Here we go unraveling . . . .

Inspired by Paul Krugman's column today and events of the last week(s), I thought I would revisit the perennial favorite health advocate's topic: health care for all.

According to Krugman,

Health care seems to be heading back to the top of the political agenda, and not a moment too soon. Employer-based health insurance is unraveling, Medicaid is under severe pressure, and vast Medicare costs loom on the horizon. Something must be done.

This has been one of those periods in which the cost of paying for health benefits for workers and retirees threatens to shut down corporations and municipalities. In my most optimistic periods I think that this "unraveling" of our expensive, inefficient, inadequate and patchwork system will finally push us toward a national solution. Yet somehow the system must still be working, at least for the private sector, since we are not seeing big business rise up to demand that health benefits become a public, not a private responsibility. We can only assume that as long as workers are willing to "take the hit" and pay an increasing amount of the costs of their care, employers will continue to see employer-base health insurance to be working to their advantage.

Thus it was with pride--at least in being a New Yorker--that we watched Roger Toussaint refuse to agree to the kind of two-tiered contract that workers around the country have been accepting in order to keep their benefits. Many in New York, including those who consider themselves supporters of labor, bristled at the refusal of the transit workers to accept even a 1% contribution--and that only for future employees--to their health benefits. After all, most of us who are private sector employees have been contributing far more than that for over a decade.

Toussaint's stand, however, had that wonderful ring of American ideals (dare we remember the Dennis Rivera of old).

"We will not sell out the unborn," Mr. Toussaint said in refusing to agree to lower benefit levels for future employees than for current employees. "We believe that future generations of transit workers should be better off than us, just as we are better off than past generations of transit workers" (New York Times, December 19, 2005). (Since there is no contract yet, it is still possible that Toussaint will end up holding firm on pensions but giving "a little" on a two-tiered plan for health benefits, according to Stanley Aronowitz, a City University of NY Sociologist quoted in the December 24th New York Times.)

But clearly the only sensible answer to the problem of rising costs of covering health care--and to the growing problem of retiree benefits that are threatening to become extinct in the private sector and to bankrupt local governments--is a national health program. I suggest you revisit the Physicians for the National Health Program web site and read (or reread) the "Proposal of the Physicians' Working Group for Single-Payer National Health Insurance" published in JAMA in August 2003.

A more recent cause for some optimism is the Emily's List fall survey, which showed that healthcare was a particularly important concern for women, and could impact how they vote in the midterm elections in 2006. The findings, among other things, noted that health care and health care costs are "winning issues" for Democratic candidates and that "Independent women, a key swing group, are looking for action and seeking a voice and leadership on the health care issue."

So, as a health advocate, my New Year's wish is that the bumper sticker, "Our National Health Plan: Don't Get Sick" (featured in my young friends' very funny and wise collection, Actions Speak Louder Than Bumper Stickers) will no longer be humorous because it is true. I guess that's a lot to wish for, so let's just hope that as the current system unravels we can take effective action toward an alternative that will acknowledge our public responsibility to truly provide health care for all at a cost that society can afford.

The Pathologists Report

I blogged about an uninsured client I have here on December 7, and cross posted at SignalHealth. It was picked up by the Kevin MD web log where a pride of irate MDs, set upon me, daring me to stand up to their criticism, mostly cherry picking my rhetoric and complaining that, HOW DARE I QUESTION THE DOCTOR"S CHARGES!! THE DOCTOR MUST BE PAID!!!

No one mentioned the anesthesiologist that wasn't there but charged as though he were, the clearly up-coded ED Doc, the unbillable supplies, the inflated room costs.
No, what sparked their ire mostly was that I was not sure I would recommend paying the Pathologist what he was said he should be paid, according to his coding.

The specimen is a miscarriage; the billing was coded as high as a pathologist could: gross and microscopic examination - as high as for a full mastectomy with nodes, for instance, or a colon resection, or an extensive soft tissue dissection. They shrieked that I didn't have all the records yet, so I shouldn't have written about it at all.

Well, now I have the records. The narrative is only of the gross examination. A total of five slides were made of both specimens (two of the fetus and three of the placenta), noted only as "representative specimens." There is no microscopic narrative. So I can't even tell that the pathologist looked at the slides - only that he took them. Actually, I can't even tell that without obtaining another record.

So tell me, Doctors, how would you code this? You think this is a level VI? The charge difference between a simple gross examination is about $400. The correct designation lies somewhere in between, and probably closer to a Level III. If you don't want to call this fraudulent (a word that really got their dander up), what is it?

Cross posted at http://www.signalhealth.com/node/550

White House Conference on Aging Removed from Life Support

There's an interesting post over at http://www.signalhealth.com/node/514 about the decennium White House Conference on Aging. (Full disclosure: I am a contributor on this blog.)

Hint: The White House didn't attend.

Further, they "lost" the papers to be presented and all in all look to have pretty well fouled up the Conference. Never mind - another one is scheduled for 2015.

It's Health Care, But Not As We Know It.

The first non-partisan survey is out on Consumer Driven Health Plans. Jointly sponsored by The Commonwealth Fund and the Employee Benefit Research Institute, the data is clear: owners of CDHPs like them less than people with more traditional, or comprehensive health care plans.

It's easy to see why. CDHPs are suppposed to transfer some of the risk of health insurance on to the patient, er, consumer. Once the consumer is sick, they get to make a choice: "Am I sick enough to buy a doctor, or do I think I will get better by myself?"

This choice is based on making a financial investment in your own health, that is, would you pay money to get whatever malady you are suffering with fixed?

Of course you have no way of knowing what sorts of prices you're being faced with, not being a diagnostician or privy to the art and science of medicine. But even if you knew your diagnosis, one of the findings in this study was that the tools for making these sorts of decisions, called "cost and quality infomation," is simply not provided by most plans. Even if it were, the survey says that the customers of health plans are not really inclined to trust them.

And why should they? Last spring UHC cut 75% of its doctors from their plan in St. Louis, based on what the MDs were willing to accept as payment. The identified "quality" doctors were those accepting the cheapest rates.

So, let's say you decide need to see a doctor, you then get make another choice: which one? The way many plans are set up, you would pay different amounts for different doctors; significantly more if you go out of network. There has been quite a bit of discussion on the importance of these tools, and what sorts of data ought to be included. Successful CDHPs should have data on providers and costs readily available.

Funny - no one talks about outcomes. I guess that's not very important.

CDHCs change behavior exacly the way its advocates said they would: they make people more cost conscious consumers of medical care.

But this study also points out that the early critics were also right: out-of-pocket costs are higher, and more people either delay or forego care due to costs.

Insurance companies have been trying for years to get out of the insurance business and with the CDHP they almost have their wish. Most of the risk premium has now been transfered to the patient. Denial of payment will become a thing of the past, as patients deny their own care due to rising out of pocket costs. The twin demons of expensive technology and the aging demographic have become temporarily subdued.

There has been lots of talk lately about universal care and the growth of the uninsured population. (Actually, the numbers have remained fairly steady, attributed often to Medicaid picking up the check.) Employers are protesting that the high costs of health insurance are unsustainable. CDHPs and their cost shifts may release some of that pressure, allowing the dysfuntional employment benefit system to totter on a few more years, paying the middle men far more than they are worth, for services that add nothing to the common good of the nation.

Lin
CrossPosted at http://www.signalhealth.com/node/513

Health Care and the Cost of War

Check out this great "counter" and find out how many kids we could insure, or people with HIV/AIDS we could treat, or immunizations we could give (or other public goods and services we could pay for) if we weren't paying for the "Cost of War."

A Helping Profession

My client was having a miscarrieage; she is uninsured. In the emergency room she was given epidural medication, then left alone for four hours. She miscarried by herself, in an observation room off the ER; the nurses checking every so often.
She was then taken up to obstetrics (cruel in and of itself), cleaned up, and placed in a bed.

Her bill is almost $10,000.

Now let's look at the problems on this bill. The anesthesiologist gave her an epidural and is billing her for 6 hours of monitoring. So I ordered the anesthesiology record and it is practically blank. After he anesthetized her, he simply left. His charge is over $1000.

The hospital is billing her for a delivery room she didn't use, and hundreds of dollars worth of non-sterile and sterile supplies that CMS says are not separately billable. The Cefotan she was given comes in boxes of ten for $120. My client was charged $78 per container.

What proceedures did the doctor perform? Aside from the initial evaluation and management, he apparently performed none. The E/M is coded as high as possible: as high as being hit by a bus, as high as a gunshot. At least he didn't charge extra because it happened after supper time.

She was charged $38 for 8 squares of gauze. She was charged for three trays of supplies, none of which is legally billable.

She was given an ultrasound that showed, yes, she was indeed having a first trimester miscarriage, something she disclosed in the history.

The only really legitimate charge is, sadly, the pathologist when it was all over.

What shall I do with this? In addition to being overpriced, the way this woman was treated is profoundly disturbing.

I'll admit that I don't have every piece of information - maybe the ER was particularly busy and no one could stay with her. Little doubt the staffing ratio is less than optimal for the physical care of patients, much less their psyches.

Providers are also being less than forthcoming with the records I need. It is difficult to even obtain an itemized bill much less anything with codes on it that will tell me precisely what happened to this woman, which doesn't play well with an advocate for the uninsured.

I shall be challenging this bill to try and bring it down by 75%. The only Doc at all sypathetic is the pathologist who dropped his fee when he heard she was uninsured. His bill I'll leave alone. Maybe.

Lin

Crossposted at http://www.signalhealth.com/node/505