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Medical Monopoly: Medicine has a major image problem

By healthcare industry, media commentary, politics, technology
image credit: Alec

When you hear the word “monopoly,” does it fill you with a warm and fuzzy feeling? (Unless you’re Hasbro, you really should say no, unless you’re a cyborg.)

Healthcare is a monopoly. We can’t DIY cancer treatment, or surgically repair a broken hip for ourselves, so we have to go to the medical-industrial complex to regain our health if we wander into the weeds, health-wise. We also have deep difficulty accessing pricing information. I’ve talked about that here over the last few years. Maybe not a monopoly in the financial-reg sense of the word, but it sure is mighty like a game of Monopoly.

This “chaos behind a veil of secrecy” (all credit for that phrase belongs to healthcare economist Uwe Reinhart) has created the impression in healthcare customers that there’s no way to tell what something will cost before you buy it. You checks the box and takes yer chances. No Get Out of the Hospital Free cards. No pass-the-admissions-counter-collect-$200 option. That’s a rotten way to run a railroad (one of the original monopoly industries in US history), and an even worse way to run a hospital.

Dan Munro wrote about this, and the star-chamber cabal that actually sets the prices in healthcare, the RUC, on Forbes.com yesterday. I’ve talked about the RUC myself. And the search for price transparency, which seemed such an outlier activity just a couple of years ago, is now popping up in the Well blog on the New York Times site, as well as on Reuters. The Reuters piece has the addition bonus of quotes from my buddy Jeanne Pinder, founder of ClearHealthCosts.com. (Yesterday was a big day in medical price transparency.)

This is the central reason I registered the hashtag #howmuchisthat with Symplur, the healthcare hashtag registry. We all have to start demanding that prices be visible, and that the RUC stop cabal-ing around with our lives and our wallets. As more and more people are finding themselves with high-deductible health insurance, asking how much things cost before you make a healthcare decision will become the norm. If a healthcare provider can’t answer that question, s/he will find that s/he’s seeing the patient panel sinking fast, along with practice revenue.

Get with it, medicine. Remake your image, and your brand, to be clear as glass and user-friendly. Outcome metrics along with pricing would be really nice, too.

2013: The Year of Healthcare Emancipation?

By e-patients, healthcare industry, healthcare price transparency, participatory medicine

Hang on to your hats – this one might wade into controversy.

django lincoln caduceus imageAs I write this (3:30pm EST on January 1, 2013), I’m listening to a conversation on NPR about the Emancipation Proclamation, which was signed into law by Abraham Lincoln 150 years ago today. I’m also reflecting on a couple of movies I’ve seen in the last 45 days: Lincoln (over Thanksgiving weekend) and Django Unchained (on Christmas Day).

Is it time for an emancipation proclamation for patients? Or should we just saddle up and have a shootout at the plantation … um, hospital instead?

Too many healthcare transactions are still conducted over the patient’s supine form. Doctors, hospitals, and other entities in the “provider” column horse-trade with health insurers, including Medicare, in the “payer” column. That means that the patient winds up shackled. No say in how much something costs, no real voice (yet) in what happens next, little interest on the part of the two trading entities in clueing us in to what’s happening.

Some of my connections in the participatory medicine/e-patients movement use a driver-rider metaphor for transforming healthcare, with the patient moving from passenger to driver in healthcare. It’s a less controversial/confrontational metaphor than referring to patients as chattel on the medical plantation. However, I’m sticking with that plantation metaphor for the moment, because too many in the provider and payer camps are still viewing patients as meat puppets, not as full participants.

Does healthcare need an emancipation proclamation? Yes. Here’s where the metaphor shifts: let’s not wait for someone to proclaim us (patients) emancipated. Let’s break our own chains, and be our own liberators.

Let’s demand that the providers and the payers give us an equal seat at the table, and then let’s …

LEARN EVERYTHING WE CAN TO BE PRODUCTIVE CONTRIBUTORS TO THE HEALTHCARE SYSTEM.

That last statement is the core of what will emancipate healthcare: patients, providers, payers, caregivers, everyone. Shared decision making – along with “patient-centered”, that’s the new hot phrase in healthcare – can only exist if all parties are able to participate in sharing the decision-making. We must learn how to understand the language of medicine, including research statistics (by the way, many doctors aren’t great at that, either). We must learn to apply critical reasoning to what we see/hear/read in the media about risks and trends in health and disease. We need to work on getting a seat at the research table to give a hard shove in the direction of making clinical research less ivory-tower and more boots-on-the-ground.

Some recommended reading for those who’d like to emancipate themselves:

Society for Participatory Medicine blog

ePatient Dave

Susannah Fox

Dr. Ted Eytan

and our movement’s own Rosa Parks (or, dare I say it, our own Django?):

Regina Holliday

Let’s liberate ourselves, shall we?

2013 Manifesto: short and salty-sweet

By healthcare industry, technology

Last year’s look-ahead for 2012 was a 5-point manifesto. Reviewing progress against that list, I see that I did pretty well, with only #2 falling a little short – which is not a bad track record.

This year, I’m keeping it tight. I’m going with a 2-rule manifesto.

Rule #1: Be accountable

We’ve all got metrics to measure ourselves against. Revenue, connections, sales, errors, accomplishments – all of those are important. The trouble comes when you focus too much on one area, which usually means that other important metrics wind up taking a back seat.

If you focus exclusively on incoming revenue, you might miss some mistakes that will cost you at least some of that revenue. If you concentrate only on building more connections in the industry, you might lose some long-term relationships that are just starting to ripen.

For me, accountability this year will be tied to two metrics: raising the revenue gained from the speaking side of my business, and widening my marketing net beyond the mid-Atlantic region. Tracking both will be easy, and each will challenge me to focus very tightly on activities and outreach that will move my game-plan forward. Accountability – at least here at Mighty Casey Media – will be baked in to the spreadsheet I’ll use to track that game-plan.

What accountability will you bake in to your 2013 goals? How will you track your progress? Who will you report to? That last one is a challenge for me, since I’m a solo-preneur. Stay tuned, since one of my accountability check-boxes will be reporting progress here, on the Mighty Mouth Blog.

Rule #2: Laugh more, bark less

That’s a purposeful scrambling of the “wag more, bark less” bumper sticker I see … everywhere. My version of wagging is laughter. If I’m laughing, there’s less risk that I’ll be screaming. Given that one of my core purposes in life is working to effect positive change in the healthcare industry, I can wind up screaming pretty easily if I don’t keep myself in check.

Barking = screaming in my world. We’re all about avoiding the screaming wherever possible. That does not mean that I’ll dampen my ferocity. Hell to the no. What it does mean is that I’ll find ways to wrap the bitter medicine in a big lump of maple sugar. “Bitter medicine” is hard truth about how healthcare has to shift from paternalism and a gold-rush mentality; the lump of maple sugar (and my biggest challenge) is finding the humor that will make that medicine go down … without resorting to barking.

Those are my Simple Rules for 2013.

Happy New Year.

The black box that caused the crash (of healthcare)

By healthcare industry, politics
healthcare money image

This week, NPR’s Marketplace aired a piece on what I have taken to calling the “black box of healthcare” – pricing. There is a committee, called the RUC, set up and run by the American Medical Association, that reports to CMS (the federal unit that runs Medicare and Medicaid) on relative value numbers for the thousands of medical procedures that wind up as billing codes in Medicare and your health insurer.

Those relative value numbers = PRICES. This isn’t considered price-fixing under anti-trust rules because the RUC reports to CMS, which then publishes the numbers on the Medicare reimbursement rate schedule. So the AMA isn’t publishing the prices, CMS is.

Fox, meet henhouse. Or, stated in another way: airplane, meet the black box that is making you crash and burn. The Marketplace page linked in the 1st graf has plenty of linkage to additional context for this issue. Read them, and weep.

How is it that an industry whose aggregate cost is now at close to 20% of US GDP gets to set its own prices, and then have them published by the federal government as The Official Price List?

It’s called effective lobbying, and it’s so effective that it’s essentially kept access to the pricing committee process a secret for decades. Which makes it pretty clear why so much of our GDP goes to healthcare, doesn’t it?

The sound bite in the story that I found the most hilarious was from Charlie Baker, the former CEO of the Harvard Pilgrim health plan in Massachusetts. His quote:

By having a process that for all intensive [sic] purposes isn’t a public process, and doesn’t appear to actually be accountable to much of anybody, I think that’s kind of un-American!

I find this hilarious because Harvard Pilgrim is a member of America’s Health Insurance Plans, the industry group that advocates (translation: lobbies) for health insurers, who also have their hands on the levers of healthcare pricing via reimbursement rates (granted, based on CMS’s published rates, which are based on the RUC’s relative value numbers). Which means that the very-American health insurance industry is a co-conspirator in this price-setting (-fixing?) game.

Healthcare pricing is such a black box that if a patient attempts to find out what something will cost before s/he has a medical procedure, s/he will be met with a blank stare, “I don’t know”, “nobody knows how to figure that out”, or some other version of “what?” that gets you no answer.

e-Patient Dave deBronkart has a terrific example of how shopping for healthcare can be done, even in the face of “what?” – click the link for the full story there. Patients acting on their own behalf to determine their economic exposure before they get medical care might begin to bend the healthcare cost curve IF they can get the price information.

Dave isn’t the only customer of the healthcare industry who’s looking for pricing, and answers to the variance in said pricing depending on who you ask. The LA Times had a piece in their May 27, 2012 business pages on how patients could negotiate cash prices at the hospital or in the doctor’s office that were far below insurance reimbursement rates IF they didn’t use their insurance.

As an industry, healthcare is deeply broken. Since the industry has been supported for decades by an economic model that hides pricing from its consumers – employer-based health insurance – the end users, patients, have no clear path to making informed choices based on quality and cost.

If you ran your business that way, you’d be out of business pretty quickly. It’s time to break the healthcare industry’s economic model – if ever there was a sector ripe for creative economic destruction, healthcare is that sector.

Data, Data, Who’s Got My Data?

By e-patients, EHR, health records, healthcare industry, medical records

 I’ll totally get one. Srsly.

I confess that I’d happily get a barcode tattooed on my neck if it meant I’d never have to fill out another ****ing health history form in a doctor’s office.

I’m totally serious.

Paper records are so … 19th century. With the advent of the current iteration of “health care reform” (which is really “health INSURANCE reform,” but that’s a blog post for another day), much has been made of the importance of Electronic Medical Record (EMR) systems in building a national Health Information Exchange (HIE).

Medicine = Acronym World. The Pentagon are pikers when it comes to fogging the battlefield with impenetrable letter-fication.

21st century health care certainly must involve a lot of easily-shared data, with health history and diagnostic information traveling literally at light speed between doctor’s offices, hospitals, and clinics. Not only does it speed care, it can ensure safety: the right record, with the right patient, makes the right care clear.

The thorny-issue part is this: whose data is it, anyway? Doctors certainly need to have full access to all the data on patients they’ve treated. Hospitals have to keep records on the people they’ve treated on their wards, in their clinics, and in their ORs. Payers (insurers, Medicare, Medicaid, et al) need data access to pay claims, track demographics, and create statistical and financial forecasts. And patients must have access to their own data, at minimum to vet it for errors, at best to own a full copy of their health history since birth to share with providers and care-givers.

I spent 8 months trying to correct an error on the report for the breast MRI I had in 2008 as preparation for my cancer surgery. The report said “family history of breast cancer.” NO. I was Patient Zero, there was NO family history of breast cancer. I fought for eight months, and I’m still only about 90% convinced the error is completely expunged. Patients need access, and we also need easy recourse to error-correction.

Back to EMRs and data exchange: access to patient data must be completely available to all concerned parties. That means doctors, healthcare facilities (hospitals, clinics, et al), and PATIENTS. However, the discussion about healthcare technology almost never includes patients. We’re considered, at best, bystanders; at worst, annoying insects.

E-Patient Dave DeBronkart – Mr. Gimme My Damn Data himself – was the 1st person I heard use the term “e-patient”. The E stands for empowered, engaged, enabled, equipped, equal – not electronic, although that’s certainly a supporting foundation for the e-patient movement. E-patients are usually placed in the “annoying insect” category by healthcare providers who don’t want to share – which can include payers, who can turn a simple record request into a Bleak-House level of bureaucracy. The most epic story in recent history, IMO at least, is Regina Holliday’s now-famous 73 Cents post (and the painting it talks about) – charging patients for access to their own data (at 73 cents a page) borders on the immoral, if not the criminal.

In the long slog through working groups, committees, implementations, and reports-to-the-board that is EMR and HIE development, don’t let the healthcare system leave us – the patients – out of the conversation.

It might be their data, too – but at root, and always, it starts with us. It’s theirs, yours … ours.

Data, Data, Who’s Got My Data?

A Modest Proposal (on Health Insurance Reform)

By healthcare industry, healthcare price transparency, politics

~ Casey Quinlan © 2010 [originally posted on the now-defunct Disruptive Women in Health Care blog, posted here for posterity.]

I will admit to a bias on the subject of health insurance, and healthcare reform: I’m one of the millions of America’s uninsured. I’m female, over 50 (I told you, now I’ll have to kill you), and I was diagnosed with cancer in December of 2007.

The first of those facts – being female – is the biggest dinger of the three when it comes to health insurance premiums. The reasoning there: women use more health services, starting in their teens and 20s and continuing through menopause. The second – my age – could signal a better rate, since women typically tail off in their use of healthcare in their mid-50s. However, the third fact – cancer within the last 10 years – gets me insurance coverage quotes of $2,000 per month, with a deductible between at $3,000 to $6,000 a year.

For the math-challenged, that’s between $27,000 and $30,000 out of my pocket per year before insurance covers Dollar One. Since that amounts to much of my annual pre-tax income in each of the two years since Cancer Year – 2008 was the last year I had health insurance coverage – I’ve remained on the uninsured list. And developed some fierce opinions about the future of healthcare and health insurance in the US.

The Patient Protection and Affordable Care Act, a/k/a “health care reform,” passed earlier this year includes some help for my situation…in 2014. Meanwhile, I’m managing to get the oral chemo meds I’ll be taking until 2013 (which cost $500 a month) with the help of a community clinic. And I’m keeping my fingers crossed that I stay as healthy as I was before the cancer diagnosis, and as I have been since I finished radiation treatment in 2008.

That’s my current health insurance policy: crossed fingers.

There are two things that I think have to happen to bring about meaningful change in the healthcare cost/payment/insurance conundrum, for me and everyone else:

  1. Tort reform*
  2. Severing health insurance from employment

I realize that the tort bar, the health insurance industry, and pretty much everybody with a job-related health benefits package will take out a hit on me for making those suggestions. But the system has fallen, it can’t get up, and until major changes – not the chipping-away-at-the-edges approach of the current iteration of “health care reform” – are made in both the US legal system and how health insurance is marketed and sold, meaningful change doesn’t have a prayer.

How would tort reform help? Defensive medicine – practicing medicine with one eye over your shoulder looking for lawyers – adds as much as $45.6Billion-with-a-b annually to US spending on healthcare, according to a Harvard study published in September. That may seem like a drop in the bucket when the total annual spend on healthcare in this country is $2.3Trillion-with-a-t, but those dollars are all coming out of our pockets one way or another. Whether it’s in higher health insurance premiums, deductibles, fee increases to help providers cover those who can’t pay, fee increases to help defray the costs of malpractice insurance, or tax dollars for Medicaid and Medicare, we pay for it.

Reducing the dollar impact of medical liability would start to address some of those costs. Tort reform would give providers a defined worst-case scenario for liability, and would reduce the sue-the-bastards incentive for patients (and their lawyers) who don’t get the outcome they want from treatment. There are no guarantees in medicine, other than that there are no guarantees in medicine. Patients who are harmed by doctors that are unfit to practice wouldn’t be left without recourse, but the dollar amount of settlements would be capped.

Now, on to my really controversial suggestion: severing the link between health insurance and employment. Employer-paid health insurance benefits weren’t common in the US until World War II, when stiff wage controls made defense plants and other employers get creative to attract and keep good employees. They came up with offering to pay for workers’ health insurance. Thus was employer-sponsored group health insurance born, and the individual health insurance market stamped with an expiration date.

If you’re selling something, wouldn’t you rather package and sell it to as large a group as possible? Insurers, helped along by federal labor laws, have had a great revenue model: sell to large employers, keeping their annual premium-per-employee at an acceptable level because of the size of the risk pool. Cherry-pick the individual market, and put a high price tag on coverage for individuals who look like they might get sick – like women.

I’m actually quite pleased with one of the provisions in the health care reform bill fines employers with 50 or more employees $2,000 for each worker if they don’t provide health benefits. Why? Because the largest US employers – Walmart 1,000,000+ US employees, Verizon 200,000+, UPS 350,000+ in the US, to name a few – will look at that figure, do the math, and discover that the fine will save them money.

Again, for the math challenged: 1,000,000 employees would cost Walmart $2Billion-with-a-b in fines. Sounds like a whacking huge amount of money…until you calculate the cost health insurance benefits for those 1,000,000 employees using the average premium, which runs between $4,000 (single coverage) and $10,000 (family) per year. The fine would save Walmart $4-10Billion a year. They could even offer their employees help buying coverage, and still save some serious money.

And break the tie between group coverage and employment.

What would happen then? I think the American people can get together and drive the market as one big coast-to-coast group, using consumer-driven health plans** (CDHPs) combined with health savings accounts (HSAs). I believe that one of the causes of the healthcare cost conundrum in the US is the passive attitude most Americans have about their health, and healthcare. Decades of coverage paid for with “other people’s money” (employer-sponsored plans) have turned us into a nation of mindless medical consumers. We want cutting-edge care, we want second, even third, opinions, we bitch about $100 co-pays, we want to never have a bad outcome. Oh, and by the way, we don’t want to pay for it.

CDHPs would help make us mindful again: about the costs of healthcare, about the impact of our choices and behavior on our health, about how to get the most value for our healthcare dollar. A consumer-driven plan – also called a high-deductible plan – has a lower premium than traditional PPO or HMO plans due to that higher deductible. It also has no co-pays. You pay for care until you max out your annual deductible – between $1,000 and $5,000 per year – and are fully covered after that. Some CDHPs cover preventive and screening care, like annual physicals and mammograms, outside the deductible.

To be truly effective, CDHPs must be tied to HSAs, both to help consumers pay their deductible costs and to encourage them to save money for future healthcare costs. Making HSA contributions with pre-tax money makes HSAs “IRAs for healthcare,” with tax penalties for non-healthcare withdrawals. Since consumers – patients – will be paying for healthcare out of their HSAs, they’ll have an incentive to both ask what a procedure or prescription costs, and to ask questions about the cost of treatment options.

We’re a consumer nation. We shop for deals on flat screen TVs, cars, iPods, and breakfast cereals. Isn’t it time we did the same thing for prescriptions and hospital costs? I for one would jump at the chance to enroll in a CHDP – unfortunately, they’re not offered to individuals in the state where I live.

Don’t get me started on state insurance commissions…

  • [2021] I no longer subscribe to this idea – not that tort reform is a terrible idea, just don’t think it would help move the needle, or the mind-set, of what I call dinosaur docs (MDs over 60 years old who have “we’ve always done it this way” syndrome)

** [2021] CDHPs have proved to be a trash fire, since too few employers have elected to fund HSAs, and individuals who have bought insurance on the Affordable Care Act exchanges have found that CDHPs are basically just catastrophic care coverage. Their out of pocket expenses are high enough that many are now foregoing care rather than seeking medical care and paying out of pocket until their deductible is met.

NOTHING ABOUT ME WITHOUT ME

By e-patients, healthcare industry, healthcare price transparency

The last few weeks have been a cluster-dance of activity in the e-patient community. Actually, pretty much any week is a fast dance in the participatory medicine world, given the drive toward healthcare reform in the US.

The loudest dance orchestra has tuned up around the controversy created when the American Hospitalspm logo Association (AHA) posted its comments on the Phase 2 Meaningful Use (MU2) rules, which are part of the Patient Protection and Affordable Care Act (PPACA), a/k/a healthcare reform or Obamacare, depending on what your preferred nomenclature is.

The bottom line: even though the Centers for Medicare and Medicaid Services (CMS) has made re-admissions to the hospital within 30 days after discharge a giant “we won’t pay you for that” red flag, the AHA stood up on its hind legs and said, regarding MU2, that they did not want to make records available to patients for 30 days post-discharge.

Which seems to mean that the AHA is either totally OK with not getting paid for a re-admission within those 30 days, or they’re trying to use a giant hammer to kill the adoption of electronic medical records technology.

A third explanation – and one that I think is actually what’s happening here – is that the last couple of years of massive IT deployment in healthcare has been really hard. And the policy wonks who wrote the comment for the AHA have little or no dealings with actual patients. Because anyone with a brain who works in healthcare knows that not empowering patients to manage their care is the best path to both bad outcomes and bankruptcy.

If you’d like to read all about the issue, you should start with

David Harlow’s Healthblawg

e-Patient Dave

Healthcare activist artist Regina Holliday (the Rosa Parks of patients’ rights)