Sunday, December 28, 2003


Some Doctors Letting Patients Skip Co-Payments from The New York Times

For years, health plans have sought to control medical costs by negotiating fees with a group of preferred doctors and requiring patients to pay extra for going outside the network. But some doctors and clinics - eager to help hard-pressed patients or calculating that it can benefit their business - have begun to foil the cost-control efforts by waiving those extra charges.

The move by these providers to dispense with collecting what are known as coinsurance payments comes as employers and insurers try to discourage overuse of health care by making patients pay more costs from their own pockets. But those efforts - and the squeeze on doctors as health plans shrink payments for in-network care - are generating resistance, experts say.

How this works out financially from the physician's standpoint is that it collects the "out-of-network" fees that insurance companies can provide, while the patient assumes no out-of-pocket costs.

Doctors are waiving coinsurance payments for several reasons, analysts say: to recruit patients who would otherwise go to doctors on a health plan's preferred list; to help people struggling with the cost of care, and to reduce their own costs for processing insurance paperwork and dunning patients who are slow to pay.

These doctors can afford to pass up the payments because the out-of-network fees they collect from insurers often are higher than those they would collect as members of a health plan's network.

Notice that this benefit does not extend to physicians within that health plan. And those who go "out-of-network" are dependent on the generosity of their physicians not to stick them with a bill...

But patients who choose an out-of-network plan run the risk of paying more than if they selected one of their health plan's preferred providers, said Randy Kammer, a vice president of Florida Blue Cross and Blue Shield. "There is no obligation for an out-of-network physician not to balance bill,'' she said, using the term for collecting charges in excess of those approved by the health plan.

And the government does not look too kindly on the practice...

Regularly waiving co-insurance payments or co-pays _ the $10 or $20 payments many plans impose for office visits - is against the rules in the government Medicare and Medicaid programs. A few states - Colorado, Georgia, Nevada, South Dakota and Texas - also prohibit the practice for patients covered by commercial insurance, according to Dennis M. Barry, a Washington lawyer who studies health care reimbursement issues.

Colorado and Georgia also forbid advertising the waivers to attract business.....

As I have posted before on 10/3 and 12/17 this is due to the regulation that Medicare patients must be charged the "lowest fees" by a physician.

While this seems to be a good deal for the patient, I have some problems with this:
Since "out-of-network" reimbursement is higher, if more take advantage of it the costs will increase to the managed care plan and they will be passed on to the patients/employers as either a) higher premiums or b)higher copays (which will add to the numbers seeking free "out-of-network" benefits). Managed care plans may then tighten restrictions on reimbursement to "out-of-network" providers, or bring them more in line with their "in-network" benefits.

It hurts the physicians within a plan that have to follow the rules and regulations. This may spur physicians to leave the plan and a vicious cycle is begun with eventually with the plan either being bereft of providers, bankrupt or both.

The physician can assume risk as well, as "out of network" benefits may be paid directly to the patient and not the provider. So you could perform an operation or provide care to a patient and they use their insurance check as "found money" and fly to Vegas while you cant put their gallbladder back in. (This happened at the Acme Surgical Corp). Temptation may arise to engage in "fee-splitting" with the patient.

(I may be wrong, but I think that one benefit of accepting Medicare "assignment" is that the physician is paid rather than the patient, lower reimbursement nonwithstanding. Please correct me if this is an incorrect assumption).
I am now being summoned to help take the tree out. Got to go.


Tuesday, December 23, 2003

sam jpeg
You are Sam the Eagle.
You are patriotic and devoted. And extremely anal.

Patriotism, Being appalled at what everyone else is
The National Anthem of America

"An American In....America"

"Men are from Mars, Women are from Venus,
Eagles are from America"

"Please stop that now! It's un-American!"

What Muppet are you?
brought to you by Quizilla

Sounds just like a surgeon!!!
Thanks to Dr. Bradley for the link.
DB links to this CNN story about the advantages of laparoscopic appendectomy compared with the more traditional open method, citing a paper in the January 2004 Annals of Surgery. While I have not received my print copy of Annals I have read the full article online and have the following comments.
The first paragraph in the CNN story reads as follows:

Patients who had laparoscopic appendectomies had fewer complications, left the hospital faster and went back to work sooner, two Duke University researchers found after reviewing results of studies involving 43,000 patients.

I wonder if the person who wrote this story read the article or even the abstract. Since the authors' begin their conclusion with:

In summary, we have shown that LA has significant advantages over OA with respect to length of hospital stay, rate of routine discharge, and postoperative in-hospital morbidity.

The authors then go on to explain some shortcomings of the study, such as conversions (lap to open) being coded as open which may affect in-hospital complications and length of stay. The authors also point out that since only inpatient data was collected that complications that arose outside the hospital may be missed. A potential bias may also rest with the use of inpatient data. A patient could have developed appendicitis during the hospitalization. If these patients were severely ill, or explored without a definitive diagnosis of appendicitis, they would not be likely to be offered a laparoscopic approach. The study did show that the infection rate was the same for both procedures in patients with abscess or perforation. The "in hospital morbidity" when broken down showed that the risk-adjusted wound complication rate was higher for open appendectomy, but other complications (cardiovascular, urinary, ect..) were not significantly higher for open appendectomy.
The problems that have hampered the wider acceptance of laparoscopic appendectomy are related to 1) cost and 2)operating time. Lap appendectomy has a higher cost than open appendectomy due to the laparoscopic instruments that are used. Does the increased procedural cost even out with the decreases in LOS seen with lap appendectomy? The jury is still out. As the authors themselves point out:

However, all aspects of LA and OA must be compared, including postoperative pain, patient's quality of life, days away from work, procedural costs, total costs, and long-term complications. The present investigation is only a first step towards an assessment of all these aspects based on representative US-nationwide patient samples. Further analyses to evaluate the above-mentioned endpoints are required to define whether LA should be considered the treatment of choice for appendicitis.

Operative time is increased for lap appendectomy, especially at three in the morning when the OR staff is not familiar with the procedures and equipment.
My routine is to perform an open appendectomy through a McBurney muscle-splitting incision for all patients unless the diagnosis is in doubt (usually a young female, and with the wider use of CT in diagnosis this is becoming less frequent) in which case I perform laparoscopy and go from there. I use generous amounts of local anesthetic and discharge my uncomplicated (unruptured) patients within 24-36 hours (Shorter than the average LOS in the paper). They can return to light duty within a few days and are at unrestricted activity in 2-3 weeks. The ruptured/abscessed ones usually stay in for 4-5 days with IV antibiotics and local wound care with delayed primary closure just before discharge.
But the LOS in the United States is nothing compared with Europe:

For instance, although Hebebrand et al from Germany reported a length of hospital stay of 5.3 days for LA and 7.6 days for OA, 28 Mutter and colleagues (UK/France) found 5.3 versus 4.9 days, 35 and Minne et al (USA) 1.1 (LA) and 1.2 days (OA). 36

A week in hospital for an appendectomy in Germany? My goodness!! Anyway, lap appendectomy is far from the standard of care, but may be soon.

Monday, December 22, 2003

Terror Alert Level
via Geekandproud

Wednesday, December 17, 2003

In today's Wall Street Journal a story (free version here courtesy of Business Word) about efforts being made by the American Hospital Association to resolve the disparity between fees billed to uninsured patients and those with Medicare or other means of health insurance. But hospitals and health plans are coming up against resistance from Medicare:

Other hospitals are planning sweeping changes to their billing practices. Ascension Health, the nation's largest Catholic hospital chain, said it will offer free care to every uninsured patient whose income falls below the federal poverty level, provided they don't qualify for government aid. (The poverty level is $8,980 for an individual, and $18,400 for a family of four.) ........

Douglas French, chief executive of Ascension, said the chain also plans to seek Medicare approval for even more dramatic price cuts. Ascension wants to bill all uninsured patients -- rich and poor -- at the same discounted rates its hospitals get from HMOs and insurers. Under that plan, "basically, nobody gets [full] charges," said Bruce Vladeck, a member of Ascension's board of directors. However, Mr. Vladeck, a former head of Medicare, said he isn't sure the unilateral discount for uninsured patients would pass muster with his old agency

Even the "evil empire" of health care is attempting to come up with a plan:

Meanwhile, another large, for-profit chain, Tenet Healthcare Corp. of Santa Barbara, Calif., said it hasn't been able to move forward on its own discounting plan, which involved billing low-income, uninsured patients at the same discounted prices it gets from HMOs. Medicare raised questions on the plan, and the company said it is awaiting a legal opinion from the Inspector General of the Department of Health and Human Services. In the meantime, Tenet says, it has drastically curtailed lawsuits against uninsured debtors and restricted the use of liens, eliminating them entirely for patients whose home is their only asset.

Hospitals and physician offices are rightly wary of crossing Medicare and getting fined or thrown in jail. My partner recently attended a coding seminar which he was told that Medicare's return on audits was $14 for every $1 they spend. Either there is a tremendous amount of fraud and abuse or physicians are being penalized for honest mistakes arising from a coding system that no one can understand. (I believe it is the latter)

The regulations that are proving to be the roadblocks are those that require Medicare patients to be charged the "lowest" fees. This would prevent hospitals from charging reduced fees to uninsured patients. This is also what inhibits "professional courtesy" in some practices.

As I posted earlier (10/3) hospitals have had to become more aggressive in collecting debt because private insurance plans and HMO's have cut reimbursement, and those patients cannot subsidize the uninsured:

In the 1980s, as powerful HMOs emerged, they began demanding their own discounts from the hospitals' listed charges. Hospitals in turn began boosting their charges, in part as an effort to set a higher starting point for negotiations. Lost in the mix were uninsured patients, who continued to be billed as they always were, unaware of the discounted rates and with no one to negotiate on their behalf.

The story also describes regulations the states are putting in place to regulate the collection of unpaid medical bills:

A new Connecticut law, which went into effect in October, makes it harder for hospitals to sue patients and to seize their bank accounts or place liens on their homes. That law also slashes interest rates charged on patient bills to 5% from 10%. In Illinois, state legislators are weighing laws that would end what they call "discriminatory pricing," the practice of billing uninsured patients more than insured patients -- on the theory that uninsured people tend to be minorities against whom it is illegal to discriminate. In New York, a pending bill in the state legislature would limit the amount hospitals could bill poor uninsured patients to no more than the sum Medicare or private insurers would pay, whichever is larger.

A fair system would also allow hospitals and physicians to deduct bad debt from their taxes, based on a Medicare fee schedule.

Monday, December 15, 2003

Ross has a post commenting on two stories; the first from Connecticut investigating the possible shortcomings of offshore medical grads, the other about the new enthusiasm of the medical licensure authority in Massachusetts to punish physicians for sexual abuse of patients. Ross does an excellent analysis of the situation in the Commonwealth, which I will not attempt to improve upon. The other article begins with a description of a patient rendered comatose after prolonged hypoxia due to an esophageal intubation. The anesthesiologist was a graduate of an Caribbean medical school. The question that I have is:
Why did the hospital credential this guy as a member of its' medical staff?!?
It seems that he had some red flags:

(Dr.) Paul spent the previous four years in a post-medical training limbo. The stretch included time spent building a house in Haiti, working as an administrative assistant in Queens and tutoring students back at Spartan, Paul testified. It did not, however, include treating patients or gaining experience in the delicate procedure he needed to perform on Humphrey.

It used to be that a physician that moved around a lot was considered "suspect" because it was felt they couldn't hold a job or had been "run out of town". Over time that has become less of an issue, especially for anesthesiologists and radiologists. Hospitals are very reluctant to deny privileges or revoke them because they are wary of being sued by a physician for "restraint of trade".
If physicians are going to hope to have any credibility in a debate about tort reform, we need to get serious about cleaning up our own house, as they are doing in Texas (via Rangel). But some libertarians feel the state should have no role in the regulation of physicians. (see my thoughts here{7/17 post})

Anyway, I've got to go to the ER now but the Hartford Courant has a series about "problem" medical schools. Today's story has tales from the Spartan Health Sciences University (spartan referring to their facilities, I'm sure). Ironic that St. Lucia, where the medical school is located, will not license its' graduates to practice medicine there.

For years, government officials and hospital administrators in St. Lucia have refused to license Spartan graduates or allow the school's students to train in local hospitals out of a "deep skepticism" of the school's educational standards.

When I was in school we had a few students who transferred from Caribbean medical schools (not this one) to the Medical College of Georgia after two years due to the strength of their step 1 boards. They told us of long periods without reliable power or clean water. I admired their tenacity in the face of adverse circumstances, and they were good students. From the interviews in the articles linked to above, I don't think the same applies here.
Posting has been infrequent over the past few days for a number of reasons. End-of-year business picks up for elective surgeries because of the fact that most people have met their deductibles and want it taken care of before the new year, I have been on call every other day for the past six days, and I have had to complete my own non-internet Christmas shopping.
Grunt Doc has a very nice list of "suggestions" for your next visit to the ED. To this I wish to add:
1. As a consultant, I am not responsible for your entire ER wait. Do not blame me if you have waited several hours and I only heard about you thirty minutes ago.
2. If the patient is a minor child or another person who cannot sign for themselves and you are the person who signs for them. DO NOT LEAVE after I have seen them, there are many papers to sign related to surgery, and you need to be around to sign them.
3. If you leave AMA, don't expect: a) pain pills b)a work excuse or c)cab fare.
More later.

Sunday, December 14, 2003



Tuesday, December 09, 2003

From yesterday's Wall Street Journal, a story (sorry, subscription required) about a ethical delima of medical trials: Do you continue to provide the patients with the treatment (chemotherapy in these cases) after the trial is completed?

Twelve-year-old Thomas Tomeny has an aggressive brain tumor. It grew back after surgery last year and didn't respond to either chemotherapy or radiation. Then, in the spring, Thomas was able to join a tiny test of an experimental radioactive drug -- and his tumor shrank by 33% after the first dose.

But despite the improvement, he was told that he wouldn't be given any more of the drug after his third dose in August. He was approved for only three doses -- a condition made clear on the consent form the Tomenys signed in the spring when they agreed to participate.

The story describes other patients in trials and their struggle to continue to receive medications. Two of the patients, one on Erbitux, and one other were dropped because they met exclusion criteria during the course of the study. They had worsening of their symptoms from their malignancy, and were able to be placed on the study drugs again.
Several reasons are given for not allowing study patients to be continued on their medications:

Cost/Supply: One is the cost: even small trials can cost millions and larger ones may run up to $100 million. The majority of drugs tested in clinical trials fail. Many companies make only limited supplies of a new drug, just enough for testing.

Study design: From an analytical standpoint, "it's cleaner and easier to write protocols that say 'this is the beginning' and 'this is the end,' " of a trial, says an FDA spokeswoman

Regulatory/legal: After the trial ends, researchers sometimes have another reason for not allowing patients to continue on the drug. If a person who does well in a trial continues on a medicine and later has a bad side effect, the company is required to report it to the FDA. Companies and researchers worry the FDA could ask questions or even suspend a drug development program if serious concerns about safety arise.

The physician and hospital involved with a trial may be lukewarm in their support of a patient trying to get continued supplies of a drug:

Patients can't always count on hospitals or doctors to go to bat for them. Hospitals compete for clinical trials that bring prestige and money. So hospital boards charged with regulating trials are sometimes reluctant to push too far on patients' behalf for fear companies will take their business elsewhere

An ethical sticky spot, to say the least. The physicians involved in a trial are torn between the very real patient sitting in front of them, and the need to be mindful of the goals and regulations of the trial.
Could not the same argument be made for offering the treatment drug to the control group at the completion of the procedure?
How can a patient make an informed choice (or one at all) when the only hope of extending their life was to enroll in a trial, and hope not to be in the control arm?
When I was a medical student an oncology attending told me that the hope of medical oncology was to make the anecdotal an everyday occurrence. A noble and worthy goal.
Well, got to go and wrap some presents.
Ozzy Osbourne was injured yesterday after a "quad bike" (ATV) accident yesterday. The injuries according to the AP:

When he was admitted, he had a fractured left collarbone, he had some damage to the blood vessel that is underneath it, he had eight fractured ribs on the left side and, in addition to that, an entirely stable fracture to one of the vertebrae in his neck

Apparently Mr. Osbourne had the arterial injury repaired and his left arm is perfused again. The most ridiculous quote from the AP story comes from a Dr. Dick Jack, the "medical director at Wexham Park Hospital in Slough, west of London":

"This is not a major problem."

The injuries described above, even in a healthy person would constitute a "major problem". Given Mr. Osbourne's age (56) and his hard living, he will have a difficult time of his recovery.

This story states that Mr. Osbourne is still on the ventilator.

Monday, December 08, 2003

LSU 34 UGA 13
Georgia simply was outplayed in all aspects of the SEC Championship game Saturday night. Georgia will now head to Orlando for the Capitol One bowl, while LSU plays Oklahoma in the Sugar bowl for the national championship, a game tainted by the abscence of USC, which finished number one in the "human" component of the BCS.

Tuesday, December 02, 2003

From Medscape a paper published in Annals of Surgery about in-hospital mortality following gastrectomy and colecomy in New York State. The results:

Overall mortality for colectomy patients was 4.6%; the adjusted mortality rate for subspecialty versus nonsubspecialty-trained surgeons was 2.4% versus 4.8%, respectively (adjusted odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.34, 0.60; P < 0.0001). Gastrectomy patients experienced an overall mortality rate of 8.4%; the adjusted mortality rate for patients treated by subspecialty trained surgeons was 6.5%, while the adjusted mortality rate for nonsubspecialty trained surgeons was 8.7% (adjusted OR = 0.70; 95% CI = 0.46, 1.08; P = 0.10).

So, on the surface it appears that "subspecialty" training as loosely defined by the authors (membership in the Society of Colon and Rectal surgeons does not require fellowship training) translates into better in-hospital mortality rates.
I don't have alot of time right now to fully pick this apart but what I noticed from the tables (scroll down) is that for both gastrectomy and colectomy the "non-subspecialists" had higher percentages of patients with CHF, ischemic heart disease, COPD, diabetes and peripheral vascular disease than those treated by "subspecialist" surgeons. A limit alluded to by the authors:

An important limitation of this study is that we used administrative data to assess the volume-specialty-mortality relationship. This did not allow us to account for the appropriateness of patient selection or for detailed comorbid conditions, nor does it give us long-term follow-up. We reduced the likelihood of confounding, however, by adjusting for risk based on comorbidities ascertained in the claims data and controlling for other demographic variables.

The authors go on to describe the impact on such studies might have on managed-care referral patterns. One problem with this is that if elective operations (colectomies, gastrectomies, ect.) are all sent off to the high-volume centers, will your average Joe community general surgeon be able to deal with the patients on an emergent basis? Will it become like cholecystectomy where the lack of experience with elective open operations (due to laparoscopy) hampers the ability of surgeons to handle the unexpected need to perform an open cholecystectomy? If the mortality rates are bad for low-volume surgeons doing elective cases, just you wait for the figures for no-volume surgeons doing emergency cases. Got to go.

Monday, December 01, 2003

From yesterday's Atlanta Journal-Constitution

Lung Cancer Awareness Month ends today; were you aware?

I was not, but read on:

Lung cancer kills tens of thousands more people than breast cancer does. But during the past month of "awareness," there have been no pink ribbon pins for lung cancer, no long marches for a cure, no postage stamps or T-shirts or bras or candy at checkout counters. Breast Cancer Awareness Month, in October, had all that and more.
Advocates of lung cancer research know their disease lacks the cachet of breast cancer. Their chosen symbol is a clear plastic ribbon. Invisible. They know that lung cancer patients often are blamed for having the disease; breast cancer patients never are.

The numbers:

The numbers for women in 2003:
Breast cancer diagnoses: 211,000 Breast cancer deaths: 40,000.
Lung cancer diagnoses: 80,000 Lung cancer deaths: 68,000.

Among men, 91,800 new cases of lung cancer will be diagnosed, and 84,400 will die.
It's not just the high numbers that worry advocates and doctors. The death rate -- about 85 percent -- is higher than for any other cancer.

Continuing along, the story goes into some of the reasons for this...

Few survivors: One reason for the shortage of money is the shortage of survivors to advocate for greater funding, lung cancer advocates said.

Sexuality: Breast and prostate cancer push emotional buttons because they are associated with intimacy and sexuality. Breast cancer does not kill as many women as lung cancer does, but it is the most common cancer among women, and it disfigures thousands. Fear of losing a symbol of her sexuality and vitality is a compelling reason for a woman to support breast cancer research, advocates for lung and breast cancer said.

Tobacco companies: Many researchers and advocates have a group of their own to blame for the funding gaps and the cultural indifference.

Let me say that I feel that the funding, research, and public awareness that the advocates for breast cancer have been able to achieve is well deserved. About half of my practice is breast disease, and the resources that are out there are impressive.
This is another example of how the perception of a disease, and the people who suffer from it, can affect the public and governmental response.
A prime example of this is HIV/AIDS. According to the CDC, there were an estimated 26,464 cases of HIV/AIDS in the U.S. in 2002. There are about $2.6 billion spent in the U.S. for HIV/AIDS research. This compares to $565 million this year for breast cancer, and $257 million for lung cancer according to the NCI (all told $4.6 billion for all malignancies). I'm not saying this is right or wrong, it's just how the system works. Should the rules of "evidence-based" medicine be applied to funding? If so, what would this do to HIV/AIDS given the numbers of patients affected? Something to consider.
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