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Demystifying Medicine One Month at a Time

Category: technology (page 1 of 10)

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.

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

“The Future, Mr. Gittes. The Future!”*

The announcement of the proposed takeover of Aetna (a health insurer) by CVS (a drugstore chain calling itself a “pharmacy innovation company”) has become a big news story. What does it mean for U.S. health care? More importantly, how will it impact us as individual patients (what some like to call “customers”)?

I don’t know.

I’m not sure anyone has clarity on this yet. We’ll have to wait and see if the deal goes through, and then how the behemoth merged company brings efficiency or monopolistic pricing to the market.

Or both.

But if you want some other visions of the health care future, think about a hospital without patients as is detailed in this article from Politico.

Mercy Virtual, which opened in 2015, calls itself “the world’s first and only facility of its kind.” The 125,000 sq. foot building houses health professionals who remotely monitor and consult for dozens of hospitals and ICUs. It’s all done telephonically, er, remotely, errr, virtually.

[Another article in that same Politico issue makes the case against hospital beds, on the basis of bed rest being counterproductive for nearly every medical condition we treat. I used to get frustrated watching people ‘decondition’ while laying around in bed. It’s a serious problem, especially in the elderly.]

Which leads directly to another future question: is the age of the virtualist upon us? Yes, as predicted in a recent JAMA column by Dr. Michael Nochomovitz, who makes the case for a medical specialty devoted to care of patients through technology.

It may be the way of the future, but it sure makes performing physical exams harder.

These times. They are a changin’.


*Chinatown. Noah Cross (played by John Huston) to private investigator J.J. Gittes (Jack Nicholson). 

Stomach Draining?

FDARecently the US Food & Drug Administration (FDA) approved a device for market called “AspireAssist.”

The device is hooked up to an incision in your abdominal wall after each meal that allows you to drain 30% of your stomach contents directly into the toilet.

Harder to gain weight (and easier to lose it!) when you’re diverting a third of caloric intake from your body into the sewer system.

It works like a “G-tube” in reverse — the kind of tube that puts liquid calories INTO your stomach in the event you can’t swallow (i.e. you’ve had a stroke or some kind of oral surgical issue that won’t let you chew and swallow). Therefore it was deemed ‘safe enough’ because SO FAR it has a low complication rate.

But keep in mind to get FDA approval the manufacturers only had to show efficacy and safety in two small trials totaling less than 200 patients. This is a lower barrier to market than would occur if the new product were a medication. [Devices and medications are held to different approval standards at the FDA.]

As for whether AspireAssist is ‘ready for prime time,’ I share the healthy skepticism of my friends over at “Updates in Slow Medicine,” who wrote:

From the Slow Medicine perspective, removing food after eating directly from the stomach using an A-tube remains an experimental approach to weight loss, and we would only recommend an AspireAssist device to a patient of ours enrolled in an appropriate clinical trial.

With more clinical experience it’s possible this could be a solution for many folks struggling with obesity. But only when we know more.

Timing is Everything

IUDs & Implant

Quick: Which US state has the highest rate of unintended pregnancy?

I’ll reveal below, but I learned the answer and several other surprising facts in an interview with Mark Edwards, the co-founder of Upstream USA, a non-profit training organization that provides technical assistance to health enterprises (medical practices, clinics, public health departments) in the use of long-acting, reversible contraceptives (known in the trade as LARC).

LARC consists of two options: IUDs (intrauterine devices) and implants — which are small, match-sized, plastic rods that deliver a slow, steady dose of hormone to prevent pregnancy. They are planted in the upper arm of women to provide another form of hassle-free contraception.

Both of these methods can be discontinued at any time, at which point fertility returns — faster, I’m told, than in the case of oral contraceptives.

Here’s a fact that surprised me about oral contraceptives (aka “The Pill”): Though when taken reliably their ‘success rate’ as a means of preventing unwanted pregnancy is considered to be 99%, over a 10 year use period, due to the challenging nature of remembering to take a daily pill, it’s likely that 61% of those taking the pill exclusively for birth control will become pregnant. Most definitely not the intended outcome. (Source: here.)

Big picture: every year in the US, there are about 6.6 million pregnancies. Of those, 3.4 million, or slightly more than half, are accidental: either altogether unwanted or ‘significantly mistimed’ — what we in the health care business describe as a pregnancy occurring 2 or more years before desired. The vast majority of these accidental pregnancies occur in women in their 20s (though teen pregnancy is a concern, only 20% of unplanned pregnancies are in teens, and the vast majority of those are in women 18-19 years old. In fact, the teen pregnancy rate has fallen significantly in the last 25 years).

That’s why, regardless of your politics, offering LARC to any woman of childbearing age is crucial. At the very first visit. As a primary care doc myself, I know that ‘family planning’ often falls down the list of concerns for patients that I see because there are so many other issues people wish to bring up in our short office visits. Thus, opportunities to provide women with LARC often fall through the cracks.

Upstream USA’s methodology includes technical assistance: training staff up to ask every woman that comes in a simple question: “Do you intend to get pregnant in the next year?”

If ‘yes,’ let’s get her into preconception care (folic acid, multivitamins, etc.). If ‘no,’ offer LARC right then and there. And the provider (doctor, nurse practitioner, or physician assistant) is trained up to put in an IUD or implant on the spot. No waiting until next time.

Why is this so important? Women with unplanned pregnancies are at greater risk for staying or falling into poverty. Their opportunity to advance in their education is diminished. Children should be brought into the world wanted — with parents that are prepared — with the maturity and resources to succeed.

It’s a fundamental choice for a woman to decide if and when she wants to have children. Of course, fewer unplanned pregnancies also means less need for abortion.

So what Upstream USA is offering is win-win-win. It’s bipartisan — a rare area that people on all sides of the political spectrum can agree upon. Upstream USA’s first big success was in none other than Texas. The organization also has partnerships in a number of other Red and Blue states.

The state with the highest rate of unplanned pregnancy? Surprisingly, Delaware. Upstream USA is there, too. And going big — across the whole state.

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