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Monday, November 29, 2010

Marijuana, Darvocet, Colchicine and the ineffective politics of medicine

The Food and Drug Administration (FDA) has made two bold steps in the last month. They have asked the manufacturers of pain medications containing the mild opiate propoxyphene (Darvon) to voluntarily take these products off the market, and they have removed from the market all generic forms of the drug colchicine that is used to treat gout.

Initially, this all seems ridiculous. Both of these drugs are nearly ancient, with a track record of successes, failures and side effects that goes back decades.  On further examination, it still seems pretty stupid, though quite a bit more complex.

Thursday, November 18, 2010

The sky is falling! Medicare payments to physicians will be cut by 24.9% on December 1, 2010!

Since Medicare, the single payer health insurance program for citizens age 65 and over, was signed into law in 1965, medical care for seniors has become more universally available and increasingly expensive. Since Medicare insurance looked to doctors and senior citizens like a blank check, services offered to older Americans rapidly expanded as did their unit cost and consumption of those services. The American government has tried various schemes for reining in spending, none of which have been popular or effective. In 1998, we decided to try the "sustainable growth rate" formula to control costs. Under that law, Medicare expenses were allowed to rise a certain amount, that which was considered to be a sustainable amount, based on inflation and other costs, and if those costs rose by more than the target, reimbursement for services under medicare would be reduced for the next year to an extent that the target of reasonable cost increases could be reached.

In 2002, Medicare payments were reduced by 4.8%, meaning that doctors who treated medicare patients, patients who already paid less than most patients insured privately, received a pay cut relative to the previous year. Many doctors decided that they could no longer accept Medicare insurance, and stopped seeing patients whose only insurance was Medicare. This was an ugly scene, with unhappy doctors and unhappy seniors.  After that time, each year's Medicare expenses have exceeded targets and congress has stepped in at the last minute and staved off cuts to Medicare reimbursement. Each year that the cuts are delayed, they are added to the next years planned cuts. Now, by the sustainable growth rate formula, doctors' reimbursements for treating Medicare patients are slated to go down 24.9% by December 1st.

Doctors are wringing their hands, sending letters to their patients and predicting terrible outcomes for the care of seniors. They are also expecting, once again, that congress will step in and avert this crisis. And of course we will be saved again from this cut because the cut is now unimaginably huge. Congress has promised a fix to the sustainable growth rate formula, because this last minute reprieve thing has gotten ridiculous and is a colossal waste of time and effort. But the problem is not the SGR, but rather that providers of care for patients with Medicare do nothing substantial, year after year, to control costs.

Oooh. Saying that could really get me in trouble with my doctor friends.Why, they might ask, is it up to us, who work so hard for such small reimbursement, to reduce Medicare costs? The answer is that nobody else appears to know how to do it, that we have a major stake in making sure that this system works, and that we have large organizations such as the AMA which have the manpower, political clout and most importantly knowledge of the situation to do the job. Congress doesn't know how to do it. They aren't medical. Patients can't do it. It's really up to us.

Where, then, is the waste? Won't we have to deny care to people who need and deserve it in order to cut Medicare costs? Absolutely not. We do so much in medicine that is unnecessary, from CAT scans that are not indicated, to surgeries that don't help, to high tech care at the end of life that was never what the patient wanted, that cutting even a fraction of it would be adequate to balance the budget. Many of the small projects funded by the health care reform bill will help, but the process is by no means on autopilot.

Yesterday I received in the mail the summary of Medicare benefits for my father in law who died in a local nursing home of pneumonia this summer at the age of 90. Both he and my mother in law had become demented, him from multiple strokes and her from Alzheimer's disease. They were at a nursing home where the care is excellent and where they know both me and my husband well. So when I saw that he had been charged over 200 dollars a day for "oral function therapy" which I have determined consisted of having a therapist coach him on eating, I was surprised and disappointed. In the bill I saw, he had charges for this and for speech and hearing therapy which over the course of 2 weeks during which he was mainly doing the work of dying, added up to over $2600. It is, of course, hard to interpret these bills, but it looks like Medicare shelled out something over $1000 for these therapies. That's a lot of money. But multiplied by the over 1.4 million people in nursing homes in the US, it starts to be real money, to the tune of $1.4 billion dollars a year. This particular item is only a tiny issue compared to all of the other nursing home related waste, and nursing home related waste is a mere speck on the horizon of total Medicare waste. The total budget for Medicare in 2010 is about 380 billion dollars, and it really looks to me like cutting 25% of this would not be hard, if we paid attention.

The question that is left for me at this point is what to do about this specific bill. I am in the same situation as many people who get billing statements from insurance companies. The amount that the insurance company leaves for the consumer is pretty small, and I'm tempted to just leave the whole thing alone, after notifying everyone at the nursing home and everyone who is a doctor who will listen exactly what these therapies end up costing.  If I call a fraud and abuse hotline at Medicare, they might come down hard on a nursing home that I think is excellent, and the real problem, which is that this sort of thing is going on everywhere, will go unaddressed.  If it was my nickel, I would never let something like this go. With an insurance company acting as an intermediary, though, the motivation for an individual, who actually knows the value of the service being given, to make the kind of fuss it takes to reduce costs, is limited.

Monday, November 1, 2010

Health Insurance Premiums go up, again

A year ago I decided to shed my company health plan and buy an individual plan with a high deductible for my family. The cost of my employer plan had reached nearly $900 for my family of 4 who never use health insurance, and the deductible was $1000, which meant that any care we have received in the last 10 years would have been unreimbursed. I found a plan with a deductible of $7000, which I could combine with a Health Savings Account for $481 a month. How clever, I thought. I have really bucked this system!

I just got my bill for the health insurance plan that Premera Blue Cross decided to provide for me in place of the plan that I signed up for a year ago. A few weeks ago I had received a glossy color sheet describing how my plan was changing, due to health care reform. My new plan would cover all health maintenance with no charge to me out of pocket, but would no longer have any coverage for various alternative medical services or eye care services. The overall deductible would be the same.

How much, you may ask, is this new plan that sucks marginally more than my previous plan? It is now about $630 bucks a month, a 30% increase over last year (with no dental coverage). As far as I could tell, there is no cheaper, crappier plan available to me. I will just have to suck it up and pay the extra nearly $2000 a year for my really truly catastrophic coverage. This will, of course, cover my deductibles on preventive services, which might have added up to as much as $200 a year with the previous plan. These figures are lower than many Americans’ since our family has no medical problems and our state has some of the cheapest medical costs in the country.

The Seattle Post Intelligencer reports that Regence has raised rates in the double digits for 4 years in a row, on average 91% since 2007. They have a nearly 1 billion dollar surplus, which increased 12% in the last year. Provisions of the health care reform bill will make health insurance more competitive, but not until 2014. That is plenty of time for insurance rates to double and then some.

Most people are in exactly the same situation that I am in, or worse, no matter whether they are insured by their employer, by the military or by the government through medicare or medicaid. To some extent, everyone has a bite taken out of their overall income due to the cost of insuring for health care. The cost of health care itself continues to rise, but much more steeply because health insurance companies continue to pay for these expenses, make the billing for them more difficult and therefore more costly, and hand all of those costs over to the consumers of health insurance with a hefty and increasing markup.

What shall we do, then? I do hope we all become uncomfortable enough with the status quo that we begin to calculate the true cost of a good health care system and re-evaluate what place our present third party payment system should have in it. Negotiating payment for the services that we as individuals or communities need and buying those services would take a great deal of cooperation between providers and consumers, but could radically reduce our dependence on health insurance companies.


An example of paying for expensive services in a proactive way is our local air ambulance service. We are a rural area and many serious injuries or cardiac emergencies are treated in our nearest big city which is 90 miles away. Sick patients are transported by Northwest Medstar to Spokane by helicopter or fixed wing plane, at a cost of over $20,000 per ride. Blue Cross will pay 30% of this if they even agree that the transport was necessary. For $59 a year, a person can buy a “membership” to Medstar which covers any air transportation needs. This is not charity, but simply a calculation by medstar of what it costs to support their services.

There are no other alternatives to our present insurance coverage that are available to me and my family at this point that are not either irresponsible or more expensive. I will continue to push for a community sponsored alternative to health insurance. Our hospital could make this happen if there was adequate cooperation from the doctor groups in town. Even without that, we could do a smaller pilot project to provide primary care, lab, hospital and imaging services. The incentive to do something like this will continue to increase as premiums rise. Interest in this has been high with our hospital’s administration and regardless of tomorrow’s election outcomes, I expect to see creative grass roots alternatives to our present third party payment system.