GlassHospital

Demystifying Medicine One Month at a Time

Category: hospital care (page 1 of 11)

Wallet X-Ray

Have you ever heard the term ‘wallet biopsy?’

A wallet biopsy is what occurs in U.S. health care when you or a loved one show up with a medical complaint to seek treatment.

From the emergency department to the inpatient hospital, to the doctor’s office or the procedure suite—at any location where an American might receive health care, you’re subject to a wallet biopsy.

Health care is a business. An expensive one. And the beast has to be fed—not only to keep the lights on, but also to buy the latest equipment and pay the folks that provide the care.

In a recent piece for Kaiser Health News, journalist Phil Galewitz updates us on how the U.S. practice of wallet biopsy has morphed into wallet x-ray.

The idea is longstanding: grateful patients (with financial means) have always looked for ways to share their good fortune with the medical establishments (and professionals) that have treated them.

Galewitz’ piece suggests that the practice of seeking out potential donors has ramped up in intensity: large health care enterprises (often university-based or affiliated) are performing financial background checks on patients they deem to be potential donors—and then aggressively wooing them.

There’s nothing necessarily wrong with this—it just smells a bit fishy. And it implies that if you’re not a grateful patient, or in financial position to be one, that you may wind up getting a bit less…er, attention? Fewer amenities? Less TLC?

Check out the article, which also ran in the NY Times, and let us know what you think of the specialty of wallet radiology.

Questioning a Health Care Sacred Cow

If you’ve worked in U.S. health care for any length of time, you’ve no doubt lived through a period of impending ‘inspection’ by the Joint Commission at your hospital or health care organization. Stress levels amongst all staff inevitably rise in the runup.

Everyone needs to look sharp, have their protocols down, and most importantly, where to find organizational policy information if it’s not available by quick memory retrieval.

One of the 800 lb. gorillas of the U.S. health care world, the JC (as it’s known) audits, inspects and accredits nearly twenty-one thousand U.S. health care enterprises.

I was always under the impression that the JC had a complete monopoly in its market–that is, if your health care organization wanted to be accredited (the vital ‘seal of approval’ for your organization’s public relations and safety standards, but also key for reimbursement through CMS) than you had to play ball with them.

In 2012, one of the hospitals at which I worked decided to go in a different direction, choosing instead to work with the accrediting agency DNV, which has its origins in the world of Norwegian shipping. For real. As in, ocean liners need a ton of regulation and safety standards so that they don’t run into each other and sink. We’re always comparing health care to airlines, right? Maybe it’s not such a big stretch after all.

Like most of my physician colleagues who’d lived through years of JC audits, we were a bit flabbergasted: “You mean the JC actually has competition?” As it turns out, the JC only controls a mere 80% of the market. Turns out it’s only a 785 lb. gorilla.

Even though this whole issue is a little bit “inside baseball,” I wrote an essay about it for NPR. My reasoning was that there’s always value in questioning monolithic conformity. And I had been really surprised to learn that there was actually competition to the JC.

Now comes a study in BMJ, led by Harvard researcher Ashish Jha. The study compared more than 4000 U.S. hospitals and the outcomes generated for 15 common medical conditions and six common surgical conditions between the years 2014-2017 in a Medicare population data set of more than four million patients.

What did the study find?

Interestingly, there was no statistical difference in 30-day mortality or readmission rates in the patients that were seen at JC-accredited hospitals vs. those at hospitals accredited by ‘other independent organizations.’ There was a slight but not statistically significant benefit in mortality and readmission rates for JC-accreditation vs. hospitals reviewed and accredited by state survey agencies.

The study raises the reasonable question: if there aren’t patient outcome differences in hospitals accredited by JC vs. those accredited by either state review (government) or other independent agencies (other privates), then should the JC enjoy such a massive industry dominance?

After all–many health care leaders cite the JC’s regulatory and inspection processes as burdensome, and argue that the whole preparation game and citation-fixing business is expensive and distracting from the core hospital mission: taking care of people.

Other JC critics cite the fact that the organization is less than optimally transparent, electing to keep its inspection reports private, despite the fact that many health care enterprises flagged for violations are able to stay accredited.

Congress has even begun an investigation into possible lax oversight.

Apparently Jha’s work has struck a chord, as there was some notable media coverage about the BMJ piece. For one, the Wall Street Journal ran a story about it, which it kept in front of its paywall, while noting that hospitals pay on average $18,000 for an inspection and annual fees of up to $37,000 to the Commission.

Cardiologist and prolific blogger John Mandrola also wrote an opinion piece titled “Joint Commission Accreditation: Mission Not Accomplished.” In his piece, Mandrola compares JC accreditation to medications or surgery that fail to live up to evidence-based standards and subsequently fall out of practice. He concludes, “If the JC’s brand of accreditation can’t show benefit, than it too needs to be de-adopted.”

Having learned that there’s an emerging marketplace of agencies equipped to inspect hospitals and health care enterprises it seems there’s an opportunity here: Perhaps the agency offering the greatest value in terms of cost, reporting, and public accountability will triumph against a behemoth that seems too complacent and entrenched in its ways.

Doximity

Have you heard of Doximity? There’s no reason why you would, unless you’re in the medical world.

Think of it as LinkedIn for doctors and other health care pros. Launched in 2011, Doximity now claims that more than 70% of U.S. physicians are members. If it’s true, that’s a pretty impressive number/captive audience.

They started an authors’ program, where medical pundits offer monthly columns.

My focus has always been on demystifying medicine for non-medical audiences, but I want to see if I can broaden the audience a bit.

My first column was a topic I’ve broached here before: how hospitals go quiet on weekends, which seems nonsensical to me. You can read it here.

The second monthly column just went up; it’s an exploration of why so much dialysis in the U.S. for people with end-stage renal disease (i.e. kidney failure) is of the variety known as “hemodialysis” as opposed to “peritoneal dialysis.” HD mostly involves patients going to centers three times a week for 3-4 hour sessions–which makes maintaining employment darn near impossible.

PD occurs at night, at home, and interestingly it works better (fewer side effects and better longevity) and it’s cheaper overall. So why do only 10% of dialysis patients use it?

In a word, money.

But the good news is that’s changing. Expect to see a significant increase in peritoneal dialysis in the next 5 years–from 10% of patients with end-stage renal disease, to 20% or more. You can read about it here.

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.

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.

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