Category Archives: General Health

NY Times: Financial Bill of Rights for Patients

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NY Times: Nine Rights Every Patient Should Demand

This article addresses a fundamental problem in medicine: lack of price transparency, and the complexity of understanding health care expenses..

The right to an itemized bill in plain English.

  • Patients can’t detect and dispute improper charges if their bills involve dozens of pages of medical abbreviations. Studies have found that 30 percent to over 50 percent of hospital bills contain errors…

The right to never receive a surprise out-of-network bill.

The right to accurate information about the provider network in my insurance plan.

  • Doctors … must be in-network for all the procedures they normally perform and on all days of the week they practice. If a provider is listed as in-network but is not, the insurer should take care of the charge.

The right to a stable network.

  • I buy my insurance policy for a year. If my doctor or insurer stops participating in my network within that year or in the midst of treating me for an acute disease, I should still be billed as an in-network patient.

The right to be informed of conflicts of interest.

  • Patients should know if their doctors own a financial stake in a testing or procedure facility before a test or procedure is ordered or scheduled…

The right to be informed in advance about any facility fees.

  • A procedure can come with different price tags depending on where it is performed…

The right to see a price list for elective procedures.

The right to be informed of cheaper options.

  • Many doctors recommend the most expensive course of care and don’t tell patients that there are other options…

The right to know that a disputed bill will not be sent to a collection agency.

  • The threat of dealing with bill collectors and a damaged credit rating is used to intimidate patients into paying up without asking questions…

I know these rights might seem like a fantasy in our current system, with its overwhelming complexity and cost. But they are actually quite similar to the rights we expect in any other sector of our economy. 

My take: The way we pay for health care does not make sense.  Understanding costs for medical care should be like reading the nutrition label boxes.  Currently, even an expert in health care has difficulty understanding what costs to expect.

Saline Shortages

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Two interesting commentaries on the saline shortages:

  • M Mazer-Amirshahi, ER Fox. NEJM 2018; 378: 1472-4.
  • AM Patino et al.  NEJM 2018; 378: 1475-7.

The first explains that large quantities of saline bags are needed each month –more than 40 million bags per month!  While saline is inexpensive, the production requires meticulous care to avoid contamination and there have been supply issues since 2014, prior to Hurricane Maria.  However, the problem has been much worse since Hurricane Maria which damaged Puerto Rico.  Puerto Rico supplies 44% of the IV bags in the U.S.  These fluids are given to virtually all hospitalized patients, either for IV fluids or as a component with medications/flushes.

Other points:

  • “Drug manufacturers are not required to have redundancy in their facilities or even a business contingency plan in case of a disaster.”
  • The  FDA has “recently approved saline products from two additional manufacturers”
  • “To conserve large-volume saline bags, oral hydration is recommended.”

The article by Patino et al provides Brigham and Women’s Hospital Oral Rehydration protocol. Key points:

  • Using their protocol, the volume of IV fluid use decreased over 30% in the first week of implementation
  • The fraction of ED patients using IV fluids dropped by 15% in the first 3 weeks of implementation.
  • Oral hydration protocols are a “rational practice change…even after the current IV-fluid shortage crisis ends.”

 

Physician Burnout -“Hidden Health Care Crisis”

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A really good review on the topic of physician burnout: BE Lacy, JL Chan. Clin Gastroenterol Hepatol 2018; 16: 311-17.

This topic has been discussed on this blog and multiple other sites.  This reference covers a lot of ground and provides a lot of useful information.  Also, some esoteric piece of information: “The term burnout first was used in the psychology literature in 1974 by Herbert Freudenberg during his work with drug addicts. He observed that many of his patients would stare blankly at their cigarettes until they burned out.”

Three key components to burnout: emotional exhaustion, depersonalization, and decrease sense of personal accomplishment

Physicians at greatest risk: perfectionists, personal qualities of idealism, and “intense sense of responsibility”

Root causes -work stress (in all its forms)

Prevention of burnout: take care of yourself, exercise, good sleep habits, “learn to say no,” use your vacation time/disconnect

Keys to treating physician burnout:

  • “learn to balance personal and professional goals”
  • “shape your career and identify stressors”
  • “nuture wellness strategies”
  • Try to become engaged in your job
  • Work on resilence

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March for Our Lives

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Today there is a “March for Our Lives”

Some relevant tweets:

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Choosing the Right Intravenous Fluids

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A recent “SALT-ED” study (WH Self et al. NEJM 2018; 378: 819-28) with more than 13,000 noncritically-ill adults indicated that patients who received normal saline had increased incidence of major adverse kidney events compared to those who received more balanced fluids like lactated Ringers’ or Plasma-Lyte A.

A 2 min quick take summary:Comparison of Crystalloids and Saline for Noncritically Ill

In a separate “SMART” study (MW Semler et al. NEJM 2018; 378: 829-39), investigators looked at balanced crystalloids versus saline in critically-ill adults (n=15,802).  The use of balanced crystalloids (compared to saline) resulted in a lower rate of mortality (10.3% vs 11.1%, P=.06) and fewer major adverse kidney events (14.3% vs. 15.4%, P=.04).

 

Exorbitant Medicine Costs -Generics Discounts Often Minimal

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A recent story in the NY Times (Patients Eagerly Awaited a Generic Drug. Then They Saw The Price. ) shows that the availability of a generic drug does not guarantee that exorbitant pricing will be remedied.

An excerpt:

Syprine, which treats a rare condition known as Wilson disease, gained notoriety after Valeant Pharmaceuticals International raised the price of the drug to $21,267 in 2015 from $652 just five years earlier…

In promoting its “lower-cost” alternative to Syprine, a Teva executive boasted in a news release that the product “illustrates Teva’s commitment to serving patient populations in need.”

What the release didn’t mention was the price: Teva’s new generic will cost $18,375 for a bottle of 100 pills, according to Elsevier’s Gold Standard Drug Database. That’s 28 times what Syprine cost in 2010, and hardly the discount many patients were waiting for.

Nearly three years after Valeant’s egregious price increases ignited public outrage, the story of Syprine highlights just how hard it can be to bring down drug prices once they’ve been set at stratospheric levels.

My take: This type of excessive drug cost is why critics demand additional regulation be placed over the entire pharmaceutical industry; it can occur only in a system which has limited competition and indirectly shares the cost across the entire system by having insurance companies foot most of the bill.

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Bright Angel Trail

What Does Richard Thaler’s Work Mean for Medicine?

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A recent commentary (J Avorn. NEJM 2018; 378: 689-91) addresses a huge problem in medicine: “medicine’s ongoing assumption that clinicians and patients are, in general, rational decision makers.”

He points out that just as Albert Einstein upended Newtonian physics with the much more complex theory of relativity, Richard Thaler’s work in economics “explained that people often don’t make choices by acting as the rational balancers of risk and reward assumed by classic economics.” (More information about his work at Wikipedia post on Nudge).

Key points:

  • “We are disproportionately influenced by the most salient and digestible information” rather than the totality of information.  This “helps explain the power of simplistic pharmaceutical promotional materials, often delivered..with a tasty lunch.”
  • “Our beliefs are shaped by recent experiences…(Last-case bias).”
  • “We often overestimate small probabilities (such as uncommon drug risks).”  Another example would be fear of dying in a plane crash which is far less likely than dying in an auto accident.

The potential remedies to flawed decision-making include the following:

  • “Academic detailing” which is a process attempting to integrate more information to counter biases
  • Nudge concept. This is a strategy of “making a preferred alternative the default choice when several options exist.”  Order entry systems in computers could default to preferred drugs (ie. best drug in class)
  • Cost constraints can affect decision-making which could include targeting copayments for payments.  For physicians/administrators, looking at what drives revenue is crucial.  “As Upton Sinclair once noted, ‘It is difficult to get a man to understand something when his salary depends on his not understanding it.'”

My take: Addressing these ideas could help reduce unnecessary surgeries, increase  high value care, and improve outcomes.  This is why Richard Thaler’s work is important for medicine.

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