NY Times: What’s Behind $urprise Billing

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NY Times: Who’s Behind Your Outrageous Medical Bills?

This article describes how “surprise bills are just the latest in a decades-long war between players in the health care industry over who gets to keep the fortunes generated each year from patient illness — $3.6 trillion in 2018.”

Key points:

  • “Forty years a go, …billed rates were far lower…and insurer mostly just paid them…That’s when a more entrepreneurial streak kicked in…If someone is paying you whatever you ask, why not ask for more?”
  • “Surprise bills are the latest tactic: when providers decided that an insurer’s contracted payment offerings were too meager, they stopped participating in the insurer’s network; they walked away or the insurer left them out. In some cases, physicians decided not to participate in any networks at all. That way, they could charge whatever they wanted when they got involved in patient care and bill the patient directly.  For their part, insurers didn’t really care if those practitioners demanding more money left.”
  • Members of Congress can address this problem and “tackle the obvious injustice. Will they listen to hospitals, doctors, insurers? Or, in this election year, will they finally heed their voter-patients?”

My take: When physicians/hospitals and insurance companies are at odds, patients/families are the ones paying the price.

Related article: NY Times: My $145,000 Surprise Medical Bill What my brief glimpse into the financial abyss taught me about the American health care system.

Garden at UNC Chapel Hill

Abdominal Pain in Children Increases With Age and With Psychological Factors

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A recent study (MP Jones et al. Clin Gastroenterol Hepatol 2020; 18: 360-7) provides granular data on a well-recognized phenomenon: stomach pain is more common in older children than younger children and is associated with psychosocial factors.

Design: “All Babies in Southeast Sweden” Study with 1781 children (born 1997-99).  Families answered questionnaires at birth, 1 year, 2.5 years, 5 years, 8 years and 10-12 years.

Key findings:

  • Abdominal pain prevalence increased linearly with age -each year the rate increased .  At 2 yrs, the prevalence was ~6%, at 5 yrs ~8%, at 8 yrs ~9.5%, and at 12 yrs ~12% (Figure 2)
  • Psychosocial factors associated with abdominal pain included lower emotional control at 2 yrs of age, parental concern for child at 2 yrs of age, and measures of parental stress.

My take: This study reinforces the idea that psychosocial factors increase the development of non-organic abdominal pain.  If they could be addressed better, GI clinics would be less busy.

Related blog posts:

Old Well, UNC Chapel Hill, Fall

Current Impact of Climate Change

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When I hear people say that the changes in climate are ‘just another weather cycle,’ I wonder if they understand the reasons why scientists are so worried.  It is not simply the historic increases in temperature.  The bigger concerns are the permanent changes in the environment that foster ongoing and worsening problems.  The atmosphere now has greenhouse gases that could take a 1000 years to dissipate even without further pollution (Related blog post: The Health Consequences of Climate Change).  This is akin to sleeping under more blankets except that in the middle of the night, when you are sweating, there is not a simple fix –no easy way to remove the greenhouse gases in the atmosphere.

A recent commentary (RN Salas. NEJM 2020; 382: 589-91) details the myriad ways that the climate crisis will affect clinical practice.

The climate crisis is a threat multiplier;  key points:

  • climate sensitive waterborne and foodborne illness
  • worsening mental health
  • heat strokes/heat-related hospitalizations
  • rising pollen levels
  • decreasing nutritional value of food
  • vector borne disease
  • trouble with medication storage (need to be stored at appropriate temperatures)
  • treatment disruptions by climate events
  • supply-chain disruptions by climate catastrophes
  • hospital power outages
  • rising temperatures could increase bacterial resistance to antibiotics

My take (borrowed from commentary): “Despite the irony, I often describe our current knowledge of the health effects of climate crisis as an iceberg.  Though we see a peak above the water’s surface, there is much to fear from the larger mass beneath –the effects that we haven’t yet identified.”

Related blog posts:

Garden at UNC Chapel Hill Campus

“The Truth About Allergies and Food Sensitivity Tests”

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This is a link to a 20 minute video regarding “The Truth About Allergies and Food Sensitivity Tests” with Dr. Dave Stutkus and Dr. Mike Varshavski. (If trouble with link, then can find with quick search on YouTube.)

A couple of clarifications:

The video (~at the 3 minute mark) does not provide much nuance on “non-celiac gluten sensitivity” (see related blog posts below)

Some other points:

  • Don’t perform Food IgG testing -this is a memory antibody and does not reflect food allergy or sensitivity
  • So-called food sensitivity IgG tests do not have standardized normal values
  • Don’t perform broad-based IgE testing; there are many false-positives and false negative

Dr. Stutkus decided to undergone ‘food sensitivity’ tests and was reportedly sensitive to nearly 80 foods.

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Have Nonprofit Hospitals Lost Their Mission?

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NY Times: Nonprofit Hospitals Are Too Profitable

An excerpt:

Seven of the 10 most profitable hospitals in America are nonprofit hospitals…

It’s time to rethink the concept of nonprofit hospitals. Tax exemption is a gift provided by the community and should be treated as such. Hospitals’ community benefit should be defined more explicitly in terms of tangible medical benefits for local residents…

The average chief executive’s package at nonprofit hospitals is worth $3.5 million annually. (According to I.R.S. regulations, “No part of their net earnings is allowed to inure to the benefit of any private shareholder or individual.”) From 2005 to 2015, average chief executive compensation in nonprofit hospitals increased by 93 percent. Over that same period, pediatricians saw a 15 percent salary increase. Nurses got 3 percent…

Additionally, hospitals should not be allowed to declare Medicaid “losses” as a community benefit. While it’s true that Medicaid typically pays less than private insurance companies, Medicaid plays a crucial role for private insurance markets by acting as a high-risk pool for patients with severe illness and disability…These large medical centers also enthusiastically accept taxpayer money for research…

Particularly in communities with a shortage of health care resources, tax exemption can make sense. In medically saturated areas, where profits and executive compensation approach Wall Street levels, tax exemption should raise eyebrows.

My take: This opinion piece makes a strong argument that many nonprofit hospitals do not deserve to be exempt from taxes. At a minimum, more transparency regarding tangible benefits is needed to assure that hospitals earn this exemption.

AJC: Georgia hospital disclosures show disparities, seven-figure salaries  According to the AJC, the Children’s Healthcare of Atlanta’s CEO made 1.9 million last year. By comparison, the Northside CEO made 4.9 million. Other tidbits: Piedmont’s chief philanthropy officer was compensated 1.2 million.

Related blog posts:

“The problem with internet quotes is that you can’t always depend on their accuracy” ~Abraham Lincoln, 1864.

Working Together to Improve Outcomes for Children with Inflammatory Bowel Disease

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Recently, we had an “ImproveCareNow Population Management” meeting.  At these regular meetings, we typically review at least one topic of interest, review data on how patients are doing (eg. hospitalizations, clinical remission, surgeries, followup visits), and discuss patients who have challenging clinical problems.  Credit for making these meetings work go to Clair Talmadge, PA-C, Samantha Gomez (ICN coordinator), and Chelly Dykes (physician leader).  Also, with regards to depression screening, we are fortunate to have the support of Bonney Reed-Knight and Jessica Buzenski.

At the latest meeting, we discussed our recent implementation of depression screening, expanded definitions of clinical remission/sustained clinical remission, and family support projects.

With regard to depression screening, we are finding that ~30% had actionable screens indicating some level of depression and ~4% screened as suicidal (requiring urgent attention).

My take: Each of these meetings and the work that goes into them make tangible improvements in outcomes.

Some of the slides are shown below.

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Treating Helicobacter Pylori Lowers The Risk of Gastric Cancer

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FDA ‘Safety Initiative’ Now Means an Ounce of Ethanol Costs $30,000

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Ethanol locks are now going to be ridiculously expensive (possibly $30,000 per month -for 1 oz) due to an FDA initiative which aims to improve drug safety. Paradoxically, this could endanger the health of many vulnerable children.

Modern Healthcare: Unapproved Drug Initiative adds up to $30 billion in healthcare costs Thanks to Jennifer Sterner-Allison for this reference.

An excerpt:

A regulatory pathway that aims to ensure drug safety is inflating healthcare spending by billions of dollars, according to a new report.

Four widely used drugs funneled through the Unapproved Drug Initiative will increase spending by more than $20.25 billion over a five-year span as manufacturers hiked prices between 525% to 1,644%…

“Hospitals are absorbing additional cost for drugs that are not innovative, not curing new diseases, do not have overwhelming R&D investment, and are often the preferred drug of choice.”…

The 2006 Unapproved Drug Initiative requires manufacturers to pull these drugs and prove to the FDA that they are safe. Typically, fewer manufacturers remain in the market after the FDA intervenes, which allows price manipulation.

Drugs that go through the UDI pathway can earn the manufacturer up to seven years of patent protection, which can prevent competition. At minimum, other suppliers of the drug targeted by the UDI also have to leave the market and receive approval, which can reduce competition.

The situation with ethanol is particularly egregious, said Erin Fox, a drug shortage expert and senior director of drug information and support services at University of Utah Health.

Belcher Pharmaceuticals is charging $1,000 per milliliter, which equates to $30,000 for one shot of ethanol, since it received an orphan drug designation through the UDI, granting Belcher’s drug exclusivity through 2025, she said. Belcher won the orphan drug classification, a status for drugs that treat rare diseases, for its treatment of hypertrophic obstructive cardiomyopathy.

“It is the perfect example of how this FDA approval process is broken,” Fox said. “Pediatric hospitals are going to be particularly impacted because ethanol is sometimes used to ‘lock’ IV ports to prevent infections in high-risk patients.”..

“FDA’s Unapproved Drug Initiative continues to have serious unintended consequences and in my opinion should be halted,” she said

My take: I have contacted the American Academy of Pediatrics and asked them to try to work on this problem.  The high cost of ethanol may prevent its routine use and result in central line infections, hospitalizations and even death in vulnerable children.

Related blog posts (on utility of Ethanol Locks):

Blogs related to Pharmaceutical Practices:

Ethanol locks can minimize infections among patients who receive intravenous nutrition (“TPN”) which was popularized by Dr. Dudrick.  Due to the exorbitant costs of ethanol, this may lead to increased infections, hospitalizations and even death.