The Short Shrift of Healthcare

This 10-part series will expose why consumers and doctors are getting the short shrift in all healthcare reform proposals:

1. Wrong priorities (ie, business over patient needs)
2. Spending too little of insurance premiums of healthcare
3. Inefficiency that robs patients of their rights
4. Healthcare organizations that think it's legal to practice medicine
5. The phenomenon of a captive audience
6. Access problems—what happened to “a stitch in time....”?
7. Effective care replaced by less costly care
8. Callous disregard for patients in their time of need
9. Failure to observe the cardinal rule of medicine: First, do no harm
10. Failure to observe the cardinal rule of managing care: Measure and manage

Wrong priorities 1) Wrong Priorities—witness the outrageous 20-30% administrative overhead of medical insurance companies; it includes a covert and obnoxious 'cost-savings-is-more-important-than-patient-care' reward system. This is even true for non-profits. It's the difference between medical business and the business of medicine—taking care of patients or profit$.

As stated in the Consumer Watchdog, Dec. 24, 2009, health insurers' rate increases, among other intolerable unaccountability, must be monitored, if not prior-approved (cross-ref. Calif. Proposition 103).

Spending too little of insurance premiums of healthcare The concept of the Medical Loss Ratio -- the percentage of the premium dollars collected by the insurance companies that are actually spent on healthcare -- helps explain how insurance companies are using you as their financial engine and what their priorities are. The health insurance industry says its average MLR is 87%, but, according to Senate research, it's significantly lower. As stated in the Consumer Watchdog, Dec. 24, 2009, "The Senate bill's requirement that insurers spend 80% or 85% of the premiums they collect on healthcare services will—absent strict rate regulation—perversely encourage insurers to raise their premium rates. In the same way that a Hollywood agent who gets a 20% cut of an actor's salary has an incentive to seek the highest salary, insurers will have incentive to increase healthcare costs and raise premiums so that their 20% cut is a larger dollar amount."

Inefficiency

Consider what happened to me: To repair my broken leg (a 4" fibula fracture), an orthopedist inserted a four-inch plate, but the surgical wound wouldn't close. So after a month of therapies, my wound specialist ordered the KCI’s proprietary V.A.C. Therapy System. He got "prior approval" from Oxford, and I was given the necessary equipment—a suction device to wear on my belt, 24 hours a day, specialized coverings that breathed, tubing, waste canisters, etc. These supplies were integral, mind you, but later Oxford hit me for $1700, saying they were an "uncovered benefit" (whatever that means).

Are these supplies any different than requiring a spacer for a child's asthma medicine (puffer) or tubing and a mask for their nebulizer treatment? Is that different than how insurance companies weasel out of their responsibility with the infamous pre-existing exclusion clauses? Here's a patient-ER scenario that is all-too commonplace in the callous world of health insurance: Insurer, not saying, but implying: "We'll decide later if it was medically necessary. Start your chemo. We'll review the indications, and we're sorry" if you died/suffered/deteriorated in the process!

PS -- Why are the "supplies" so expensive? Because KCI sterilizes, packages, and boxes five sets, and charges $237.45 or $253.30 per box, even if you only need one set. In other words, they, like the insurance companies are more interested in getting their revenue than helping you afford the care you need. I need to add that while I was at the Wound Center, I saw a number of patients in need of extraordinary wound care (diabetics, peripheral vascular disease) being denied necessary care by their insurers because of contract exclusions, pre-existing conditions, bureaucratic delay, or other insurmountable hurdles.

Managed care organizations practicing medicine (without a license)

Recently, Aetna refused to pay for a visit of a child with a probable goiter and strong family history who needed diagnostic lab tests—they do not accept rule-outs. Last week, Oxford levied a $50 deductible and $25 co-pay for the most efficacious eardrop we have in our armamentarium. The reason for this decision? This drop, containing an antibiotic and a steroid, was not available generically; they were forcing me to use a plain ear drop —not what the doctor ordered!

The phenomena of a captive audience

The pharmaceutical industry makes our drugs the most expensive in the world and is getting Congress to protect their trade as a quid pro quo for support and TV adds in favor of healthcare reform. See, also, "Latest Public Option Concession Comes into Focus," which reveals how "several prominent House Democrats" acknowledged, that "they will likely have to give up a public option for insurance coverage in healthcare reform negotiations with the Senate." I don't know about you, but I hate to see serious reform reduced to politicians seeing what concessions they can extract for their vote.

Then there's human nature—docs ordering more visits when paid by the visit; referring more when not at risk for those referrals, especially the tough cases; reducing care when prospectively paid (eg, capitation), and the worst example yet an orthopedist telling a fibula fracture patient to use a boot and crutches or stay in bed for 3-6 weeks when he learned he would not get a surgical fee. (Yes, this really happened to me!)

Access problems When patients require specific therapies and an insurance company uses technicalities to refuse coverage or makes patients wait incessantly on the phone, transfer calls to who knows now many departments and the makes the frail or sickly patients jump thru hoops, it's time to move away from the insurance model. Returning to my own experience getting wound therapy (post-op), I even heard from the Wound Center that patients more needy and less well off then I were refused vital therapy; we all know that these refusals, delays and denials were mostly in the interest of maximizing corporate profits at the expense of patient's lives or limbs.

Is that any different than a doctor ordering the wrong test, wrong specialty consultation, or wrong med and then making the patient pay for the wrong care?

Can we excuse fractionalized care where one hand doesn't know what the other is doing?

Is that different from predictable, repetitive, avoidable mistakes in the hospital setting?

This happens daily, for example, when patients use the ER rather than a medical home (their doctor's office) for routine or non-urgent care.

Ineffective care For example, antibiotics for obvious viral disease manifest over the short term by bronchitis, sinusitis, nasopharyngitis, or otitis media and marked by the absence of fever or major discomfort. 50% of Abdominal CT scans. 50% of patients without back symptoms having "bulging disks" on their MRI, etc.

Callous disregard for patients in their time of need Healthcare is a right, not a privilege. The privatization of healthcare in this context doesn't even make sense to me. As stated in the Consumer Watchdog, Dec. 24, 2009, patients must have recourse; ERISA pre-emption and immunities, notwithstanding, patients who have health coverage paid for in part or full by employers must be "able to hold insurers legally accountable for denying medically necessary treatments."

Failure to observe the cardinal rule of medicine: First, do no harm

Prescribing antibiotic for bronchitis or ordering every test in the book, over and over, for the worried-well may be expedient (and it sure takes less time than explaining why the doctor won’t order the test).

Failure to measure, failure to manage

Karen Davis, President of the Commonwealth Fund, has been advocating that Medicare change its payment policy and move from volume-driven to value-driven healthcare. See several of my previous blogs, including:

"One Cannot Measure What One Does Not Manage": Rationing and Reform (Part XIII-s)

"One Cannot Measure What One Does Not Manage": Invidious Cost-comparisons (Part XIII-e)