pegged it.) We had a strong financial investigations unit in our company. It is estimated that 15 percent of health care costs go to fraud. This hoarding of pseudoephedrine caught my eye in a New York second. I turned to my son and explained it to him. Sudafed can easily be converted to methamphetamine. Forget the hand wringing over divorce; that pharmacy tech b1itch deserved to be behind bars.

We (my former BCBS plan) got someone fired (at UVa) for trying to forge the date on a stress test that should have been done BEFORE the expensive intervention procedure they did. They did it to get the intervention procedure paid for. Sorry, but that's just plain illegal. I guess this guy is now pumping gas somewhere, because no hospital in its right mind would hire such a person after such a blackballing.

Moral of the story?

1) Keep up with the paperwork.

2) Have zero tolerance for dishonesty.

And finally... I think her day was pretty representative of any hospital administrator.

- Bill

[IJ]

Sorry I missed it--but I can't really handle the show. From what I've seen of the C-suite's daily life at untold millions of multiple different committees, there's nil serious confrontation and tons and tons of meetings.

Hospitals that demand more.... well, they should be able to show the data. Sadly it's enough to have the patient's confidence. As I've mentioned here before, Partners in Boston demands more for the same procedure than Caregroup even though Caregroup had more volume and better outcomes/practices. Partners, however, had patient loyalty because of the MGH brand.

As far as the author showing "bias," that philosophy is the same one you cite here all the time Bill. You think people never let anything slip in casual conversation (was he on tape or something)? I'm sure any CEO that takes home 73 million in retirement packages has GOT to believe that argument. Or they couldn't sleep! And if a good CEO COULD hold it all in--well, you know that all that rampant sex, discord, mystery, conflict and misbehavior on the doctor shows is made up for drama right? The WHOLE thing is blown out of proportion and designed to speak to popular issues (like an episode of Law and ORder supposedly not related to current events). Author wasn't picking on CEOs--author magnified everything.

PS: House is also a sociopath. He'd be sorted out ASAP or released if his behavior in a real hospital was like that. Oh, and wasn't he on stimulants too?

[CANDANeh]

PS: House is also a sociopath. He'd be sorted out ASAP or released if his behavior in a real hospital was like that. Oh, and wasn't he on stimulants too?

I like the show, man you guys have crazy hospitals in the U.S.A. Phew...thank goodness for free health care here

[Glenn]

1) Don't let your insurance lapse.

Serious question from me this time, drawing on your insider perspective:
How do you avoid a lapse in insurance when you have employer-provided insurance and you change jobs (either voluntarily or not) and there is a "pre-existing" condition? Our health insurance has been through my wife's job for almost 20 years. We now have a family member with diabetes. When I complete my PhD we most likely will be moving elsewhere for my job, and the benefits through my wife's work will end. How will we be able to get the diabeties covered given that will become a pre-existing condition for any new health insurance coverage?

"House" started out a pretty show, but lost me when the interns changed and especially when they had that thread where he literally stole drugs and others covered for him. I haven't seen it for the last couple of seasons, largely due to the evening classes I teach, so I don't know what it's like now. I do tend to like how Hugh Laurie portrays House, whether I agree with the plot thread or not...although how he can hide his heavy accent through all those shows is beyond me. Not sure his House character is really all that different from his Prince character on "Black Adder" though

[Bill Glasheen]

I like the show, man you guys have crazy hospitals in the U.S.A. Phew...thank goodness for free health care here

Things aren't always as they appear, Leo. Trust me on that one. When you're on the inside, you're privy to sheet happening that the public never finds out about.

I've seen enough comparisons in hospital quality to know that the Canadians don't have any bragging rights on the U.S. Lower utilization? Absolutely. For instance they're a lot less likely to have a surgical intervention when a patient is suffering from narrowed coronary arteries. The death rate isn't any different, but that angina sure can suk. You trade one poison (high cost) for another (high pain).

"Free" health care? Are you sheeting me?

George, who was that black Canadian comedian who had the black wooden dummy? He had a really funny joke about Canada's high taxes. That before the black wooden puppet started hitting on Jimmy Malone's blond wife. Oy! Funny as hell.

Trust me - nothing in life is "free."

But I'm glad you're happy. That's all that counts.

- Bill

[Bill Glasheen]

You think people never let anything slip in casual conversation (was he on tape or something)?

Profit happens, and it isn't bad. CEOs of health insurance companies long ago stopped with the lavish behavior. An appearance of extravagance is considered in VERY poor taste.

I know my world, Ian. Trust me - that kind of conversation never happens. That scene was high on the cinematic license. You know... Confronting the CEO in a restaurant who happened to be dining on a thick steak. All metaphors apply.

I hear now and then that a doctor will drive a fancy car. The only doctor I ever knew who did health care for free was an MD who worked in my research unit. She spent one day a week volunteering her services in a free clinic. She's now the Virginia State Health Commissioner. These are rare birds.

PS: House is also a sociopath.

You either aren't a good judge of character and/or you don't follow the show. His "sociopathic" behavior is a device he cavalierly uses to achieve an end. He also has personality "issues" - as do all of us. (You have an edge to your personality as well, Ian. It's partly why I like you. ) Interestingly enough, he tries to hide his softer side so he can keep both his enemies and his direct reports on their toes.

High on testosterone? You bet. I've seen MUCH more such bad-boy behavior in surgery. Like fighter pilots, it's part of the breed. It's why you don't find females flocking to that specialty.

He'd be sorted out ASAP or released if his behavior in a real hospital was like that.

Oh no he wouldn't. I can name names... The better you are, the more you can get away with "cowboy" behavior. Just don't mess up.

House is the MD equivalent of Manny being Manny. But if you don't know baseball and you didn't follow the 2004/2007 Red Sox championship teams, you might not know what I'm talking about. (See Manny Ramirez)

Oh, and wasn't he on stimulants too?

He was addicted to oxycontin because of his constant leg pain. The addictive personality would come up in the plot line.

Never happens, you say? Guess again. We kicked such doctors out of the network all the time when said behavior affected patient care.

No on knows for certain, but the statistics that are usually kicked around is that anywhere between 10-15 percent of physicians are addicted to either alcohol or drugs

- Physician's News Digest

So a "Dr. House" - while perhaps a tad exaggerated for our entertainment - is a very believable character.

- Bill

[Bill Glasheen]

How do you avoid a lapse in insurance when you have employer-provided insurance and you change jobs (either voluntarily or not) and there is a "pre-existing" condition?

In short... Never let coverage of SOME kind lapse. I've done the health insurance policy hop twice in the last year. While I'm healthy and a "steal" for anyone managing someone my age, all new insurance companies want your full history of coverage.

The original purpose of HIPAA (formerly known as Kennedy-Kassebaum) was to protect people such as your wife. As long as you're constantly covered, then you're fine. No new insurer can treat your wife's diabetes as a pre-existing condition. As soon as you have a lapse in coverage, you're screwed. And that's the way it should be. A P&C company wouldn't pay to reimburse you for stolen articles if you bought insurance AFTER you were robbed. And no single-payer, government-run system would tolerate you not paying your (exceedingly high) taxes each and every year.

Hope that helps.

FWIW, people in your situation tend to be good, stable, and loyal employees. Think about it.

- Bill

[Valkenar]

As soon as you have a lapse in coverage, you're screwed. And that's the way it should be.

Well I think that's pretty absurd. Missing a month of insurance should not make you screwed for life. Not unless *maybe* during that month you did something that created a chronic problem. Even so, I don't want to live in any place whose inhabitants agree that people being screwed is ever "the way it should be"

people in your situation tend to be good, stable, and loyal employees. Think about it.

I think it sounds like paradise for someone who believes that corporations are righteous masters and that servility for anyone not in the top few percent is just great because hey, it's so productive. Frankly, what you're implying here sounds like it has a lot in common with indentured servitude. If anything could turn me to a life of crime, it would be feeling like some a-hole is upstairs is gloating because he's got me under his thumb like that. I honestly might prefer wasting away from chronic disease to being the system's "good, stable and loyal" slave laborer.

[Glenn]

Hope that helps.

Thanks Bill, I think it does. I was not aware that new insurers could not treat a condition as pre-existing if you were switching from existing insurance without any lapse, that's good to know.

I think we have only ever had one lapse in insurance. We moved to Nebraska in 1991 without any jobs lined up until after we got here, so there was about a month there when we would have had no insurance. Easy to take those chances when you're young, healthy, and have no kids, I couldn't imagine doing something like that now!

[Bill Glasheen]

As soon as you have a lapse in coverage, you're screwed. And that's the way it should be.

Well I think that's pretty absurd. Missing a month of insurance should not make you screwed for life.

THREE (3) mistakes here, Justin.

1) Insurance companies "forgive" small lapses. The usual tolerance is 45 days. And you can have repeated such lapses. It's for this reason that people like me have to do all kinds of crazy "denominator" manipulations when calculating HEDIS process quality scores.

2) If you're someone like me and you are healthy, you can get away with it and not be screwed. This is why the young and healthy play Russian roulette and decide to go without. And they often succeed without consequences.

My father had 8 kids and never paid for health insurance until he was forced to do so by the colleges we went to. Since we were all healthy, it cost us nothing.

3) There's a limit to how long a condition can be considered "pre-existing." I don't have the figure with me, but it's something like a couple of years. After that, the insurer has to pony up.

IF you have a chronic condition and are stupid enough not to buy insurance, you are NOT "screwed for life." First of all, you can always pay out of pocket. Many wealthy people do this. And if you aren't paying for insurance and aren't paying the EXTREMELY high taxes that happen in a government run system, then you should have enough spare change to pay for any care you need. If not, well then you're an idiot.

Let's say you are a contractor and get paid in cash or by check every time you do a job, Justin. Should I feel sorry for you if you didn't set money aside for taxes come April 15?

THERE IS NO FREE LUNCH!!!!!!!

Even with that mantra... You can always walk into an ER and get care. It may not be Cadillac care, but they will stabilize you. They may bill you and force you into bankruptcy, but you will be treated. At least you'll be alive to complain about it.

I think it sounds like paradise for someone who believes that corporations are righteous masters and that servility for anyone not in the top few percent is just great because hey, it's so productive. Frankly, what you're implying here sounds like it has a lot in common with indentured servitude. If anything could turn me to a life of crime, it would be feeling like some a-hole is upstairs is gloating because he's got me under his thumb like that. I honestly might prefer wasting away from chronic disease to being the system's "good, stable and loyal" slave laborer.

You know what, Justin? You are only a few intellectual steps away from me converting you to a libertarian way of thinking.

- Bill

[Glenn]

Frankly, what you're implying here sounds like it has a lot in common with indentured servitude.

Welcome to the corporate world!
And why I hope to never go back to it.

feeling like some a-hole is upstairs is gloating because he's got me under his thumb like that.

Honestly, no one can really gloat because everyone at all levels is under the same pressure. The CEO is under the thumb of the shareholders and can be out in a second if they wish it. S/he is as much an indentured servant as anyone, maybe even more so since those positions are more high-profile. I decided fairly early on that corporate management was not for me since I doubted I could play the game that well.

[Glenn]

3) There's a limit to how long a condition can be considered "pre-existing." I don't have the figure with me, but it's something like a couple of years. After that, the insurer has to pony up.

Bill, can you clarify this one a bit, are you saying an insurer has to provide coverage if a person has had a condition longer than or shorter than that couple of years?

[Bill Glasheen]

3) There's a limit to how long a condition can be considered "pre-existing." I don't have the figure with me, but it's something like a couple of years. After that, the insurer has to pony up.

Bill, can you clarify this one a bit, are you saying an insurer has to provide coverage if a person has had a condition longer than or shorter than that couple of years?

Laws can vary by state.

Let's say you have Type I diabetes and have no insurance. You choose instead to pay cash for your insulin at the pharmacy, and cash for your MD visits to get the scripts for your insulin.

Now you have a good job with a health insurance benefit. They take the data on you and find out you didn't have coverage for X number of years. Well... that diabetes is now classified a pre-existing condition. Your new health insurance company isn't obligated to pay for treatment of that disease you've had for a long time and chose not to get coverage for. But... there is a limit to how long they can refuse to pay for any claim with a diagnosis of diabetes (or insulin or tuberculin syringes or blood sugar meters or whatever). At some point of coverage, you are forgiven your refusal to pay into "the system" and they will start paying for your diabetes care. It no longer has to come out of your pocket.

The purpose is to keep people from avoiding getting insurance until they need that heart or hernia operation. But the disincentive not to pay into the system has a time limit.

If you lie about your health and/or your coverage history, an insurer may contractually refuse to pay for treatment. The reasons have to do with appropriate pricing of your policy, etc.

- Bill

[Glenn]

OK, I get what you're saying now. That "couple of years" is not the time limit on how long you've had the condition (which is what I thought you meant) but rather how long you have to be on an insurance plan after first buying one before the insurer has to cover the condition. That makes sense. It is really no different from the suicide exclusion that life insurance policies usually have, which states that if you kill yourself within a certain number of years after you buy the policy then the insurer does not have to pay, but if you kill yourself after you have had the policy for that number of years then they do have to pay. The obvious purpose there is to keep suicidal people, say someone whose family is struggling financially, from buying life insurance right before killing themselves. Not many suicidal people will wait years for that exclusion to expire before they kill themselves, they'll either do it sooner or no longer be suicidal by then.