Search for tag: "medicare"

There are many, many things that we could do to improve health care. But one of the largest disconnects, at least in my opinion, is that we have insurance and financing, whether it's the government through Medicare, the state through Medicaid, or private insurance that sits in a silo over here and then we have providers and patients. Physicians are extremely smart people. It's very hard to get into medical school and to get through medical school. They're extremely knowledgeable. They are focused on delivering high-quality care to their patients to make them better. They really understand the pharmacological and physiological toxicity of care that they're delivering.

But what they don't know and don't think about is something I like to call financial toxicity, that is, all of this care costs something. Somebody is paying for it. The government is paying for it. The state is paying for it. An employer is paying for it. The patient is paying out of their pocket. It has a cost. And yet the decisions on what is going to be ordered, when, and how are made at the point of care largely in the absence of that cost. So physicians don't understand the financial toxicity that is associated with the ordering of the types of tests and procedures that they're doing.

I'll give you a good example of this. So drugs, at the point of care where the physician is entering a drug into an electronic medical record, entering the prescription, the patient is sitting there. The physician is telling the patient, "I'm going to order this particular drug for you. What pharmacy would you like to pick it up at?" Done. Nobody talked about what that drug is going to cost that patient. The physician doesn't know. Certainly, the patient doesn't know. The patient dutifully gets up, gets in their car. They're actually going to be adherent. They drive to the pharmacy. They look at the pharmacist.

The pharmacist says, "Well, Miss Sunshine, that'll be $233."

"$233?"

"Yes, because you haven't met your deductible yet. And the cost of the drug is $233."

And Miss Sunshine says, "Got rent to pay."

No conversation has gone on with the physician who was ordering it, who could have ordered, potentially, something less expensive, had a different conversation about it, prepared the patient for the cost of the drug, not because the physician didn't want to. The physicians are largely in the dark about the financial toxicity of care that they deliver.

So that’s one of the things that we are starting to experiment with, because we're both an insurer and a payer. And as an insurer, we adjudicate the claim. So for every one of our members, we know where they are against their deductibles and their out-of-pocket maximums. We know what their benefit structure is because, when the claim comes in, we adjudicate it. We're pushing that adjudication information into the electronic medical record so it's visible to the physician at the point of prescribing.

So now the physician can see, "I'm ordering red fairy dust for you, Miss Sunshine. Oh, it's going to cost $233, wow, I didn't realize that, because you haven't met your deductible. Let's have a discussion about whether this is a good idea. I could order green glitter, not quite as good, but would probably do the job, and that would cost $40. What would we like to do here?" and so that we can stop blindly pushing financial toxicity down on to patients.

Oncology is a good field to talk about financial toxicity. The last chance for a patient is often an experimental drug. Overwhelmingly, the government and private insurers do not cover experimental drugs for some very good reasons. This would mean that using an experimental drug as a last-ditch effort on a patient, who's already highly-debilitated, would be full out of pocket for the patient. That drug could cost $25,000, $30,000, $40,000, $50,000. And asking the patient to bear that cost when the actual probability that the drug is going to be successful is extremely low, that's a financial toxicity on mentally the patient and their family.

It's a huge amount of financial toxicity. And there are some patients who would prefer to ensure that that $50,000 was available for their grandchild to go to college as opposed to take a last-ditch effort with a drug that probably isn't going to work.

But at the point of care, it's not actually known to the oncologist what the cost of this medication is going to be. So I really think the merger of the actual cost of care with the provision of care at the point of care is incredibly important to try to mitigate or at least understand financial toxicity and make informed choices and decisions about it.

Historically, in this country and internationally, we've not had much appetite for talking about the cost of health care because we view life as priceless. And so it seems quite crass to many people to be talking about "This drug costs or this procedure costs $2,000. I don't really think it's worth it in you." We have made large strides in shared decision-making. But it's really been about the impact of the treatment, the probability of success of the treatment, and the physiological impact of the treatment.

Now, we need to talk about the money side of it, which is the same conversation. "We think this treatment will have this benefit for you, and here's the cost, the cost that you are going to bear for this treatment." It's an important conversation to be talking about whether a $2,000 test has enough efficacy that you're asking this patient to take out their wallet and write a check for $2,000. So I think we're making a lot of strides in that fashion.

There's still a fair amount of uncomfortableness with it. We don't train our physicians to talk about the resource cost, much less the price, those are two very different ideas, of what they're delivering. Nor do we teach them to talk about making decisions about when to stop delivering care. That's a very uncomfortable place for many physicians, particularly for physicians in oncology and other specialties where people often end up needing palliative care or end-of-life care. That's a very hard conversation to have.

This idea about how should we train physicians and other clinical practitioners to have these conversations about financial toxicity, clearly, we need to start in our medical schools, to be part of the medical curriculum. I do teach occasionally at our medical school, and I do talk about how we finance health care. And largely, they're not so interested. That's not what they went to medical school for, to talk about the price of services. But I do think we have to start there. We have to get that going. But that'll be years before it shows up at the bedside. So we honestly have to start with our clinicians in practice now.

And I think if I were running, I'm not, I'm sure clinicians will be very happy to hear that because if I were running this, it would be part of your recertification. So when clinicians have to take their boards again, their recertification for their specialty, part of the financial toxicity would be part of your boards.

Dr. Jones: So you live longer if your doctor is female. That's what the research suggests. Well, let's look at this a little more carefully, okay? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Healthcare and full disclosure, I'm a female physician and this is The Scope.

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health," with Dr. Kirtly Jones, on The Scope.

Dr. Jones: It seems as if every major news outlet brought forth the research that people live longer if their doctor is female. Okay. That sets us up for some controversy and some potential bad feelings. But let's unpack the numbers and take a closer look.

The study was published in JAMA Internal Medicine. This is a well-respected journal and it looked at medical billings for hospitalizations around the country for people over 65 with a number of common medical problems such as pneumonia, heart failure, or urinary tract infections, to name a few. They analyzed over 1.5 million admissions between January 2011 and December of 2014. Wow, that's a lot of hospitalizations. But in fact, they just picked a random 20% of all the admissions in the US to study.

They specifically looked at the outcomes of death in the 30 days after admission or readmission to the hospital. Those are just the two things they looked at. And then, they looked at whether the physician who billed for the admission was a female or a male. It's amazing what you can find on the internet.

Of course, they had to look carefully to see if the patients of male physicians were sicker than those of women. They had to look at the age of the patients to see if they were older in the male doctor group than the female doctor group. Then, they looked at the doctors to see if the females were younger. And they were, on average, about five years. And if they had had more recently finished their training, which women physicians had by about five years. Then, they had to control for all these factors in their statistical analysis. They chose hospitals where the doctors who provided care tended to work on shifts, so the admitting doctor was not by the choice of the patient.

Well, it was pretty good study and with really big numbers. And the envelope, please. Patients who were cared for by female physicians were less likely to die in 20 days. Now the real numbers. Patients cared for by female physicians had an 11% chance of dying in the 30 days. You should know that the average age of these patients was 80. Compared to the rate of death within 30 days of 11.5% in those patients cared for by male physicians, that is one-half of 1% difference.

Now, because the number of patients is so large, one-half of 1% is statistically different. However, if you're thinking of changing your doctor, that's a pretty small difference for any one person. To save one death in 30 days, you had to have 233 people cared for by women for every one cared for by men.

Similar numbers were found in the rate of readmissions for hospitals, and the females compared to males was slightly less. Some people argue that the difference is very small for any individual patient. But if you look at hospital admissions for the elderly over the entire United States, there are over 10 million hospitalizations among Medicare patients annually. And one-half of 1% of 30-day mortality could add up to a lot.

So, what's this about? Physician sex doesn't make a difference in outcome. It isn't the extra x chromosome or the estrogen level that makes the difference. It must be some behaviors in female physicians that are just a little different than men. We call that a gender difference, not a sex difference. Sex is the chromosomes in the biology; gender is the behavior.

Studies have found that female physicians are little more likely to adhere to clinical guidelines in care and practice more evidence-based medicine. Women tend to use more patient-centered communication and provide more psychosocial counseling to their patients than males. It's hard to know exactly what is the difference in practice that accounts for this small difference in patient outcomes.

Of course, to me, it may all boil down to a factor that all women know. Women are more likely to stop and ask for directions, right? In fact, we are trying to teach more protocol-based and evidence-based medicine to all our medical student these days, men and women. And we are teaching patient-centered communications more.

So maybe our women and men graduating from medical school will be more comfortable asking for directions. And everyone, patients and doctors, will get where they're supposed to go.

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Interviewer: What are the major issues facing health care right now in the United States? It seems like there are so many of them and it could be confusing and hard to sort out what exactly is going on. Well, we've got an expert that's going to help us do that next on The Scope.

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Interviewer: Dr. David Sundwall is a professor of public health at University of Utah School of Medicine. He's also a leader in health care policy and advocacy. So we all want quality health care that's affordable and available to all. What do you think we can do to achieve this?

Dr. Sundwall: Well, this is where I have to be careful because I start sounding like a socialist. I'm a Republican and would favor a single payer system. I think if we have something more like what they have then other enlightened countries, whether it be Canada or Germany or Switzerland, where they spend a lot less than we do for health care but somehow manage to cover all of their citizens, that's what we would ultimately like to get to.
That's a long time coming because there's such a reluctance in our country to have this uniformity. There's a belief that heath care ought to be private, it ought to be in the marketplace, and yet we have lots and lots of experience now showing marketplace doesn't make it more affordable, it doesn't lower the costs, and it doesn't make it more accessible. So we're moving in the right direction, I think, with what they're trying to do with the ACA and we're trying to do here in Utah with some Medicaid expansion if the governor is successful, but we've got a long way to go.

Interviewer: What do you think the three biggest challenges are to overcome in the health care arena that we face right now?

Dr. Sundwall: Its costs, primarily, its universal access which the ACA or the ObamaCare tried to get out by having it a mandate that people have insurance. And so I would say access to care, it would be cost of care, and how much care do we consume.
One of our sessions is how do we care for aging population. It's just a huge challenge for us when we have about 70% of health care costs are spent in the last six months of life. Now, forgive me for the details on that. The point I'm making is we spend way too much for what seems like futile care, not really extending quality of care but just a few months.

Interviewer: Not extending quality of life. Like, it's just all about keeping the person alive at that point.

Dr. Sundwall: It's been said that we delay death, not continue life.

Interviewer: That's interesting.

Dr. Sundwall: We're all going to die and that's a big thing. I just had a patient this week who I'm appalled that he's an 86-years-old from England, immigrated here recently to be with his children, he and his wife who are in their 80s. They discovered one of our fine big medical centers. He had an aortic aneurysm and they operated on him at 86 when he was already anemic, he already has diabetes, he has some COPD or lung disease, and why they took that risk, I don't know, but it must have cost many, many thousands of dollars. And now he is in a demented state because of the anesthesia. He's confused and in the psych ward at one of our hospitals, just because of his confusion that's totally related to his surgery. Anyway, it's unfortunate. He has a very, very poor quality of life but he's still with us. I guess that was the goal. I don't understand.

Interviewer: Yeah. Those are some tough questions.

Dr. Sundwall: Yep.

Interviewer: You've said, and it's been said, that we have kind of a strange dichotomy in the United States. We've got the best technology and medical science, yet when you look at how we rank among the developed nations in regard to health status, we're 42nd. We spend more money than anybody else. We've got better stuff than anybody else but we're not providing better. Why?

Dr. Sundwall: Well, like I say, that has grown up since Medicare and Medicaid were passed in 1965. A health economist in Washington named Lynn Etheridge, who was the head of the OMB for President Carter, said it as well as anyone I've ever heard. He said, "That passage of Medicare and Medicaid was a catalyst. We're shifting more money from one sector of an economy to another than has ever happened in the history of the world."
So now can you imagine just 50 years later we're now spending three trillion dollars on health care related services. That means that there's a whole lot of people doing very well about off of health care, meaning the providers of services, whether you be a hospital or a doctor, medical device maker, pharmaceutical company, there's just a whole lot of people that do well because we've shifted all these public money into health care and the private insurers followed suit with the levels of what they would pay.
So it's going to be a challenge. For us to fix our costs, it's going to hurt someone's pocket. We're going to have to redistribute that money. We should put more into public health, preventive medicine, those sorts of things that prevent illness in the first place, not just keep fixing an abdominal aortic aneurysm in an 86-year-old. And I'm always reluctant to cite an example because if it were me or a grandfather or maybe I'd want it done, but that's where you can see how hard this is. We want what we want when we want it, not what we can afford.

Interviewer: It's almost one-fifth of GDP, health care spending.

Dr. Sundwall: Yeah.

Interviewer: How does that get reversed? That's a lot of money.

Dr. Sundwall: Well, this is the challenge we're facing, and I for one don't think it can happen voluntarily because meaning for all the best efforts of, say, The University Hospital here to do more efficient services or to do things more appropriately, not to do duplication. Those are just really trimming at the edges. The only way to probably get a handle on this would be as in other countries where they have global budgets where they say, "This is what we'll spend for health care. Live within that. So be it." And that of course leads to some inconvenience. That leads to some delays in care, but it is what they can afford.
I mean, it is embarrassing, isn't it, when countries spend half as much as we do have better health? And so the figures are skewed because we don't cover everybody. So our bad outcomes relate to the fact that we have still several million people that don't have health insurance or access to care with they need it. That's what pulls us down. But you're right, our high-tech is the best.

Interviewer: Why is it so important making sure that we give people that don't have access to health care access?

Dr. Sundwall: You know, I think any economist or someone that knows this information believes that if everyone is covered it means that you don't have the degree of uncompensated care. People will get care sooner and more appropriately and in the right setting if they have health insurance. We've shown through so many studies that having health insurance certainly relates to health and that makes sense. However, one of our state legislators said it's a bad idea because then they'll go to the hospital and hospitals are dangerous places. I think that's a pretty fallacious argument.
I'll give you an example. I'm not bragging, but I've been fortunate to get to be 73-years-old and never been hospitalized. I don't have any chronic illness, I'm not diabetic or I don't have hypertension, and I'm grateful for my good health. But my employers over the decades of my life have been paying my health insurance so I float all boats. People like me have been paying for the care that other people need, and if everyone had coverage, you'd have a better pool to cover those people who are currently not covered and that means they'd likely be healthier and not be caught having this costly illnesses when they need medical care that they've delayed or put off for a long time. By the time they get it, it costs a lot and maybe they've been getting episodic care in emergency rooms. Isn't that silly? You go for a cold and you're charged $1000? That's just not right.

Interviewer: Yeah. It's truly now to prevention and a pound of cure. Keep people healthy, then they don't get those diseases and those conditions that cost a lot of money, then.

Dr. Sundwall: Don't get sick from them. Maybe they could get treated earlier and therefore a lot more appropriately.

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Interviewer: How you were admitted to the hospital may affect how much you owe. Don't be surprised by the bill. I'll tell you what it means and what questions to ask next on The Scope.

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Interviewer: I'm here today with Dr. Russell Vinik. Dr. Vinik is an internist specializing in hospital care. He's also the head of the utilization review committee. What this committee does is it works between the hospital and doctors to see that patients get the right bill. Russell, tell us about how one is admitted to the hospital and how that can affect how much a patient pays.

Dr. Russell Vinik: When people are admitted to the hospital their doctor has to choose what status to put them in. A lot of people think that if I'm coming in and going to spend the night in the hospital I would be considered an inpatient, but there are actually two different statuses. There's inpatient, and then there's the other status of people expected to have a short stay that are typically billed as outpatient, and that really makes a big difference in how they are billed.

Interviewer: I would think that most people wouldn't even be aware of the differences in these categories. This doesn't make sense.

Dr. Russell Vinik: Yeah, and it doesn't make sense. The way that most insurers, including Medicare, are set up is they have very different payments, and they have bundled payments when people come into the hospital as inpatients. Whereas if they're outpatients Medicare has what we call Part B that does that payment, and it's typically billed as a percent of what's charged. Then, the patient is responsible for a percentage of that copay. If they're put in an outpatient procedure they usually have a higher copay to pay depending on what kind of supplemental insurance they have.

Interviewer: How much higher charges can a patient expect if they're billed under this observation status you're telling us about?

Dr. Russell Vinik: It depends on what procedure or what they're in the hospital for. If it's just for monitoring and they're not having many invasive tests it may be only a few hundred dollars. If they're having a major procedure like a pacemaker or a defibrillator placed, those can be upwards of $50,000 for the procedure, and if their copay is 20% that's a big...

Interviewer: That's a big hit. That's a really big hit. I would bet that most people aren't even aware that they could be responsible for that if they're admitted to the hospital.

Dr. Russell Vinik: They can't, and a lot of patients just don't understand the rules. Medicare has its own set of rules right now which says that inpatients are typically patients expected to require two midnights in the hospital. Every other insurance company has slightly different rules, so it's very important for patients to know what their benefits are, and if they are scheduled for a procedure to know whether it might be an inpatient or an outpatient procedure.

Interviewer: So, buyer beware. They should ask what their benefits are. That's one of the things I'm getting from you. Is this mostly Medicare that we're talking about?

Dr. Russell Vinik: This is mostly Medicare, but every insurance company does make this distinction between inpatients and outpatients. Medicare patients typically have a higher outpatient deductible and copayments than a lot of private insurance plans, and this is where a supplemental plan can help pick up those deductibles.

Interviewer: You mentioned this two midnights rule, and there have been some stories in the press about this new two midnights rule. Can you tell our listeners about that just a little bit more.

Dr. Russell Vinik: Prior to October 1 of this year Medicare and most insurance plans used what we call medical necessity to decide if a patient needed to be inpatient or not. That depended in part on how long they were expected to be in the hospital but in part on how sick they were, how intensive the services that they were getting in the hospital were going to be. You can imagine that's a hard thing to figure out. Medicare tried to simplify it a little bit and said in general patients who stay in the hospital two midnights or more are considered inpatient. They don't want hospitals to just keep everybody two midnights, so you still have to need to be in the hospital for two midnights and be getting care that can only be done in a hospital.

Interviewer: I also understood from some of the articles that I read that patients admitted under this observation status might not be eligible for rehab.

Dr. Russell Vinik: Right.

Interviewer: So, if they came in with a broken hip, and they had that repaired, and somehow they were under observation status they would have to front most of the bill, I would think, for the rehab.

Dr. Russell Vinik: Medicare has a rule that says in order to qualify for skilled nursing facility placement you have to be in the hospital as an inpatient for three midnights. A patient, and we've had this happen, who might fall, didn't really break anything, they're not well enough to go home but not sick enough to need a major operation, they don't often meet that rule. It puts a lot more burden on the patient and their family, because the doctors are forced to comply with these rules. They can't keep a patient for three nights just so that they can get them into a care facility.

Interviewer: What should a patient do to better understand this categorization?

Dr. Russell Vinik: Most important is to know your benefits. There are certainly lots of different insurance plans out there. Know your benefits. Ask your doctor if you're going to be an inpatient or an outpatient. If there's a question you can always appeal if you don't think your doctor is doing the right thing. There are appeal rights for just about every insurance plan as well as Medicare.

Interviewer: Russell, other than knowing your coverage and your status as a patient, is there anything else you can do to sort out whether you belong in inpatient versus observation status?

Dr. Russell Vinik: It's a hard thing. If you're unsure, it's always a good thing to ask your doctor about, and they can help. Unfortunately, doctors are being put in a difficult position by the insurance companies and by Medicare. They have a set of rules they've got to follow. If they don't follow those rules they could be accused of committing fraud, so they really have to follow these rules. Sometimes there's a little bit of gray area where a patient might go one way or the other, and that's where a discussion with your doctor can help. Doctors are being forced by these insurance companies and Medicare to follow their rules.

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