Dec
10

Our healthcare system is breaking – part 2

Earlier this week I wrote the first in what is likely to be a wholly dispiriting series of posts documenting the decline of our healthcare system.

Make no mistake, in many areas it is coming apart at the seams. While the causes are many, there’s no question COVID has both sped up and steepened the fall.

Healthcare job vacancies are twice the historical high, with one out of every ten jobs unfilled. We are missing about 1.9 million nurses, doctors, technicians, administrators, lab techs, therapists, nutritionists, counselors, case managers, social service workers, aides, and support staff.

From the Bureau of Labor Statistics… note the graph includes both social workers (about 200k openings) and healthcare about 1.7 million.)

At the end October,

  • more than half of the healthcare job openings were for RNs
  • 15% were for LPNs
  • 7^ for nursing assistants
  • 17% for therapists.

Many of the healthcare workers that have been able to hang in there are exhausted, scared, emotionally scarred and beyond frustration.

Statistics don’t mean anything? OK, here’s what this feels like…

What does this mean for you?

You don’t know what you’ve got till it’s gone. 

Reminder to Trolls and Cowards

I highly value disagreement but only if it is courteous, fact-based and the other side isn’t hiding behind anonymity.

A reminder to all commenters; with rare exceptions – as in when I know who you are – anonymous comments are banned. You know who I am, it is only fair that I, and your fellow readers, know who you are. Indeed there are sometimes good reasons for anonymous comments, but never when you attack, insult, denigrate, and rant. So, Cowards are not welcome here.

Similarly, I’m done debating Trolls who engage in fact-free rants and/or cite completely not-credible “sources” (no, InfoWars is NOT a credible source). If you want to debate, avoid these common pitfalls.


Dec
9

A promising new tool for physical therapy

I’m approached by lots of companies looking for advice on how to get their products/services into the workers’ comp and/or group health space…most are:

  • not exactly ready for prime time &/or
  • don’t have enough solid research behind them &/or
  • have glaring deficiencies &/or
  • just don’t feel right.

But when Bill Zachry called me about Plethy, I paid attention (disclosure – Bill is a long-time friend and colleague, has huge experience in workers’ comp, and is one of the finest people I know).

While Plethy’s Recupe is technically in the digital musculoskeletal space, Recupe is unlike other approaches in that the technology is not the focus, rather a key component of a comprehensive approach that supports physical therapists’ work with patients. Yes there’s a smartphone-based app, yes there’s a sensor that is used to help the therapist monitor exercises and recovery, yes the data can be seamlessly shared with other members of the patient care team.

In my experience devices of this kind are either driven by technologists or clinicians – both have challenges. Technologist-driven approaches often have significant clinical gaps, while clinicians’ efforts are usually clunky and hard to use.

Plethy has involved orthos, DPTs, and other clinicians in the entire development process, which has been managed/done by highly experienced tech experts with deep background in tech product development.

Tech should NEVER displace the involvement of clinical experts. Rather tech should support those experts, provide actionable information and do so with minimal hassle factor.

So far, Recupe checks those boxes.

What does this mean for you?

We are getting there…

note – I am an advisor to Plethy.


Nov
30

Facts vs beliefs

The medical community is wrestling with ethical issues arising from vaccines.

Simply put, should unvaccinated people infected with COVID be treated differently than the vaccinated?

This isn’t just an academic exercise; here in the Upper Valley of New Hampshire and Vermont, emergency rooms, critical care units, ICUs and Pediatric ICUs are stuffed full of COVID patients, almost all of whom are unvaccinated.

The Governor has issued an Executive Order intended to give hospitals more flexibility in setting up overflow units. At least two NH hospitals have postponed or halted elective surgeries as a result of the latest COVID surge.

Michigan may be in even worse shape.

The implications are real and potentially tragic.  Parents, friends, children or neighbors in car accidents, struck by heart attacks or strokes, suffering from kidney failure or pancreatitis or appendicitis or anaphylactic shock may find their local hospital doesn’t have an open bed and/or is operating short-staffed.

The latter is worsening by the day, as nurses, support staff, physicians and other clinicians are exhausted, frustrated, angry and despondent over long hours and the need to treat unvaccinated COVID patients. That and a relatively tiny number of healthcare providers have also bought into the lies perpetrated by antivaxxers, exacerbating the staffing shortage as they lose their jobs.

The exception to this discussion is for populations that have been mistreated, lied to, abused and misled by eugenicists masquerading as researchers.

The arguments for NOT treating those adults who are unvaccinated by choice (rather than due to a medical exemption) go like this…

  • the “slippery slope” argument – once we do this, then we’ll
    • refuse to treat obese people for heart disease, kidney disorders, diabetes, hypertension etc; smokers for heart disease, cancer or COPD; drinkers for liver disease – as if individual decisions with repercussions limited to that individual are the same as antivaxxers’ potential to spread infections, contribute to variant development and possibly kill family members, kids, health care workers and co-workers in the process.
      • as long as we’re talking about obesity…it isn’t
        • communicable,
        • preventable by vaccination, or
        • filling ICUs to over-capacity.
  • the false equivalency argument
    • refusing to treat the “unvaxxed by choice”? than you shouldn’t provide care to women who have unplanned pregnancies – as if a one-time event is equivalent to a person’s brazen willingness to potentially infect dozens of us.
  • the “you are violating my freedoms” argument
    • if we can ban smoking in schools, restaurants, offices, airports and public transportation, we can certainly require immunization and penalize those without valid exemptions (if you think you should be “free” to smoke in a school or medical facility, that’s a whole different issue)
      • Oh, and pets are required to be immunized against dangerous diseases, as are kids.

Which leads us to the facts vs beliefs issue.

“Beliefs” – that you are a better driver than anyone else so should be allowed to drive at twice the speed limit through a school area and your child doesn’t need to be in a child safety seat and you don’t need to wear a seatbelt and you can hold your liquor so driving buzzed isn’t a problem for you; that you know more than 99% of the experts so you won’t get vaccinated, that children don’t die of COVID are NOT facts.

And when those beliefs are demonstrably false – as the anti-vaxxers’ arguments clearly are – the moral dilemma becomes more complicated.

“Freedom” isn’t free – if you want to be free to be unvaccinated, then you – no one else but you – have decided to accept the consequences of that decision.

Actually, that’s not right – because your decision is directly affecting your neighbors, family members, and co-workers. It is directly affecting my family members who work in healthcare, people you will infect, and lives you will disrupt.

In fact, freedom from disease, from economic disruption, from grief when loved ones die – comes at a cost – and that cost – however slight – is all of us getting vaccinated.

What does this mean for you?

Spare us the false equivalencies, the slippery slopes, the my freedoms nonsense, get the damn vaccination and wear a damn mask.

And when you get COVID, stay home and don’t interfere with our freedom to be free of COVID.

A more comprehensive discussion of the arguments against vaccination is here.

 


Nov
10

for hospitals, Cost ≠ Quality

Some hospitals are efficient – defined as delivering excellent care at relatively low cost, while others are quite inefficient – high cost, not great care.

Then there are the high cost and unknown quality of care facilities – but the net is this – cost ≠ quality, and quality does not cost more.

The Lown Institute has done some great research on this, and identified the nation’s 10 most efficient hospitals – the criterion being how much Medicare was charged compared to how many patients died 30 and 90 days from admission. OK, that isn’t by any stretch a comprehensive definition, but the results were revealing.

Costs ranged from $9,000 to $27,000 per patient…and if all hospitals operated as efficiently as the top 10, we taxpayers would save $8 billion each year.

Of course private payers are charged more, and pay more than Medicare. Nonetheless, efficient hospitals are going to be efficient for all payers.

Here’s the top ten.

  1. Pinnacle Hospital (Crown Point, Ind.)
  2. Saint Mary’s Regional Medical Center (Reno, Nev.)
  3. MercyOne Dubuque Medical Center (Dubuque, Iowa)
  4. Encino Hospital Medical Center (Encino, Calif.)
  5. Park Ridge Health (Hendersonville, N.C.)
  6. Oroville Hospital (Oroville, Calif.)
  7. Saint Michael’s Medical Center (Newark, N.J.)
  8. UnityPoint Health-Meriter (Madison, Wis.)
  9. East Liverpool City Hospital (East Liverpool, Ohio)
  10. Maple Grove Hospital (Maple Grove, Minn.)

Curious about another hospital?  Click here to find out how it ranked.

What does this mean for you?

Knowledge is power – but only if you use it.


Aug
12

Hypocrisy and Hippocrates

A physician posting on MedPage blamed many of the problems in healthcare on private equity…and for-profit insurers.

That takes some…[insert anatomical reference here]. While his assault on Private Equity does have some merit, I can’t let his assertion that the profiteers are insurance companies stand.  What makes me nuts is Liu’s mindless and demonstrably false assertion, coupled with his complete inability to see that he is part of US healthcare’s cost problem.

Dr Mitchel Liu stated “For-profit insurance companies have long been regarded as the ultimate offenders in medical profiteering.”
Wow. Coming from a physician, who make more than docs in any other country, that is ballsy indeed.
Reality is physician compensation is a key driver of healthcare costs, and one of the reasons our healthcare costs are so much more expensive than other countries’. For-profit healthplans do make billions…but their margins are tiny compared to healthcare providers.
Liu also says:
“It’s time for medicine, including individuals and professional societies, to restore the integrity of the physician-patient relationship by taking a strong stand against all forms of corporate greed.”
Well, docs are often partners in Ambulatory Surgical Centers and hospital outpatient surgery centers.  Many docs belong to big multi-specialty groups that are quite profitable.  And, docs make a lot of money.
What does this mean for you, Dr Liu?
How about taking a stand against physician greed, Dr Liu?

Jul
27

that giant sucking sound…

Is coming from hospital trauma centers vacuuming thousands out of your wallet.

Trauma centers are supposed to handle the worst trauma cases – those from major car accidents, gunshots, airplane crashes, building collapses – you get the picture. Smelling gold, some hospital systems – including HCA – figured out that “activating” trauma centers lets them charge fees up to$50,000 per patient – even if that “trauma center” never actually treats the patient.

The fact that HCA has opened trauma centers in 90 of its 179 hospitals – many in close proximity to other trauma centers – indicates it is not a pubic health need as that “need” is already being met.

Shockingly, Florida is once again the poster child for what look to be abusive billing practices.  From Kaiser Health News:

In Florida alone, where the number of trauma centers has exploded, hospitals charged such fees more than 13,000 times in 2019 even though the patient went home the same day,

Florida trauma activation cases without an admission rose from 22% in 2012 to 27% last year, according to the data. At one Florida facility, Broward Health Medical Center, there were 1,285 trauma activation cases in 2019 with no admission — almost equal to the number that led to admissions. [emphasis added]

Work comp and auto alert…

Peter Johnson penned a deep dive into the explosive growth of trauma centers in the latest edition of Health Plan Weekly [subscription required]. In his article, Peter reported the number of Level I and II trauma centers almost doubled from 2008 to 2020, going from 305 to 567.

From his piece (Peter was quoting me):

It is abundantly clear this [the growth in the number of trauma centers] is not due to a years- or even months-long dramatic increase in apartment building fires, accidents, gun fights, or multi-car crashes.

Trauma used to be defined as high-acuity, emergent cases involving severe injury. Not any more at some of these facilities. Reports abound of patients with minor injuries requiring stitches, cold compresses, and even just a baby bottle and a nap billed for trauma activation.

What does this mean for you?

Any facility bill with a trauma center charge must be subjected to very careful and thorough review. Especially in states that allow higher payments for so-called “outliers”.

Auto insurers – pay attention!!


Jul
22

The hospital war is ramping up.

The Biden administration is clamping down on hospital mergers and ramping up enforcement of surprise billing laws. 

Meanwhile, most hospitals are pretty much ignoring the requirement that they post prices. and are going to the mattresses to fight over mergers. (going to the mattresses is what Mafioso did back in the day during major turf battles)

I’ve written extensively about the impact of mergers on cost – it goes up, a lot – and quality – no evidence that it improves. But this isn’t just about hospitals, it is about the entire healthcare system and where it is headed.

Hospitals accounted for $1.2 TRILLION in spending back in 2018

Price is the reason healthcare is so damn expensive here compared to other developed countries; and price is driven more and more by hospitals. Pricing power is how hospitals and health systems generate ever margins, pricing power is what they get when hospitals merge and reduce competition in markets.

This from Cooper and Gaynor:

A number of studies have examined individual hospital mergers and found price increases of greater than 20% (e.g., Town and Vistnes 2001, Krishnan 2001, Vita and Sacher 2001, Gaynor and Vogt 2003, Capps et al. 2003, Capps and Dranove 2004, Dafny 2009, Thompson 2011, Tenn 2011, Gowrisankaran et al. 2015).

The FTC has conducted a series of merger retrospectives. These analyses have found price increases of 20% to 50% (Haas-Wilson and Garmon 2011, Tenn 2011, Thompson 2011).

There has also been work analyzing “cross-market mergers” of hospitals that are not geographically proximate competitors (Dafny, Ho, and Lee 2019, Lewis and Pflum 2017). These studies have observed cross-market merger effects that raised prices between 10% and 17%.

That’s how Tenet reported record profits last quarter, it’s why Michigan’s two largest systems are merging.

The merger thing has gone on so long that 4 out of 5 hospital market areas are “highly consolidated” – meaning the locally-dominant health systems have pricing power, and can use that to dictate prices to payers of all kinds. Mergers peaked several years ago – not because they are losing popularity, but rather because there just aren’t that many merger targets any more.

Because hospitals thrive on profitable services, we’re seeing cutbacks in less-profitable lines, cutbacks that are limiting the availability of services especially in rural and under-served areas. 

What does this mean for you?

We have got to get control of the hospital beast before it eats us alive.


Jun
17

Thursday catch-up

Doing my best to avoid work on Fridays…so moving this occasional catch-up post to Thursdays…

COVID

Promising news on the effectiveness of a drug to help infected patients fight off the virus was reported by the Economist. The good news – Regen-Cov:

saved the lives of many of those unable to make their own antibodies in response to SARS-CoV-2. Such “seronegative” individuals constituted about a third of the 9,785 hospital patients in the study…compared to a control group given standard treatment … 20% more patients survived

The bad news – it’s stupid expensive, and supply chain issues are hampering production.

A study conducted by the National Institutes of Health indicates COVID may have been in circulation earlier than originally thought. Blood samples from Illinois, MassachusettsMississippi, Pennsylvania and Wisconsin indicate the virus was in those states in December 2019. An earlier CDC study found similar evidence in California, Oregon, and Washington.

These findings indicate a better and more thorough process to identify disease outbreaks may well be warranted.

Comp drugs

WCRI is hosting a timely webinar on Interstate Variations and Trends in WC Drug Payments on June 24. Register here. Gotta say I’m darn impressed by the researchers’ ability to obtain, analyze, and report on payments as recent as Q2 2020. This makes WCRI’s information much more actionable for regulators, clinicians, and payers alike.

Dr. Vennela Thumula and Dongchun Wang of WCRI will be guiding us thru their findings; the webinar is free.

I am finishing up the latest Annual Survey of PBM in WC which will have 2020 and 2019 data; last chance to participate and receive a detailed, respondent-only version of the report. If you want to participate let us know in the comment section below (there’s no cost to participants).

Couple interesting – and very preliminary – takeaways…

  • growing interest in transparency, along with an increased awareness that this isn’t a simple issue.
  • spend continues to decrease, with respondents attributing some of the decrease to COVID.
  • opioid spend continues to drop, but most respondents are still struggling to help chronic pain patients/long-time users of opioids reduce usage.
  • there’s a growing awareness that the PBM pricing model needs to change. With spend declining and a push for transparency, knowledgeable payers understand that paying PBMs less year after year is not sustainable.

Previous public versions of the Survey Report are available here for download at no cost.

 

 

 

 

 

 

 

Hospital pricing

Hospitals are supposed to be publishing their prices – at least Federal regulations require them to. But those smart, sneaky administrators are figuring out all kinds of ways to avoid telling you how much it will cost for that MRI, drug, band-aid, or lung transplant.

From JAMA:

hospitals must publish discounted cash prices (applicable to uninsured patients) and payer-specific negotiated rates. Second, hospitals must display price data, including expected out-of-pocket costs, for “shoppable services” that can be scheduled in advance (eg, office visits) in a consumer-friendly manner that facilitates service-specific comparisons across hospitals (eg, price estimator tools). [emphasis added]

As of early March, only 17 of 100 randomly selected hospitals were complying with the regulations. The penalty for non-compliance is…wait for it…

$300 a day.

Perhaps if the Feds charged hospitals the same way hospitals they charge us, we’d have a bit more compliance. 

How about…the Feds tell the hospitals after the fact what the cost will be, based on a “compliance chargemaster” that takes into account the hospital’s margin, quality scores, number of collection suits it has filed, and medical error rate.

Thanks to the estimable David Deitz MD PhD for the head’s up.

Wellness works

Finally, HealthAffairs reports wellness programs don’t really improve population health, reduce healthcare spending, or improve employment outcomes. 

Almost 40 years ago, I was halfway through a Master’s of Science in Health/Fitness Management when it became obvious this was NOT going to be a lucrative career…quite the opposite. Not saying I was prescient, just that employers sensed this was a nice-to-have and not a got-to-have, and that lack of importance showed in salaries.

Dodged that bullet.

And really finally, congratulations to my favorite baseball team – the White Sox have the best record in baseball after taking 2 of 3 from Tampa Bay. I

know my friends in the Bay area will be heckling me when the Rays surge again…hey, you gotta take advantage of good news when it comes!


May
24

Bipartisanship at last!

An excellent article by Washington Monthly’s Eric Cortellessa described a Senate antitrust hearing focused on hospital and health care system consolidation.

Believe it or not, the problems created by hospital consolidation have brought bipartisanship to the Senate, with arch-conservative Josh Hawley and liberal icon Richard Blumenthal agreeing that consolidation is bad.

Hawley opined”private equity and their [sic] intervention here is actually helping drive consolidation in a way that is unhealthy in this industry and can be particularly harmful for rural communities…”

Blumenthal: “incentives and self-interest of the private equity funds drive the finances rather than respect and care for the patients who are there or the professional staff who ensure quality care.”

It’s not just private equity – most consolidation is driven by massive health care systems looking to dominate markets and thereby control pricing. And that’s exactly what happens.  According to chair Amy Klobuchar, “hospital prices are 12 percent higher in monopoly markets compared to those with four or more competing hospitals.”

That’s one reason profits are zooming for hospital companies Tenet, UHS, HCA and CHS.

What does this mean for you?

Nothing good.

 


May
19

It’s the price – and the network penetration – that drives cost.

That’s the conclusion I reached after reviewing WCRI’s latest treasure trove of research on medical prices paid for professional services in workers’ comp. [report is free to download] Sure utilization is a very important driver, but the biggest difference in medical costs across states is price.

Rebecca Yang PhD and Olesya Fomenko PhD  have outdone themselves with this edition, cementing their reputation as two of the most knowledgeable experts in the nation on medical costs in workers’ comp.

Kudos to WCRI for including data from the first half of 2020 in their report…the fine folk in Boston have done a great job speeding up data collection and analysis to the point where we have data that is less than a year old. This is helpful indeed for anyone trying to understand what’s happening and why and what to do about it.

Takeaways

  • Wisconsin’s professional services (MD, PT, etc) are darned expensive. WI has a very provider-friendly
  • While prices paid in non-FS [fee schedule] states generally increased more than in FS states, NJ is an exception. WCRI noted that NJ saw a pretty significant increase in network penetration during the study period; I’d suggest NJ’s employer direction laws directly contributed to lower price increases.
  • Network participation varies widely, and generally the more the growth in network penetration, the lower the increase in prices paid.  However, in some cases (PA), it doesn’t.
  • Finally, there’s a VERY useful chart on p 39 providing network penetration rates for each of the 36 states studied. 

What does this mean for you?

This is extremely useful information, with many nuggets buried in the 190 page report.  IF you aren’t a WCRI member – join now!