GlassHospital

Demystifying Medicine One Week at a Time

Costs of Care Redux: Extremis Edition

It’s not new to GlassHospital readers, but coverage of outrageous health care bills in the United States is having a bit of a moment.

At least two major news sources, NPR and Vox, are running series in which people who have received bills for health care that seem outrageous can share them with investigative journalists and get help.

Based on the success of her book An American Sickness, doctor/journalist/editor Elisabeth Rosenthal and Kaiser Health News are working with NPR to produce one of these stories for web and radio every month.

Story #1 told of a urine test (screening for drugs) that was billed at $17,850. This is not a joke.

Story #2 compared the difference in price between the same CT scan performed at a hospital vs. a freestanding radiology center. [Hint: hospitals are MUCH more expensive places to get tests done.] The same CT scan of a man’s abdomen performed at a local hospital was billed at thirty-three times the price of the outpatient center.

The most recent story featured a disabled Oklahoma librarian, who had surgery on her arthritic foot. When she had sticker shock at the charge of more than $115,000 for her surgery and three day hospital stay, she did a smart thing and asked for an itemized bill. The most outrageous finding? A charge of $15,076 for four tiny screws implanted in her foot.

The moral of these stories is a) hospitals and laboratories can egregiously mark up their prices, without warning, clarity, or fairness; b) if you are faced with such a bill, you simply MUST ask for an itemized list of charges if you want any hope of contesting them.

If you think charges for actual care can be outrageous, how about being charged for NOT getting care?

Vox tells one woman’s story of fainting, going to a nearby Emergency Department, then declining to be treated. Why did she decline? Fear of an exorbitant bill.

So what happened?

After being given an ice pack and a bandage, she declined treatment, went home, and subsequently received a bill for $5,751.

A Surprising Reason Some Still Don’t Like Obamacare

The Affordable Care Act (“Obamacare”) has slowly become more popular as Americans discover that the law has lowered the number of people without health insurance and provided baseline benefits to millions of us (preventive care, youth coverage under parents until age 26, doing away with pre-existing conditions, etc.), without causing massive social or health care disruption.

Critics of the ACA cite ideals like letting the marketplace sort things out, rather than relying on government intervention to do so. Of course, the individual mandate, the requirement to be insured, was scaled back by the late 2017 tax reform law–such that people on the individual insurance market will be able to opt out in 2018 and beyond if they choose without penalty (even though the US Supreme Court ruled in 2012 that the mandate is constitutional).

Recently, a reader sent me a fascinating article about why some evangelical Christians also dislike Obamacare. It’s known as crucicentrism.

Not all evangelicals hold this worldview. According to a source cited in the article, about one quarter of evangelicals espouse this viewpoint.

Still–what does it mean? From the aforementioned article:

To secure a permanent place at God’s side is far more important than any short-lived torment to the body. From this perspective, then, the greatest kindness one can show others is to help them reach the salvation of the Cross.

Such a crucicentrist view on compassion explains puzzling statements by white evangelicals like Mark Green, a Tennessee state senator. “Sickness,” Green told a church group, “is one of the main avenues that bring people to religion.” In the Gospels, he said, “every person who came to Christ came to Christ with a physical need. It was either hunger or a disease.” When the government created the ACA it did a “great injustice” because, Green explained, by helping people regain their health, it had limited “the Christian church’s role” and robbed sick individuals of the opportunity “to come to a saving knowledge of who God is.” People who fell ill would now look “to the government” instead of to God.

In this worldview, suffering is seen as a pathway to faith, which will lead to salvation. And, I presume, better health.

Maybe this shouldn’t be surprising. After all, institutions have always needed members, missions, and money to maintain their existence over millennia.

But I do find this inclination shockingly uncharitable.

What do you think?

Social Hospitals?

Evolution of hospitals is a theme we’ve visited before.  A couple of years ago, these words appeared in GlassHospital:

I once had a teacher tell me, “No one should ever need to be in a hospital. Except for some cardiac conditions that require immediate care, the only people winding up in hospitals are frail elders, and those with social problems and no place to go — the mentally ill, the destitute, the homeless.” I remember feeling a bit shocked by this, but as I reflected on it, I realized he had a point. I should start with the assumption, he told me, “that almost no one really needs to be there and they’re better off at home.”

Hospitals have their origins as almshouses, places where the poor could go to seek care and sustenance. Over time, they co-evolved to become places of teaching, and in the early 20th century university-based medical schools partnered with charity hospitals in particular to train future generations of doctors.

Now a recent NY Times  op-ed  asks, “Are Hospitals Becoming Obsolete?”

Medicine has advanced so that many illnesses and procedures that used to require days in the hospital now can be treated in an office setting. It seems the more we study it, the more we realize that people do better when they convalesce in their home environments.

Another recent article discussed an additional factor contributing to the demise of hospitals: hospital at home. WHY NOT have medical care in your home, including IV therapy and even advanced procedures like dialysis if they’re available and they work?

One other line of reasoning asks about HOW we apportion hospital beds, suggesting that maybe we’ve de-commissioned too many psychiatric beds for treating people with severe mental illness. Given the horrible shooting sprees in the news recently, several commentators are asking if it’s time to re-invest in mental hospitals.

One idea here: if hospitals continue to consolidate and atrophy, perhaps we should re-purpose them to more ably handle social issues that continually confront us: nutrition, jobs, education, housing, etc., etc.–by offering services and information for people with those needs.

The question is how we structure and finance that transition.

J.P. Berkazon

It was a big story: It held the news cycle for more than 24 hours, until something about some memo sucked up all our oxygen.

It was about business. And health care.

BIG businesses doing something to TRANSFORM health care.

The announcement caused the stock prices of other big companies in the ‘health care space’ to drop.

We’re still fuzzy on the WHAT.

As to the WHO: Amazon, Berkshire Hathaway, and JP Morgan Chase. The three behemoths plan to come together to form a non-profit entity to ‘disrupt’ health care.

The WHY: health care for their > 1 million combined employees (and all over the U.S.) costs too damn much.

The headlines were breathless, e.g. Forbes: “Amazon, Berkshire Hathaway, and JP Morgan Could Disrupt U.S. Health Care and Capitalism as we Know It.”

Capitalism as we know it.

It’s a great story. It has compelling figures. I, like many, want to believe that it’s possible to disrupt our piecemeal, overwrought, and insanely expensive health care non-system.

Many others have tried. And failed.

Here’s a contrarian view on the big announcement from a seasoned observer. Is his skepticism warranted or can Amazon and friends do for health care what they’ve done in retail and web services?

What do you think? Can J.P. Berkazon crack the U.S.  health care nut?

@GlassHospital

Minister of Loneliness

U.K. Minister of Loneliness Tracey Crouch

The United Kingdom has appointed a Minister of Loneliness, according to several news reports this month.

In announcing the appointment, British Prime Minister Theresa May said

I want to confront this challenge for our society and for all of us to take action to address the loneliness endured by the elderly, by carers, by those who have lost loved ones — people who have no one to talk to or share their thoughts and experiences with,

As more people live longer than ever, loneliness is compounded by physical infirmities that make social interactions difficult.

As a doctor, I consider loneliness a genuine risk to good health, even if the title of said minister reminded me of Monty Python’s famed “Ministry of Silly Walks.” (Apparently, I was not alone in this thought.)


@GlassHospital

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