Rising ER Costs & Changes in Billling Codes

USAToday: ‘Really astonishing’: Average cost of hospital ER visit surges 176% in a decade, report says

An excerpt:

The average emergency room visit cost $1,389 in 2017, up 176% over the decade. That is the cost of entry for emergency care; it does not include extra charges such as blood tests, IVs, drugs or other treatments…

In 2008, 17% of hospital visits were charged the most expensive code. That surged to 27% of visits in 2017, the report said. The average price for the most expensive code more than doubled from $754 in 2008 to $1,895 in 2017.

Hospitals also increased billings for the second most expensive code, but they billed the three least expensive codes less often compared to a decade ago.

Related blog posts:

Healthcare Company CEO Salaries

Becker’s Hospital Review: Highest-paid CEOs in 2018: Who made the list from healthcare  The full list includes 200 chief executives from public companies with revenue of at least $1 billion. Thanks to Jeff Lewis for pointing out this list.

Total compensation may include salary, bonuses, perks, stock and options.

  1. Hologic, Stephen MacMillan — $42 million
  2. Align Technology, Joseph Hogan — $42 million
  3. Regeneron Pharmaceuticals, Leonard Schleifer — $27 million
  4. Centene, Michael Neidorff — $26 million
  5. Universal Health Services, Alan Miller — $24 million
  6. Abbott Laboratories, Miles White — $23 million
  7. CVS Health, Larry Merlo — $22 million
  8. Merck, Kenneth Frazier — $21 million
  9. Abbvie, Richard Gonzalez — $21 million
  10. Johnson & Johnson, Alex Gorsky — $20 million
  11. HCA Healthcare, R. Milton Johnson — $20 million
  12. Pfizer, Ian Read — $20 million
  13. Bristol-Myers Squibb, Giovanni Caforio — $19 million
  14. Cigna, David Cordani — $19 million
  15. Vertex Pharmaceuticals, Jeffrey Leiden — $19 million
  16. Thermo Fisher Scientific, Marc Casper — $19 million
  17. Amgen, Robert Bradway — $19 million
  18. UnitedHealth Group, David Wichmann — $18 million
  19. DaVita, Kent Thiry — $17 million
  20. Gilead Sciences, John Milligan — $17 million
  21. Alexion Pharmaceuticals, Ludwig Hantson — $16 million
  22. Humana, Bruce Broussard — $16 million
  23. Celgene, Mark Alles — $16 million
  24. Biogen, Michel Vounatsos — $16 million
  25. United Therapeutics, Martine Rothblatt — $16 million
  26. IQVIA Holdings, Ari Bousbib — $16 million
  27. Eli Lilly, David Ricks — $16 million
  28. Baxter International, José Almeida — $16 million
  29. Biomarin Pharmaceutical, Jean-Jacques Bienaimé — $16 million
  30. Danaher, Thomas Joyce Jr. — $15 million
  31. Molina Healthcare, Joseph Zubretsky — $15 million
  32. Tenet Healthcare, Ron Rittenmeyer — $15 million

Canaletto.  El Gran Canal desde San Vio. Thyssen-Bornemisza Museum. https://www.museothyssen.org/en/collection/artists/canaletto/grand-canal-san-vio-venice


What Went Wrong with EMRs: Death by a Thousand Clicks

Link: Death by a Thousand Clicks Where Electronic Health Records Went Wrong

This lengthy article highlights a lot of issues with EMRs/EHRs including data sharing between systems, pulldown menus, disruption of physician-patient interactions, upcoding, safety risks and provides numerous personal examples.

An excerpt:

The U.S. government claimed that turning American medical charts into electronic records would make health care better, safer, and cheaper. Ten years and $36 billion later, the system is an unholy mess…

Instead of reducing costs, many say, EHRs, which were originally optimized for billing rather than for patient care, have instead made it easier to engage in “upcoding” or bill inflation…

More gravely still, a months-long joint investigation by KHN and Fortune has found that instead of streamlining medicine, the government’s EHR initiative has created a host of largely unacknowledged patient safety risks…

Compounding the problem are entrenched secrecy policies that continue to keep software failures out of public view. EHR vendors often impose contractual “gag clauses” that discourage buyers from speaking out about safety issues and disastrous software installations…

EHRs promised to put all of a patient’s records in one place, but often that’s the problem. Critical or time-sensitive information routinely gets buried in an endless scroll of data, where in the rush of medical decision-making — and amid the maze of pulldown menus — it can be missed…

[Problem with scrolldown options]: [doctors] had to read the list carefully, so as not to click the wrong dosage or form — though many do that too..

The numbing repetition, the box-ticking and the endless searching on pulldown menus are all part of what Ratwani called the “cognitive burden” that’s wearing out today’s physicians and driving increasing numbers into early retirement…

Beyond complicating the physician-patient relationship, EHRs have in some ways made practicing medicine harder,.. “Physicians have to cognitively switch between focusing on the record and focusing on the patient,” … “Texting while you’re driving is not a good idea.a.. But in medicine … we’ve asked the physician to move from writing in pen to [entering a computer] record, and it’s a pretty complicated interface.

My take: This article makes many good points.  Though, if you polled physicians in our group, hardly any would choose to go back to what we had before EMRs.

Related blog posts:

Tackling High Drug Costs -Lessons from Australia and Brazil

In two related commentaries referenced below, the authors detail how Australia and Brazil managed to provide a blockbuster hepatitis C virus (HCV) medication without following the going-broke example of Blockbuster video stores.

  • Australia: S Moon et al. NEJM 2019; 380: 607-9
  • Brazil: EM da Fonseca et al. NEJM 2019; 605-6.

Australia provided a lump-sum payment of approximately 770 million dollars (in U.S.) over 5 years in exchange for an unlimited volume of direct-acting antivirals (DAAs). As a result of this approach, Australia managed to treat many more patients at a much lower cost.  “The government would have to spend …U.S. $4.92 billion more to treat the same number or it could treat 93,000 fewer patients with a fixed budget” of approximately U.S. $766 million.

With the Australian approach, the authors note that it is analogous to a patent buyout and works if the ongoing drug manufacturing cost is low and the manufacturer is able to meet growing volume demand.

Brazil’s approaches for DAAs relied on either threatening loss of patent protections and/or enabling local generic production of sofosbuvir.  This resulted in ~90% price discount. Patent protection in Brazil is granted only if a medication is approved by both INPI (Instituto Nacional da Propriedade Industrial) and ANVISA (Brazilian Health Regulatory Agency).

My take: Given the rising costs of medicines, examining how other countries surmount these financial barriers is important.  In my view, the often arbitrary and exorbitant pricing by pharmaceutical companies will erode the support of protective policies in the U.S. which thus far has helped produce many advances.

Skull Rock, Joshua Tree National Park


“Grateful Patient Programs”

From NY Times: Hospitals Are Asking Their Own Patients to Donate Money

This article in the NY Times reviews a growing trend of non-profit hospitals asking patients for contributions; sometimes, physicians are asked to help identify potential donors.

An excerpt:

Many hospitals conduct nightly wealth screenings — using software that culls public data such as property records, contributions to political campaigns and other charities — to gauge which patients are most likely to be the source of large donations…

These various tactics, part of a strategy known as “grateful patient programs,” make some people uncomfortable…it could make patients worry that their care might be affected by whether they made a donation.

My take: Should hospitals simplify the process by adding a line on the bill for a tip?

Badwater basin, Death Valley


Why Hospital$ Are Hiring More Doctor$

A recent article in the Wall Street Journal details the consequence of hospitals hiring more doctors, especially primary care.:

The Hidden System That Explains How Your Doctor Makes Referrals

Key points:

  • “Hospitals are getting more aggressive in directing how physicians refer for things such as surgeries, specialty care and magnetic resonance imaging scans, or MRIs.” This often results in more out-of-pocket expenses for patients.
  • “Insurers have been working to steer patients toward doctors’ offices and other non-hospital locations for many types of care, because they are generally less expensive. The same service often costs twice as much or more when delivered in a hospital setting, compared with a doctor’s office.”

Thanks to Bryan Vartabedian’s 33mail for this reference. He notes: “The doctors in the private space relished the article as evidence of the dangers of the physician employee. But we have to remember that when doctors own their own businesses, the pressure to do things for money is huge.”

Near Zabriskie Point at Sunrise, Death Valley