Happy New Year, GlassHospital readers.
The year’s end provides the opportunity to reflect on the year that was.
These few stories stuck out as some of the most impactful of the year–and what they portend for the future:
1. Gene editing: In November, at the International Summit on Human Genome Editing in Hong Kong, Chinese biologist He Jiankui shocked the world with his announcement that he had manipulated at least two embryos to change a trait (or more??) in twin baby girls. The reaction was mostly critical, including calls for a moratorium on the use of CRISPR gene-editing in humans.
The upshot: stories like this will be with us for the foreseeable future. While the power of CRISPR to remedy harmful genetic conditions seems hopeful and fantastic, there’s a whole history of eugenics movements that should guide us to avoid the hubris of selecting for ‘desirable’ traits in humans.
2. #ThisisOurLane: Also in November, an NRA staffer (to this point unknown) tweeted a response to an article in the Annals of Internal Medicine recommending that doctors ask patients about gun use and safety as a health measure. The tweet infamously suggested, “someone should tell self-important anti-gun doctors to stay in their lane.” This was met with a firestorm of response from doctors across the spectrum, particularly those that care for gunshot victims (ER docs, surgeons, etc.) who tweeted under the hashtag #ThisIsOurLane.
The upshot: It’s hard to quantify the cumulative impact of the conflict, which is sure to go on, but the Justice Department did just ban bump stocks.
3. Bill of the Month: NPR, in conjunction with Kaiser Health News, started a monthly series examining outrageous and inexplicable health care bills. It’s been one of their (repeatedly) biggest stories of the year, as exemplified by the (insured!) Texas teacher who faced a $108,951 hospital bill after treatment for a heart attack (he was taken by ambulance to an out-of-network hospital–hardly the time, it seems, to price compare).
The good news: His bill was lowered to $332 after the glare of national media attention.
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.
In the ‘old days,’ doctors were taken on junkets to sunny destinations and indoctrinated with the latest and greatest in brand name medications. The trips were paid for by the pharmaceutical firms that manufactured these drugs.
Trips like this started to become unseemly, and the public began demanding more transparency in the relationships their doctors had with drug companies. A database was created to keep track of the monies flowing to docs from drug companies.
Docs can still get a meal (as long as it’s ‘educational,’ i.e. there’s a lecture along with it) and the traditional branded pens and pads of paper for the office. Sometimes drug reps (the sales people for the pharma firms, known in the trade as ‘detailers’) bring by bagels or doughnuts to woo the staff and steal a few minutes to tell us about their latest product.
The big money comes to the select few who become ‘thought leaders,’ i.e. spokespeople on behalf of certain drugs. This can range from five to six figures. Per year.
Docs have always been a little defensive about having these relationships explored or highlighted. “No drug company influences the way I prescribe,” is a common sentiment.
“I prescribe the best products that are on the market,” is another retort — not hard to defend, as the brand name drugs create the perception (at least) of being the best.
Conventional wisdom has always held that drug companies wouldn’t spend the billions that they do on marketing if it wasn’t beneficial. Proof of that has been hard to come by, though, as there wasn’t a way to clearly demonstrate a relationship between drug company payments and the rate of prescribing brand name (i.e. heavily marketed, more expensive) drugs.
Now there is.
In a beautifully conceived and executed investigative report, the non-profit news source ProPublica has linked the pharma payment database with the Medicare Part D (which since 2003 has paid for prescription drugs for seniors) database.
You know what?
There’s a perfectly linear correlation: Docs that receive payments (in one database) prescribe more brand name drugs (from the other database).
Nothing about this is illegal. There’s no doubt that some of the doctors receiving payments genuinely believe the brand-name products they prescribe are better. It’s just that no one can claim with a straight face any longer that payments to doctors don’t influence the way we prescribe.
(Mind you, the drug companies have known this all along, but have kept this information private as ‘proprietary’ information. Trade secrets, you know.)
If you like this kind of reporting, you can listen to a story about the investigation here:
Ever received a bill for a health service that troubles you? Does it seem too much?
Is it hard to understand what you owe from what insurance pays? Does it seem like the share you pay always goes up?
Medical costs are a universe unto themselves. How doctors and medical facilities (hospitals, radiology practices, etc.) come up with their charges seem to lack any rational basis.
Famously, in his article that became a book, author Steven Brill challenged the CEO of a big health insurance company to explain his ‘explanation of benefits’ (the bill-like statement you get that is NOT A BILL), and the CEO couldn’t do it. Here Brill recounts the story in an interview with Minnesota Public Radio. Context — Brill had a big operation for an abdominal aortic aneurysm, so he decides to use himself as a test case:
After I got home, about 2 or 3 days later, I received in the mail 36 different explanations of benefits from my insurance company, in 36 different first class envelopes, which tells you something about how inefficient the system is.
As I started to open them, I thought to myself: I’m the world’s leading expert on hospital bills and insurance bills, this is going to be fun. When I opened the third envelope, it said the following. This is an explanation of benefits from United Healthcare, which is headquartered in Minnesota: Amount billed: $0; amount paid by insurance: $0; amount you owe: $154.20. I looked at it and I looked at it. If nothing was billed, how could I owe $154.20? I turned it over, I tried to decode it, I couldn’t figure it out.
As it happened, before I went into the hospital, I had scheduled an interview with the CEO of United Health out in Minnesota … So as soon as I was able to travel, I went out to Minnesota and I did the interview. … And then at the end, I reached into my pocket and took out that explanation of benefits and handed it to him. I said: “I’m wondering if you could just help me understand this, I’m having trouble figuring out what this means. How could I be billed $154 if nothing was billed?”
He looked at it and he looked at it, he turned it over, he looked at the coding, and finally looked up and said to me: “I could sit here all day and I could not explain that to you. I have no idea what it means. I don’t know why they sent it to you.”
I said, “Aren’t you they?
That explanation of benefits is the single most common form that consumers receive in what is by far the largest industry in the United State: The healthcare industry. Tens of millions of those explanations of benefits go out from United Healthcare every year, and the head of the company can’t even understand what it means, so how are the rest of us supposed to understand what it means?
As an entree to discuss the issue of health costs in the U.S., and people’s disparate reactions to them, I share with you the story of Mrs. Sutton, a patient of mine who had a somewhat atypical reaction to the cost of her colonoscopy — even though she owed nothing out of pocket. I also want to emphasize how poorly doctors do in helping patients anticipate their costs of care. Reliable pricing information is hard for us to come by, too — as some commenters note. But some new companies (apps, of course) are trying to tackle this issue head-on.
Click on the box below to read it. Feel free to add your own story to the mix.
Thanks for reading.