health care

New NACCHO president on Zika, equity & the ACA: ‘We can’t do this alone. We have to do it together’

kkrisberg — Fri, 11 Aug 2017 23:02:26 +0000

New NACCHO president on Zika, equity & the ACA: ‘We can’t do this alone. We have to do it together’

Umair Shah’s story isn’t an uncommon one in public health. Starting out in medicine, with a career as an emergency department doctor, he said it quickly became clear that most of what impacts our health happens outside the hospital and in the community.

Today, that philosophy drives his work as executive director of Harris County Public Health (HCPH) in Houston, Texas — an agency that serves the third-largest county in the nation, home to about 4.5 million residents. In fact, Shah, who first joined the agency in 2004 and become director in 2013, said the agency’s mantra is this: “Health happens where you live, learn, work, worship and play.” Last year, HCPH became the first public health department in Texas to be selected as Local Public Health Department of the Year by the National Association of County and City Health Officials (NACCHO), which recognized HCPH for its commitment to engagement, equity and innovation.

Take for example, its work with Microsoft on mosquito “smart traps.” The traps, now being piloted in Harris County, can identify a mosquito by the oscillation of its wings and capture data on the environmental conditions at the time it was caught. The hope is that public health practitioners like Shah can eventually use all that data to predict where disease-carrying mosquitos will show up and where the agency should deploy the preventive measures that head off potential disease outbreaks.

“We’re not looking at the public health of yesterday or today, but toward the public health of tomorrow,” Shah told me. “That’s how we’re positioning ourselves.”

In July, Shah became the new president of NACCHO. He spoke with the Pump Handle last week about achieving healthy equity, the impact of the Affordable Care Act and elevating the public health narrative. (The following has been edited for clarity and length.)

Pump Handle (PH): In becoming NACCHO’s new president, you talked about changing the “invisible narrative” around public health. Why do you believe this is important and how do you recommend local public health workers go about that?

Shah: The challenge we have in the public health field is that we’re all very good at what we do and yet our work is largely invisible — like the disease outbreak that doesn’t happen — and so it’s hard to show the value of that work. So raising the visibility, drawing attention to actual work being done...that helps people value that work and then they become interested in investing in that work.

Here in Texas — because we’re such a football-loving state — I like to describe public health as the offensive line of the team. There’s lots of other players on the team that often get the recognition...but it’s public health doing all the blocking and pushing that allows the rest of the team to be successful.

We have an investment issue in our country. The vast majority of health-related expenditures go to health care delivery systems and not to public health and prevention. So we need to be thinking about how we can reframe that, and I believe the public health workforce has a role in that. We are the ambassadors of our field and when we’re willing to raise the visibility of the work we do, it translates into reframing the value proposition, if you will, of public health.

PH: Your agency has a strong focus on embedding health equity principles in everyday public health work. Why do you believe equity-focused work is so important at this particular time?

Shah: Equality really is the lens by which we approach so many of the activities we’re engaged in. At HCPH, we have a strong stance toward incorporating the social determinants of health into everything we do, from theoretical modeling to our response to Zika — we even have a health equity coordinator embedded in our multidisciplinary (Zika) response team.

We’re finding that communities are feeling that they’re being left out. …They feel like they don’t have a voice or don’t see a role for themselves in the decision-making process. Health equity really allows us to (elevate) community voices and perspectives as well as the social factors that determine health. Often, we find that it's the areas not traditionally in the purview of public health that we need to be focused on. That’s why we’ve taken such an assertive role in incorporating health equity into our work.

PH: You work in a state at high risk of Zika virus. Can put in context just how much work and coordination it takes to prepare for Zika and the possibility of a local outbreak?

Shah: HCPH confirmed the first Zika positive case back in January 2016, and it was before a lot of the interest happening around Zika domestically. That meant we had to build the plane while we were flying it.

We worked very diligently with our federal, state and local partners, and with a number of health care organizations, hospitals systems, providers, medical societies — all sorts of different stakeholders. At the end of the day, it was an incredibly instructive process in the real need for government to work together with the public in ensuring the health of our community and in preventing what could have been a remarkably worse situation.

Our department spent $1.5 million of its resources on Zika last year. We waited quite a bit of time for things to come through from the federal level and for Congress to approve a package, but we couldn’t rest on our laurels. We had to be very aggressive.

We’ve been investing an incredible amount of resources, staffing and capacity building not just in mosquito control, but in epidemiology, communications, policy work, environmental and veterinary work. This multidisciplinary approach gives us the best opportunity to respond to Zika in our community. That said, it only takes one mosquito to get Zika from a traveler from a Zika-affected area and — boom — now we have Zika in the community. We have to stay vigilant and that’s the real challenge.

PH: According to recent data from your agency, Harris County’s infant mortality rate is higher than both the state and national averages, with black families experiencing a disproportionate amount of that burden. What is your agency doing to address this?

Shah: This goes back to the health equity issue.

There’s a number of things we’ve been doing. We’re participants in Global Latch through our Women, Infants and Children (WIC) program, which is an opportunity to remind new mothers about the importance of breastfeeding. We’re members of the Harris County Child Fatality Review Team, where we review cases of children who have died through a prevention and policy lens. We operate 16 different WIC sites or prevention clinics throughout the community, where we use an equity lens approach to address the mitigating factors that impact health with a particular family.

We see this as a global issue that requires a multifaceted approach from the health department. So it’s not just an approach of our clinics and WIC sites or just the human health side; but really believing it requires a look at the (social) conditions too.

PH: How important has the Affordable Care Act been for the community you serve?

Shah: The ACA has had a great impact both in widening access and in creating opportunities for us to partner with the health care sector.

Sometimes there’s this perspective that because Texas didn’t expand Medicaid, that we haven't made any efforts, or few efforts, to improve coverage. But even without Medicaid expansion, the uninsured rate has dropped both statewide and locally. Enrollment increased in the marketplace from 135,000 in 2014 to almost a quarter-million in 2017. But we still have a good portion of our community, especially in certain communities, who aren’t aware of how to access health care coverage. We have to make sure people are aware they may be eligible for subsides.

But we also have to recognize that while health care coverage is important and necessary, it’s not sufficient. We need to recognize that health goes beyond health care…and when health care and public health work together, we can leverage the entirety of our systems to improve the health of our community.

What’s been missing in all the discussions around the ACA repeal is that a significant portion of CDC funds is in the ACA’s Prevention and Public Health Fund (PPHF) — if that fund went away, you’d have a 12 or 13 percent cut to CDC’s budget. We receive about $1.5 million through the PPHF...and so if you have a reduction in dollars at the federal level, you start to have an impact on what’s happening in Texas to the tune of about $28 million. That’s just through the health departments — the PPHF monies also go to community groups. We have to remember public health in all of this.

PH: The PPHF has become a critical source of funding for a variety of public health activities at the local level. Can you provide a couple examples of what we stand to lose if that fund disappears?

Shah: We’d lose dollars for surveillance, epidemiology, infectious disease response, health promotion. Many of those dollars aren’t just about disease, but about infrastructure and capacity. For example, when we have something like Zika or Ebola, we can chase the dollar by being reactive or we can have a system where local and state public health are well-resourced. That means we’re not being reactive to the next disease of the day, but proactively building capacity so we’re ready to respond to myriad issues.

PH: As a physician, you came to public health via the world of medicine. As such, what’s one thing you wish public health workers better understood about their colleagues in medical care? What’s one thing you wish those in medicine better understood about public health?

Shah: I don’t want to forget the importance of the public health-health care interface. What I would say is we can’t do our jobs effectively unless we work hand in hand with each other.

When you look back at Ebola, it is an incredible testament that only Mr. (Eric) Duncan (the first Ebola patient diagnosed in the U.S.) and two additional nurses were exposed. That is an incredible success story, and yet that is also the challenge for public heath. When I treat cancer in a child, I can show you a poster child for cancer treatment. But it’s much harder to show the image of the kids who were prevented from getting cancer in the first place.

At the end of the day, we can’t do this alone. We have to do it together.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years. Follow me on Twitter — @kkrisberg.

kkrisberg Fri, 08/11/2017 - 19:02

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Affordable Care Act

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Public Health - General

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Harris County Public Health

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Senate Health Care: John McCain is busy

gregladen — Sun, 16 Jul 2017 07:01:59 +0000

Senate Health Care: John McCain is busy

John McCain has a good heath care plan, and if has his way, you won't.

The Senator most often accredited for thinking for himself (that's a lie) will vote with Russian agent Donald Trump and the rest of the Republicans to take away Obama care. The moment he gets a chance.

However, he can't right now because he is indisposed, recovering form surgery.

We at Greg Laden's Blog wish Senator McCain a speedy recovery and hope he is well. But we also urge him to think about his privilege and not take access to the sort of health care he has from other Americans.

Speaking of the Russians, The Looking Glass War, the fourth George Smiley novel by John le Carré, in Kindle form, is currently and temporarily two bucks. Just thought you might like to add that to your collection.

gregladen Sun, 07/16/2017 - 03:01

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Republican Health Care Plan

Must admit my first thought when I heard the reason given for the delay in the vote was "Oh, the irony!". My second thought was "GOP's double standards".

They've already taken access to the health care he has away from other Americans. Congress was supposed to be on the exchanges. Then they declared themselves to be a small business and took themselves off the exchange.

What's left of McCain after one removes the blood clot?

McCain's been polishing his fake maverick image so long you'd think he'd have worn right through the brass by now. I wonder what the Senate and House would look like if there was a mandatory 75 year retirement age....

Off topic, I'd be interested to see your (GL) take on the latest Minneaopolis police shooting. A middle-aged white woman from Austalia in her pajamas fatally shot outside her home while talking to two officers about a reported suspicious incident she or her husband had called in... both officers had their body cams turned off and the car camera recorded nothing. Most of the usual excuses can't be rolled out and used in this case.

MikeN, Congress is not and never was exempt from the Affordable Care Act. Before it took effect they bought insurance from a program that was used as a model for the exchanges.

But: the final ACA bill included this language.

the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are — (I) created under this Act (or an amendment made by this Act); or (II) offered through an Exchange established under this Act.

The notion that Congress excused themselves from ACA is simply another right wing line of crap.

This headline pretty much explains my exact feelings on John McCain. The article is pretty good too

http://theconcourse.deadspin.com/i-dont-want-to-hear-another-fucking-wo…

Magma, the media would like to jump to the usual narrative of racist white cops kill black person, but here it is reversed. So Washington Post instead makes it all about gun control since Australia confiscated all the guns. That it was a police officer that did the shooting should be relevant, but then there would be nothing for them to report.

MikeN, you are misstating what happened in Australia.

#5 MikeN "Magma, the media would like to jump to the usual narrative of racist white cops kill black person ..."

I'm puzzled by your comment. For example: Are you implying that no racist white cops have ever killed a black person? Or is it that such a thing should not be mentioned by the media even if it is a common occurrence?

I am saying that the media is eager to report this narrative regardless of the facts of the case. If George Zimmermann were Jorge Mesa(his mother's surname), you likely would have never heard of TrayVon Martin. Frequently the media reports this narrative then when the facts come out there is a 'narrative collapse'. For example, 'hands up don't shoot' is a lie. In the early 90s they caused massive rioting in LA by only showing part of the tape of Rodney King's beating by cops.
They edited out Zimmermann's call to the police, changing
'He looks like he's up to no good.'
'Can you tell us what race he is, white, black, hispanic?'
'He looks black.'
to
'He looks like he's up to no good. He looks black.'

" but here it is reversed"

So only white people should have their guns controlled. "mike"???

" That it was a police officer that did the shooting should be relevant"

It is, you foetid pile of dingos kidneys. In every story I've read about it, moron.

" If George Zimmermann were Jorge Mesa"

He wasn't. He made a fake narrative so he could kill a black man for being dangerously negro in his presence. And you white racist fucks believed him.

You're eager to make every white man non racist, aren't you, "mike".

And loathe the media for not letting you keep your protective unreality around you.

Why are you such a delicate snowflake, "mike"?

"Frequently the media reports this narrative then when the facts come out there is a ‘narrative collapse’. "

Really? WHERE?

"by only showing part of the tape "

Uh, first, that is only about part of the tape itself, dickhead, so you're fake too. Second,the police continuously give out a fake claim until tape shows them lying their asses off. And in the current case, despite all the laws requiring them be on, neither cop has working bodycam footage. The destruction of evidence should be, as it is with ordinary people, considered evidence of guilt.

"They edited out Zimmermann’s call to the police,"

Which would be wrong why? All he says is what he wants to be believed, it's no more valid than a statement without evidence.

Still with the hold on posts?

Australian gun control is irrelevant when it's a cop that did the shooting. Police in Australia have guns too.

Latest news on McCain is brain cancer, glioblastoma. Nasty.

No moderation updates yet?

Do you really love in a different reality mikeN? You line about guns bring confiscated in Australia isn't true, and you neglect the fact that Zimmerman was told by 911 to stop following Martin. He chose to confront him and it ended badly

its "surgery" dumb ass

Dean the exact nature of Australian gun control is irrelevant to my point- it was the Post that brought Australian gun control into a story about a police shooting. Unless Australian police don't have guns this is a meaningless detail for the Post to include.

Martin attacked Zimmerman. Zimmermann did as he was told and went back to his truck. By this time, Martin had been convinced by his girlfriend who he was talking to on the phone that Zimmerman was a gay predator after him and his brother and decided to kill him. This gay detail went unnoticed for a long time because people(including me) thought the girlfriend's testimony was saying 'cracker' when it was 'ass cracker' which I have never heard before.

"Dean the exact nature of Australian gun control is irrelevant to my point-"

Then your point was irrelevant to the subject of gun control, and it was you trying to shoehorn it in there.

"Martin attacked Zimmerman."

Lie.

"Martin had been convinced by his girlfriend who he was talking to on the phone that Zimmerman was a gay predator after him and his brother and decided to kill him. "

That was a big line on the racist sites (Limbaugh, national review, breitbar, blaze, etc...) but it was their misrepresentation of her comment: her testimony was that she told Martin to run from him, not attack him.

You don't follow any real news sources do you?

I find it remarkable that MikeN lets his right wing views cloud his judgment. Pretty well anywhere else in the developed world the Zimmerman-Martin incident would never have happened. Only in gun-happy USA would it not only occur but would this blatant murder be condoned. Zimmerman was clearly looking for a confrontation. He had his gun and clearly felt empowered by it. So he followed Martin until a confrontation was inevitable. If he had mindedhis own damned business Martin would be alive today and this sordid event would have happened.

I never said she told him to attack. Only that she suggested Zimmerman was gay. This suggestion set off TrayVon.

And you never said that your "information" was from horrendously unreliable sources, "mike". You also never said that you have not investigated the facts yourself to see if your sources of "information" were correct.

You never said that Zimmerman stalked Martin after getting his gun. Nor that Zimmerman murdered Martin.

There's a whole heap of what you didn't say.

But what you DID say meant Martin's girlfriend told him to meat Zimmerman because he was gay.

@ MikeN

Martin attacked Zimmerman. Zimmermann did as he was told and went back to his truck.

Revisionist*, much?
Yes Martin did, but the proper term is "stand your ground". Oh, but that only applies if you are a white Yankee.
And no, Zimmerman didn't. He may have been on his way back, but he was still happy to confront Martin.
Martin confronted Zimmerman head-on. And then, the situation escalated into physical assault and point blank shot.

Since you are talking about stuff left out of the police tape, you forget the part where Zimmerman said, right after the "he is black" part, "these [redacted], they always get away.".
(source - Wikipedia, among other places)
What did Zimmermann meant by this? Well, his home was burglarized by two Black men a few weeks before the shooting, while his then-girlfriend and child were hiding on the second floor. The two criminals fled once they realized that policemen were on their way.
This time, Zimmermann made sure the frightening Black teen didn't escape.

*I'm French. Look up who we reserve this term for.

Correction, looking at news reports, the girlfriend testified that Martin said 'creepy ass cracker'(after first saying 'creepy, white'), and she suggested to Martin that Zimmerman was a rapist.

"March 13, 2012 - Sanford Police Department's homicide detective Christopher Serino recommends Zimmerman be charged with manslaughter. Zimmerman "failed to identify himself" as a concerned citizen or neighborhood watch member on two occasions that night. Serino reports that he thought Zimmerman's head injuries were "marginally consistent with a life-threatening episode, as described by him, during which neither a deadly weapon nor deadly force were deployed by Trayvon Martin."

"Authorities release seven 911 calls from the night of the shooting. In one of the 911 recordings, Zimmerman, against the advice of the 911 dispatcher, follows Martin."

Zimmerman did not return to his car, he followed Martin. Reality is not on your side.

Ah, and how was that suggested? There's nothing in "creepy-ass cracker" (you know, like a creepy white dude stalking you) that says "rapist", but maybe you know more about what crackers do, "mike" to know this.

Because as far as I can see, "rapist" is only what you are suggesting.

That was in another news report. What she told him on the phone. I can't find a complete transcript.

Then do not pass on without having checked. Doing what you did just wastes everyone else's time and you just turn about and say "Don't shoot the messenger!!!".

But you stated it as if it were true and you believed it.

Next time at the very least you have to say "I don't believe this report" first.

Dean the Sentinel says that on the 16th Serino told them otherwise.

http://articles.orlandosentinel.com/2012-04-02/news/os-trayvon-martin-f…

Wow you ever contribute anything. Martin said to girlfriend 'creepy ass cracker' according to girlfriend. Girlfriend said she told Martin she thought he was a rapist. This was her testimony in court. It is possible she made the whole thing up.

The transcripts I posted were from the final police investigation.

"Wow you ever contribute anything. "

Thank you, I will ever contribute.

" Girlfriend said she told Martin she thought he was a rapist"

But no quote of her saying that. And it appears I was giving your idiotic claims more credit than they were due, "mike", since the problem now is not MERELY that "cracker-ass creep" doesn't say "rapist", but no actual words from the girlfriend were made.

So, this claim of her calling Zimmerman a rapist (or gay, or whatever your made up bullshit is now or next) was entirely a fiction and you're liable to just complain that it was from "some news source" and that we should not blame you for talking such bollocks.

Will you ever contribute something from a working adult mind, "mike"?

"Dean the Sentinel says "

Did you check them? if not, then you have ZERO REASON to accept one over the other.

As someone who preens themselves on being a skeptic despite everyone else pointing out the fallacy in this belief of yours, you should be leaping at the chance to check up who has the right story.

Oh, and whining "But THEY said it!!!!" merely is showing that you're credulous of what THEY said. Not that you were right to make the claim. YOU SHOULD INVESTIGATE FIRST.

Dumbass.

I hope that McCain finds himself running over the lifetime or annual cap of his insurance policy because of his chemotherapy costs for his brain cancer.

Not because I wish him ill, but because I wish he find out what it feels like when you haven;t enough money to save your life under the republican ideas of a "free market" for healthcare.

It's sure as shit he'll not be aware of it by means of *empathy*.

If american police could not shoot the people who call them in the first place, that would be great. Thankyou.

Dean, your transcript looks like it came from CNN's Fast Facts. The area is a T shape, his truck is at one end. From the call, Zimmerman went towards the other end where the gate is while Martin went down the T towards his dad's house. Killing happened at the intersection, consistent with Zimmerman going back to his truck while Martin doubles back rather than going home.

http://www.huffingtonpost.com/2012/03/16/trayvon-martin-911-audio-_n_13…

It appears the 'witness' that says Zimmerman followed Martin is the last one, as she's the only one who says any events before 'someone was screaming help help help'. She says she saw them talking, nothing about following as near as I can tell.

Dean, #5, Congress's health care is coming from SHOP, the small business health options program, which is for businesses with less than 50 employees.

Under the Affordable Care Act, members of the U.S. House of Representatives, the Senate and their office staffs who want employer coverage generally have to buy it on the health insurance exchange. Before the ACA passed in 2010, they were eligible to be covered under the Federal Employees Health Benefits Program. (People working for congressional committees who are not on a member's office staff may still be covered under FEHBP.)
The members of Congress and their staffs choose from among 57 gold plans from four insurers sold on the DC Health Link's small business marketplace this year.
Approximately 11,000 are enrolled, according to Adam Hudson, a spokesperson for the exchange. The government pays about three-quarters of the cost of the premium, and workers pay the rest. They aren't eligible for federal tax credits that reduce the size of insurance premiums.
For some other members of Congress, declining exchange coverage was a political statement.
"There are several who, because of animus to Obamacare, rejected the offer of coverage, and either buy on their own or get it through a spouse," said Sabrina Corlette, a research professor at Georgetown University's Center on Health Insurance Reforms.
Proposed bills to replace the ACA don't affect this provision of the law, said Timothy Jost, a professor emeritus of law at Washington and Lee University School of Law in Lexington, Va., who has written widely on the regulation of health care and its reform.

For the other one: police transcripts from final investigstions.

"Dean, your transcript looks like it came from CNN’s Fast Facts"

An odd accusation given your "Well, that' what this site said" defences.

"(People working for congressional committees who are not on a member’s office staff may still be covered under FEHBP.)"

So, maybe, like, spouses of senators or their family members? Tell me, does FEHBP include a spouse or family member from being included? 'cos if so, a Senator with a wife who works for a congressional comittee could be covered by their wife's insurance and not have to use any purchased plan.

Dean, you repeated what I said. Congress is not a small business, so why are they buying health insurance from the small business exchange? They gave themselves a special exemption. Well more accurately, OPM gave it to them illegally.

No, he quoted the current situation from a reliable source.

Is your complaint that you and dean agree on something? Maybe you can show us where dean said you were wrong so we can see if your post at 44 is at all relevant to dean's post at 41

We at Greg Laden’s Blog wish Senator McCain a speedy recovery and hope he is well. But we also urge him to think about his privilege and not take access to the sort of health care he has from other Americans.

McCain voted against the move, according to news reports.

Frogot the link.
https://www.nytimes.com/2017/07/27/us/politics/obamacare-partial-repeal…

Study: Where you live determines what you pay for medical care

kkrisberg — Tue, 03 May 2016 16:09:36 +0000

Study: Where you live determines what you pay for medical care

If you’re pregnant and live in Cleveland, Ohio, it’s likely you’ll pay about $522 for an ultrasound. If you live about 60 miles south in Canton, Ohio, it costs about $183 for the same procedure, a recent study found. Why such a significant price difference? Researchers couldn’t single out one overriding factor. But the study does tell us this: place matters when it comes to how much you pay for health care.

The study was published last week in Health Affairs and was based on data from the Health Care Cost Institute, a commercial claims database that includes nearly 3 billion paid claim lines (those are the individual line-item services in your medical bill). Researchers focused on claim data between Jan. 1, 2012, and Dec. 31, 2013, and examined prices for 242 common medical services across 41 states and Washington, D.C. Right off the bat, the study acknowledged that health care costs typically vary across different locations — after all, the cost of doing business (e.g. wages, rent, supplies) is different in each community. Plus, insurers don’t automatically set a price — they negotiate prices with providers and hospitals in each insurance plan, which means those costs vary wildly too.

Certainly from a patient perspective, it’s difficult to tease out why a particular medical service has a particular price tag. And this study shows that even researchers who study these kinds of questions for living are having a hard time pinpointing consistent and justifiable reasons why some of us pay much more than others for the same medical procedure — even if we live a short car ride apart. Here are some examples of what they found.

In examining how states compare to the nation as a whole, researchers found that 95 percent of prices for 241 services in Florida were at or below national averages. In comparison, about 75 percent of prices for 240 services in Ohio were at or below national averages; 30 percent of prices for 232 services in Connecticut were 20 percent higher than national averages; and more than 45 percent of prices for 221 services in Minnesota were 50 percent higher than national averages. California was home to the largest in-state difference in average price, while Virginia was home to the smallest difference.

For example, the price of knee replacement in Sacramento, California, is about $57,504; about 400 miles south in Riverside, California, it costs $30,261. In Dallas, Texas, knee replacement costs about $45,275; about 350 miles west in Lubbock, Texas, it costs $28,456. In Virginia Beach, Virginia, the procedure typically costs $39,298; about 100 miles north in the state capital of Richmond, it costs $39,292 — a difference of just $6.

The study also found some significant price variations for an ultrasound — a service the researchers described as “similar in scope and quality across providers, care settings and geographical areas.” For example, in Jacksonville, Florida, an ultrasound typically costs about $457; less than 200 miles south in Orlando, it costs $180. In Philadelphia, an ultrasound costs about $466; about 100 miles west in Harrisburg, Pennsylvania, it costs $232. And back in Virginia Beach, an ultrasound costs $275; to the north in Richmond, it costs $271 — a difference of $4.

In calling for continued research into what exactly is driving these price variations, the study stated: “The questions that remain for researchers, policymakers, and health care leaders are as follows: Why do prices for the same service differ markedly across distances of only a few miles, and what amount of that difference is justifiable?”

To read the full study, visit Health Affairs.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for nearly 15 years.

kkrisberg Tue, 05/03/2016 - 12:09

Tags

government

healthcare

Public Health - General

What you see in some of the reference cases is that the insurance company will pay for transport and a hotel for a companion if you travel for lower prices (For example you can do a lot of travel for 30k by going from Sacramento to Riverside Ca, Or from Dallas to Lubbock, Tx (there is a med school in Lubbock, Texas Tech)
Of course I have expected for a while that some insurers for things like knee replacements would look at say Costa Rica with the travel deal (perhaps even throw in first class flights)

I would be interested to see a cross-reference between the inflated charges and high-prestige hospitals/facilities/physicians. Also an overlay of people without insurance.

Healthcare Habits Die Hard

milhayser — Wed, 25 Nov 2015 13:33:40 +0000

Healthcare Habits Die Hard

As the U.S. seeks to drive down medical spending, one goal is to eliminate tests and treatments that are ineffective while encouraging price competition among things that work. Passing the buck on to the consumer isn't enough; on The Pump Handle, Liz Borkowski reports that giving patients an incentive to save money on health care causes them to see the doctor less, not "shop smarter." Meanwhile, Orac provides an update on "Choosing Wisely," a program meant to weed out useless procedures by appealing to the prudence of medical specialists instead of patients. In the three years that it has been in effect, the initiative has had little measurable impact. As Orac writes, "As much as physicians want to do the right thing for their patients, changing behavior in large numbers of people is among the most difficult human endeavors of all."

milhayser Wed, 11/25/2015 - 08:33

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Public health ROI: Study finds investing in lead poisoning prevention could reap millions in benefits

kkrisberg — Fri, 13 Jun 2014 14:18:03 +0000

Public health ROI: Study finds investing in lead poisoning prevention could reap millions in benefits

Childhood lead poisoning is one of those health risks that everyone has likely heard about, but many probably think it’s a problem of the past. However, a recent study reminds us that in just one state — Michigan — the effects of childhood lead poisoning cost about $330 million every year. And that’s a conservative estimate.

But estimating the cost of childhood lead poisoning wasn’t the only goal of the study, which was released earlier this week. Study author Tracy Swinburn, a research specialist at the University of Michigan Risk Science Center, wanted to know what kind of financial return residents could expect if state policymakers decided to invest in lead abatement (decreasing or removing lead risks in homes). Knowing that the majority of child lead exposure is related to lead-based paint in older housing stock, she and her colleagues estimated it would cost $600 million to remediate the 100,000 high-risk housing units in Michigan. That investment, they found, would pay for itself in as little as three to six years. In fact, 30 years down the road, the accumulated return on investment for the lead poisoning prevention tactic would grow be $10.50 for every $1 invested.

“If we can offset some of these (health and social) costs with quality lead abatement programs then we can make an economic case as well as a public health case,” Swinburn told me. “Lead isn’t very sexy. It doesn’t get as much attention as other new public health and environmental pollutant issues, so we hope this study will help. We think it’s an issue worthy of more attention.”

Childhood lead poisoning is linked with behavior and attention problems, academic difficulty, hearing problems, irreversible declines in IQ, brain and nervous system damage, and delayed growth and development. To conduct the Michigan study, Swinburn and colleagues considered four well-documented effects of lead exposure: increased health care, increased crime, increased need for special education and a decline in lifetime earnings.

In terms of health care costs, the study estimated immediate treatment, which includes diagnostic testing, nurse visits and therapy to treat heavy metal poisoning, at $280,000 annually, as well as lead-associated ADHD treatment at more than $18 million annually. Crime costs were estimated at $32 million annually in incarceration for lead-related juvenile crime and $73 million in lead-related adult crimes, which included costs to victims, legal proceedings, incarceration, and lost earnings for both perpetrator and victim. (For more on the association between lead and crime, see this study and this study.) Special education costs were estimated at $2.5 million, and lead-related loss of lifetime earnings was estimated at $206 million. Swinburn noted that the costs are conservative estimates and don’t account for all of the secondary impacts of lead exposure, such as the parent of a child with ADHD who has to regularly miss work and lose income.

The study found that the $600 million needed to address lead within 100,000 of the most at-risk homes in the state would accrue benefits of $230 million annually, totaling more than the initial investment in just three years. The study is the first to compare the impact of lead exposure in Michigan to the cost of lead abatement. With the prevention tactic making good economic sense, Swinburn concluded:

These economic returns on investment in lead abatement are all in addition to the value of the health and well-being of thousands of Michigan children, and their families, who experience the effects of lead exposure each year. Even without this benefit, on an economic basis alone, this assessment suggests that lead abatement is an investment worth considering.

Sadly, it’s not likely that Michigan policymakers will invest $600 million in lead abatement, Swinburn said. Still, she said the study can illustrate the great benefits of preventing lead exposure and help justify current investments in lead poisoning prevention. Swinburn also told me that it’s not an over-reach to think that lead poisoning prevention could contribute significantly toward narrowing health and social inequities.

“I would certainly like to think that it’s a great way to start tipping things toward better equality, especially in communities and neighborhoods facing a lot of challenges,” she said. “(Lead abatement) could help boost public health and quality of life. …It could be a promising way to help make progress.”

According to 2012 data from the Michigan Department of Community Health, nearly 70 percent of Michigan children are tested for lead exposure within the first years of life. And while overall numbers of child lead poisoning have dramatically declined, certain communities face disproportionate burdens — for instance, 10 ZIP code areas in Detroit were home to lead poisoning rates higher than 2 percent. Nationwide, 535,000 young children have blood lead levels high enough to put their health at serious risk. In fact, a 2009 study examining the national benefits of lead paint control concluded that each $1 invested resulted in a return of $17–$221 or an overall savings of $181 billion to $269 billion.

Swinburn hopes her study will help shine a light on childhood lead poisoning and the sound economic argument in favor of prevention.

“There are a lot of advocates working hard on this issue,” she said. “But it is an issue that doesn’t often get attention because people thinks it’s been dealt with already. We hope we can help put it back on the radar.”

The full study, “Economic Impacts of Lead Exposure and Remediation in Michigan,” is available here. To read our previous coverage about the economic argument for lead poisoning prevention in Detroit, read Celeste Monforton's post here.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.

kkrisberg Fri, 06/13/2014 - 10:18

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Brain and Behavior

How refreshing to read quantification of the social impact of lead poisoning. This is the data we need to advocate for change and required testing of children.

Wouldn't it be something if policymakers responded appropriately to data on the social cost of public health hazards---especially those affecting children. Regrettably, far too many are only interested in the "costs to business" or "unfunded mandates to government agencies." As Kim points out, the ROI for lead-paint abatement is immense. If we invested in ridding the housing stock of lead paint, we'd eventually not have to needlestick children to see if they are poisoned. Eliminating the hazard would prevent children from having to be poked.

Obama Makes Hospital Charge Masters Public

denialism — Wed, 08 May 2013 13:23:38 +0000

Obama Makes Hospital Charge Masters Public

And the best article on the implications of this, surprisingly, comes from Huffington post authors Young and Kirkham:

The database released on Wednesday by the federal Centers for Medicare and Medicaid Services lays out for the first time and in voluminous detail how much the vast majority of American hospitals charge for the 100 most common inpatient procedures billed to Medicare. The database -- which covers claims filed within fiscal year 2011 -- spans 163,065 individual charges recorded at 3,337 hospitals located in 306 metropolitan areas.
...
Within the nation’s largest metropolitan area, the New York City area, a joint replacement runs anywhere between $15,000 and $155,000. At two hospitals in the Los Angeles area, the cost of the same treatment for pneumonia varies by $100,000, according to the database.

We discussed this issue before when it was brought to the public's attention by Brill's "Bitter Pill" piece in Time. Hospitals have a wildly-irrational billing scheme that represents a war they are in with payers. However, Brill was wrong to attribute excess costs of US healthcare to the charge master problem, while the HuffPo piece gets this issue right. It's not a problem for insurance companies, or government, since they don't pay these bills. It only screws payers without negotiating power or knowledge of how to navigate these bills - the uninsured:

"The charge masters are totally irrational," Robert Laszewski, a former health insurance company executive who consults for health care companies as president of Alexandria, Va.-based Health Policy and Strategy Associates, wrote in an email to The Huffington Post.

Hospitals used to base prices on health care costs and on the need for profit that would, among other things, enable them to make investments in their facilities, Laszewski explained. "They became the baseline from which the hospitals started," he wrote. But over time, hospitals raised charges in anticipation of negotiating discounts with private health insurance companies while maintaining their revenue streams, he said.

Prices have continued growing over decades to the point where there is no plausible justification for them, according to Laszewski: "Over the years, the charge masters have become more and more disconnected from reality."

And since they haven't been public or shared before now, I suspect each hospital probably has some set of services that appear to be priced excessively compared to their near neighbor. The costs haven't grown so much from a response to the treatments they provide, so much as the perceived ability to force insurers to pay a larger portion. Each hospital has probably independently evolved a strategy to do this, hence the wide variability in pricing.

The charges are the prices hospitals establish themselves for the services they provide. Although Medicare and Medicaid don't base their payment rates on these figures, private health insurance companies typically do, which means they usually pay more for the same health care than the government does. That translates into higher premiums for people with insurance. And uninsured people are expected to pay the full list price or a discount from that number, which tends to mean they pay more than anyone else.

When a hospital doesn't get paid as much as it wants from one source, it tries to make up the difference in other ways, such as billing so-called self-pay patients -- almost always the uninsured -- for the full list price of a service, said Robert Huckman, a health care expert at Harvard Business School. Even when hospitals agree to huge discounts for patients who can't pay the bill, those discounts are taken from inflated prices much higher than those the government or private insurance companies pay, he said.

"The charge master is complete nonsense that really doesn't matter -- unless you are an uninsured person and you're getting these huge bills driving you toward bankruptcy," Laszewski wrote. "The biggest irony of the U.S. health care system is that only the uninsured -- often people who don't have a lot of money -- are the only ones the hospital expects to pay these incredibly inflated list prices!"

Hospitals also inflate charges to raise money for things that aren't related to treatments, said former Sen. David Durenberger (R-Minn.), who is senior health policy fellow at the University of St. Thomas in Minneapolis.

"The biggest factor by far, in my experience, is what are you trying to cross-subsidize," he said. Hospitals will increase charges to finance things like technology upgrades and education and research and to compensate for their operational efficiencies, Durenberger said.

We've discussed extensively the sources of excess costs in US healthcare. It's not the chargemaster. It's excessive administrative costs of private health insurance, excessive drug costs (everything from direct-to-consumer advertising, the fact US citizens are charged more and GWB made it so medicare can't negotiate for lower drug prices), inefficient delivery (primary care in the ER), redundant delivery, lack of a government-implemented or regulated standardized electronic medical record (EMRs from private companies actually increase costs), defensive medicine, excessive end-of-life care, and excessive reimbursements of procedures and diagnostic testing.

What will this data release mean for health care costs? Probably not much as the hospitals will now just normalize excessive bills to each other, rather than just having their own individually-irrational billing scheme. The charge master is unjust, but it's not why we pay more for healthcare overall.

There is a solution to the charge master problem though, and it was found in New Jersey. Force hospitals to charge the uninsured what they charge Medicare. It's that simple. It's that easy.

denialism Wed, 05/08/2013 - 09:23

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In Germany, we have the "Gebührenordnung für Ärzte" (GOÄ), the "regulation of fees for doctors". It regulates (almost) everything a doctor/clinic can charge. The good thing: Every payer pays (more or less) the same for a procedure (there is some leeway). Regardless whether you are uninsured and pay it out of pocket, regardless whether you have a "private" insurance*** (and what then those "private" insurances pay for any procedure), it is all in a list. And then for the "gesetzliche Krankenkasse", a highly regulated insurance system that most of Germans have, there is a similar "Einheitlichen Bewertungsmaßstab" (EBM).

Obviously there are problems, like what to do with new procedures? Or if costs sink (e.g. for diagnostic tests), how do you transfer that lower cost to the payer?

But overall it works quite well. The risk of going bankrupt due to having to go to the doctor is quite mitigated here in Germany.

*** We have here in Germany two types of insurance the "gesetzliche Krankenversicherung", which is a highly regulated insurance "for everybody". Then we the possibility for the rich to leave this solidarity system and got to an "private" insurance.

may photographer be utilized ?

There Are Legitimate Criticisms of Obamacare - Hospitals Should not be Penalized for Readmissions

denialism — Tue, 02 Apr 2013 03:38:46 +0000

There Are Legitimate Criticisms of Obamacare - Hospitals Should not be Penalized for Readmissions

Crazy ranting about impending socialism/fascism aside, there are legitimate critiques to be made of Obamacare. One policy in particular that raises my ire is penalizing hospitals over performance metrics and penalizing readmissions in particular. The way it works is, patients are admitted to the hospital, treated, and eventually discharged, but a indicator of failure of adequate care is if that patient then bounces back, and is readmitted shortly after their hospitalization:

Under the new federal regulations, hospitals face hefty penalties for readmitting patients they have already treated, on the theory that many readmissions result from poor follow-up care.

It makes for cheaper and better care in the long run, the thinking goes, to help patients stay healthy than to be forced to readmit them for another costly hospital stay.

So hospitals call patients within 48 hours of discharge to find out how they are feeling. They arrange patients’ follow-up appointments with doctors even before a patient leaves. And they have redoubled their efforts to make sure patients understand what medicines to take at home.

Seems reasonable, right? These are things that are part of good medical care; good follow up, clarity with prescriptions, etc. It should be the responsibility of hospitals to get patients plugged into the safety net, assign social workers, and make sure patients won't fail because they lack resources at home. However, the problem arises when the ideal of punishing readmissions as "failures" crashes into the reality of the general failure of our social safety net:

But hospitals have also taken on responsibilities far outside the medical realm: they are helping patients arrange transportation for follow-up doctor visits, get safe housing or even find a hot meal, all in an effort to keep them healthy.

“There’s a huge opportunity to reduce the cost of medical care by addressing these other things, the social aspects,” said Dr. Samuel Skootsky, chief medical officer of the U.C.L.A. Faculty Practice Group and Medical Group.

Medicare, which monitors hospitals’ compliance with the new rules, says nearly two-thirds of hospitals receiving traditional Medicare payments are expected to pay penalties totaling about $300 million in 2013 because too many of their patients were readmitted within 30 days of discharge. Last month, the agency reported that readmissions had dropped to 17.8 percent by late last year from about 19 percent in 2011.

But increasingly, health policy experts and hospital executives say the penalties, which went into effect in October, unfairly target hospitals that treat the sickest patients or the patients facing the greatest socioeconomic challenges. They say a hospital’s readmission rate is not a clear measure of the quality of care it provides, noting that hospitals with higher mortality rates may also have fewer returning patients.

“Dead patients can’t be readmitted,” Dr. Henderson said.

This is a problem with the careless application of rewards and penalties tied to medical outcomes. While I think it's a healthy response that hospitals are taking on more of the social work that formerly would have been the arena of government programs, there is another defense mechanism used when government creates perverse incentives in health care. When you create payment incentives for good outcomes, you run the risk of patient selection, discrimination, and fraud. My favorite paper on this topic comes from the British NHS, and their attempt to reward physicians based on better clinical outcomes. My advice with this paper (and with most papers frankly) is to ignore what the authors say about their data (and the amazing success of their program!) and just look at the data for yourself. What they found with rewarding physicians based on health metrics was that doctors that treated the young, healthy, and rich did well, those with more patients, poorer patients, and older patients did more poorly. Finally, physicians that filed lots of “exception reports” to eliminate all their poorly-performing patients did great (yay, fraud!).

Metrics are good for identifying problems, but the mistake is the assumption that poor performance at a metric has everything to do with the physicians or the hospitals, or that slapping a penalty on poor performance will fix the problem. Sometimes, you're studying society, not medical care. Incentive structures that put the burden on hospitals to take care of the most basic needs of their patients are going to penalize those hospitals that take care of the neediest, sickest, oldest patients, and reward those who treat insured, wealthy, younger, and fewer patients. Worse, if you penalize hospitals for taking care of difficult patient populations, I can predict the outcome. More bogus (and occasionally dangerous) transfers, more patients dumped on public and university hospitals, and all the other tricks of patient selection private hospitals can engage in to avoid getting stuck with the economic losses. That is, patients who are really sick, really poor, really old, and most in need of care will get transferred, obstructed, and dumped. Hospitals that are referral centers, major university and public hospitals that can't refuse or transfer problem patients, will end up with the disproportionate amount of the penalties because they are often the healthcare providers of last resort. Not surprisingly, the early data already shows this is happening:

The second important development was the release of data on who will be penalized: two thirds of eligible U.S. hospitals were found to have readmission rates higher than the CMS models predicted, and each of these hospitals will receive a penalty. The number of hospitals penalized is much higher than most observers would have anticipated on the basis of CMS's previous public reports, which identified less than 5% of hospitals as outliers. In addition, there is now convincing evidence that safety-net institutions (see graphsProportion of Hospitals Facing No Readmissions Penalty (Panel A) and Median Amount of Penalty (Panel B), According to the Proportion of Hospital's Patients Who Receive Supplemental Security Income.), as well large teaching hospitals, which provide a substantial proportion of the care for patients with complex medical problems, are far more likely to be penalized under the HRRP.3 Left unchecked, the HRRP has the potential to exacerbate disparities in care and create disincentives to providing care for patients who are particularly ill or who have complex health needs, particularly if the penalties are larger than hospitals' margins for caring for these patients.

It would be unfortunate if in the course of creating incentives for better care, we fall into the same old trap of punishing those who take care of the neediest. What we need instead is to acknowledge one major source of bad outcomes is a broken social-safety net. We can't just keep creating these unfunded mandates that put all the onus of taking care of the uninsured, the poor and elderly on hospitals, and punish the centers that already carry the largest social burdens with responsibility for the failure of our nation to take care of its own. Unfortunately, our answer to problems like these is always to create one more shell game that hides the real, unavoidable costs of taking care of people by shifting it around. This will just result in higher bills on the insured, more crazy chargemaster fees, overburdened public and university hospitals, and ultimately, a system of regressive taxation.

denialism Mon, 04/01/2013 - 23:38

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Increasingly, these performance metrics require the doctor to coerce patients into excessive screening and excessive treatment, e.g., a doctor may be penalized if too many 40-year-old females "fail" to get annual mammograms, or if too many patients are not statinized down to an acceptably low LDL no matter how low the expected benefits in their subgroup or what harms they suffer as a result. I do not want to know that my doctor may have her pay cut because she facilitates my making rational, informed decisions, rather than abusing me, lying to me, or "firing" me because I wish to do so. It's either grossly unfair to her, or creates such a conflict of interest that I would no longer be able to trust any of her advice.

I wonder if this penalty applies to repeat ER visits. Because the number of drug seekers that keep coming back would put most hospitals out of business.

This is a concept that has very broad application. For instance, we've gone down the path of rewarding and punishing teacher based on performance when many of the causes of student performance are out of their control. Who suffers? Those teachers and the kids they teach in the schools that have economically disadvantaged populations.

Another problem with this scheme is that we don't really understand what causes readmissions. Reducing readmissions is the holy grail of health services management in single payer systems, but research on the problem doesn't give clear results and predictive efforts are poor. Given this, even hospitals trying their very best to reduce readmissions won't necessarily be able to.

Obamacare includes a range of methods to save money that are based on fanciful use of IT and predictive stuff. I think I read somewhere the intention to save $50billion through computerization. These schemes won't work ...

Your comments on the British QOF system are a bit unfair - that system is an add-on to the standard contract and is largely aimed at improving public health practice rather than core services. Also patients in the NHS don't pay for anything and GPs can't exclude anyone. Failures of QOF aren't necessarily clinical failures.

@ Mac

Agreed. Metrics are frankly poison, because they give stupid thoughtless people a blunt instrument to punish others despite an incredible complexity of factors at work. Before metrics are systematically applied to reward/punish behaviors you really have to think about what you're studying, and figure out if youre measuring performance, or society.

@Faustusnotes
I agree, the IT thing has not worked, EMRs have raised costs as for-profit EMR manufacturers design their software to bilk Medicare. Now, if we had a real progressive at the helm we'd just flush all these worthless companies down the john, or at least come up with a universal record format, that both inhibits fraud, and promotes the cost-saving advantages of EMR. As long as we have a dozen EMR companies competing for market share by making their software incompatible with everyone elses while at the same time screwing the payers with automatically-checked boxes, we're going to see increased costs. Screw those guys. Some people hate Monsanto. I hate medical software companies.

I wasn't being unfair to the British QOF system, that's what the data shows their program is doing. I agree, it's not worsening care, but it is just rewarding doctors who take care of easy patients. As such, it's a waste of money, and kind of offensive.

Bluegrass Geek - No, this does not apply to patients who make multiple ER (or doctor) visits, only patients who are admitted to the hospital. The idea is that if you are admitted for heart failure, say, and you are treated and released and a week later you are back in the hospital for it again, obviously they must have failed to stabilize your condition adequately, and they shouldn't be financially rewarded for the fact that you now need more inpatient care. I'd like to buy this argument, having seen a family member repeatedly hospitalized for the complications of malpractice committed during a first hospitalization. However, not all repeat hospitalizations are preventable. When people are seriously or chronically ill or FTD (fixin' to die), things do happen.

What's more, this policy could lead to more harm for patients, and in more ways than those Dr. Hoofnagle has already noted. It is widely accepted in American medicine that providers may put butt-covering ahead of patients' well-being. If a doctor is not punished for finding excuses to keep patients in the hospital longer, but will be punished if he "lets" them go home quickly, where most will be happier and safer, and then some of them return, then he may well bully them all into staying until he is very sure they're stable. During that time, some of them will contract C. difficile or MRSA and be entered into horrific intervention cascades - for which the hospital will be paid .

Mark, I think the problems are bigger than just private companies competing the way you describe. Big IT projects are doomed to fail, and it doesn't matter which system one tries to use. The NHS is now something like 10 years behind on its NpFit project for just this reason. My opinion is that conservative-thinking health managers see IT improvements as an easy alternative to real innovative thinking about cost-cutting and efficiency improvement, and introduce bloated and impossible programs where small, simple changes would be enough.

I do like the idea of hospitals being required to provide some kind of warranty to their patients, especially on large-volume, low-risk procedures like cataract surgery, etc. But not until we have a better understanding of what factors affect rehospitalization.

I think QOF doesn't so much encourage doctors to pick up the easy patients as it reveals quantitatively what NHS doctors have always been doing. There are huge inequalities in the NHS even though it is a free service, and although it hasn't fixed those inequalities QOF does show the difference in service quality up. I don't know if you've ever experienced NHS care, but the quality and depth of service provided by British family doctors is absolutely terrible, and they are really overpaid for it. Reforming that sector is crucial to improving inefficiency in the NHS. I think that Obamacare is also going to include a shift towards increased role for primary care - I think this is another example of buzzword panacaea that never delivers the gains its advocates claim.

Sadly, Obamacare is a dog's breakfast...

Fixing the Chargemaster Problem for the Uninsured

denialism — Wed, 20 Mar 2013 10:00:21 +0000

Fixing the Chargemaster Problem for the Uninsured

For those disturbed by the evils of the hospital chargemaster as exposed by Brill's piece in time, Uwe E. Reinhardt's proposed solution is a must read.

While the hospitals are never going to charge the uninsured the same rate as they charge medicare (and probably be less forgiving the more they think they can get out of you), that's no reason we can't force them to with state law. Apparently that's what Reinhardt had them do in Jersey:

In the fall of 2007, Gov. Jon Corzine of New Jersey appointed me as chairman of his New Jersey Commission on Rationalizing Health Care Resources. On a ride to the airport at that time I learned that the driver and his family did not have health insurance. The driver’s 3-year-old boy had had pus coming out of a swollen eye the week before, and the bill for one test and the prescription of a cream at the emergency room of the local hospital came to more than $1,000.

By circuitous routes I managed to get that bill reduced to $80; but I did not leave it at that. As chairman of the commission, I put hospital pricing for the uninsured on the commission’s agenda.

After some deliberation, the commission recommended initially that the New Jersey government limit the maximum prices that hospitals can charge an uninsured state resident to what private insurers pay for the services in question. But because the price of any given service paid hospitals or doctors by a private insurer in New Jersey can vary by a factor of three or more across the state (see Chapter 6 of the commission’s final report), the commission eventually recommended as a more practical approach to peg the maximum allowable prices charged uninsured state residents to what Medicare pays (see Chapter 11 of the report).

Five months after the commission filed its final report, Governor Corzine introduced and New Jersey’s State Assembly passed Assembly Bill No. 2609. It limits the maximum allowable price that can be charged to uninsured New Jersey residents with incomes up to 500 percent of the federal poverty level to what Medicare pays plus 15 percent, terms the governor’s office had negotiated with New Jersey’s hospital industry.

Reinhardt also makes clear that the problem of excess cost is not the chargemaster or hospital profits, which are not so extraordinary, as did I in my original piece (at least compared to excess drug costs, insurance administration, inefficiently delivered service and unnecessary services etc). But the injustice of the uninsured facing these inflated bills that are designed to antagonize large payers like health insurance companies, should be addressed. You can't bleed a radish, and hospitals should stop trying to when it comes to the uninsured. Since they won't without government encouragement, such legislation should be considered at the state and national levels.

denialism Wed, 03/20/2013 - 06:00

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Honestly, well made points. And I was not even aware that NJ did that. I think the best thing for everyone probably would be a system of rate setting similar to that. Either in each state or federally mandated (maybe a baseline there and states can expound on it). Hospitals definatly need money for equipment and personel, but that said I think using price setting of some sort (including drugs) will really help people get the care they need and not go bankrupt getting it. Not to mention would probably lower insurance rates as well.

I agree with Mark that pegging fees to the uninsured to Medicare fees is a sensible solution. Medicare fee schedules are easy to come by and the reduction of fees to something within the realm of reason would encourage the uninsured to make good on the care received. As is is now, the unpaid bills of many uninsured people become the bulk of the "charity care" the hospital provide. Putting a reasonable price tag on a visit introduces some fairness to an otherwise non-negotiable and unfair equation.
Cheryl

What is the cause of excess costs in health care Part 4 - Time's "Bitter Pill", CEO compensation and the Kafkaesque chargemaster

denialism — Mon, 25 Feb 2013 13:14:38 +0000

What is the cause of excess costs in health care Part 4 - Time's "Bitter Pill", CEO compensation and the Kafkaesque chargemaster

Steven Brill's extensive piece in Time has generated a good discussion once again on why Americans pay so much more for health care than other countries, and while I agree with most of his critiques, he seems to have gotten overly hung-up on the hospital chargemaster.

Readers of this blog know I've also discussed reform in health care, the diverse sources of excess cost including price gouging on pharmaceuticals, defensive medicine, expensive end-of-life care, the high cost of primary care in the ER etc, and both Brill and I appear to have relied on the same sources of data in the McKinsey report. We've also discussed the "hidden tax" of the uninsured, as well as some signs of reform (although of note, my belief that and EMR would reduce waste has proven wrong as the software designers have designed their programs to gouge medicare on behalf of the doctor - increasing costs!).

Brill has written a piece for Time that takes a different tactic, however. Rather than starting from the data on sources of excess costs (although he does reference them), he starts with the patients' bills and then tries to figure out where all these expenses come from. This is a creative and innovative approach to the problem, except I cringed when I read it because I knew what he was going to find before the end of the first page. Medical bills are insane.

The total cost, in advance, for Sean to get his treatment plan and initial doses of chemotherapy was $83,900.

Why?

The first of the 344 lines printed out across eight pages of his hospital bill — filled with indecipherable numerical codes and acronyms — seemed innocuous. But it set the tone for all that followed. It read, “1 ACETAMINOPHE TABS 325 MG.” The charge was only $1.50, but it was for a generic version of a Tylenol pill. You can buy 100 of them on Amazon for $1.49 even without a hospital’s purchasing power.

Dozens of midpriced items were embedded with similarly aggressive markups, like $283.00 for a “CHEST, PA AND LAT 71020.” That’s a simple chest X-ray, for which MD Anderson is routinely paid $20.44 when it treats a patient on Medicare, the government health care program for the elderly.

Every time a nurse drew blood, a “ROUTINE VENIPUNCTURE” charge of $36.00 appeared, accompanied by charges of $23 to $78 for each of a dozen or more lab analyses performed on the blood sample. In all, the charges for blood and other lab tests done on Recchi amounted to more than $15,000. Had Recchi been old enough for Medicare, MD Anderson would have been paid a few hundred dollars for all those tests. By law, Medicare’s payments approximate a hospital’s cost of providing a service, including overhead, equipment and salaries.

This is the fascinating aspect of his article but also the tragedy. Because Brill becomes so highly focused on what hospitals charge, and the apparent horrifying mark-up of medicine, I worry that people will come away thinking that this is the cause of excess costs.

The problem Brill is describing is that the costs itemized by hospitals on their bills come from a mysterious document called the "chargemaster". I'm pretty sure no one knows how the costs are calculated, and I know there is no rational basis for the prices on it. But as shocking as the bills that are generated by these documents are, they are largely irrelevant to the excess costs of healthcare. The chargemaster is a red herring, and despite Brill's protestations that it is some central evil in health care expenditure, it really isn't.

The tragic circumstances Brill describes, repeatedly, are what happens when someone who is uninsured, underinsured, or paying out of pocket for medical care experiences when they receive their bill. It is covered with charges that seem insane - because they are - and lacking the knowledge and tools to deal with these ridiculous charges, the uninsured, understandably, believe they need to pay this full, ridiculous bill. But they don't, and shouldn't. An uninsured person receiving one of these bills is a little like a tourist who has just been dropped in a foreign bazaar, with no understanding of the rules of the market, discounts, haggling, gouging, or any idea of what other actors in the same market are paying. The reality is that hospital bills, and many other bills in medical care are little more than an opening gambit in an irrational, and largely incomprehensible, cost war between providers and payers. Hospitals, knowing that insurers never pay a full hospital bill, and will haggle and discount charges away or pay a percentage of "chargemaster" costs, push back by artificially inflating costs - as demonstrated throughout Brill's article. When someone who doesn't have the power or expertise of the insurance company receives their bill (hospitals of course can't send different bills to different kinds of customers right?) they end up paying more, or worse, think they have to actually pay the full bill, because they have fallen into this market without the tools or knowledge to navigate it.

The proof of this are the medical bill advocates Brill interviews for the article. For a fee, you can hire someone who has similar expertise as the payers to fight back, and often reduce these bills to a tiny fraction of their original amount.

Shocked by her bill from Stamford hospital and unable to pay it, Janice S. found a local woman on the Internet who is part of a growing cottage industry of people who call themselves medical-billing advocates. They help people read and understand their bills and try to reduce them. “The hospitals all know the bills are fiction, or at least only a place to start the discussion, so you bargain with them,” says Katalin Goencz, a former appeals coordinator in a hospital billing department who negotiated Janice S.’s bills from a home office in Stamford.

Goencz is part of a trade group called the Alliance of Claim Assistant Professionals, which has about 40 members across the country. Another group, Medical Billing Advocates of America, has about 50 members. Each advocate seems to handle 40 to 70 cases a year for the uninsured and those disputing insurance claims. That would be about 5,000 patients a year out of what must be tens of millions of Americans facing these issues — which may help explain why 60% of the personal bankruptcy filings each year are related to medical bills.

“I can pretty much always get it down 30% to 50% simply by saying the patient is ready to pay but will not pay $300 for a blood test or an X-ray,” says Goencz. “They hand out blood tests and X-rays in hospitals like bottled water, and they know it.”

After weeks of back-and-forth phone calls, for which Goencz charged Janice S. $97 an hour, Stamford Hospital cut its bill in half. Most of the doctors did about the same, reducing Janice S.’s overall tab from $21,000 to about $11,000.

Brill also seems very disturbed by two consistently capitalistic elements of hospitals, high compensation of hospital CEOs and non-physician administrators, and the ability of "non-profit" hospitals to actually make a profit. The difference, is, of course, "profits" in this case go back into the hospital, hiring staff, into equipment, buildings, etc., rather than shareholders pockets so one could argue the money largely goes back into the community (disclosure - I work for a non-profit hospital). But what about CEO pay? Brill seems largely offended that they make so much, even making the suggestion at the end of the article that hospital profits be taxed at 75% (insuring no one will ever invest in them again) and that CEO pay be limited to some multiple of a lower-level employee's salary. Sounds wonderful, except it will only work if that model is applied to CEOs across the board. Brill cites hospital CEO compensations of between 1-4 million dollars. But the average CEO salary is about 13 million dollars as of 2011. Yes CEOs are paid too much, but it's a global problem, not just in healthcare. If anything, healthcare CEOs are payed a great deal less than their counterparts in other industries, it seems strange to single out healthcare as the one service where CEO pay is somehow more sinful than in others, especially if you want hospitals and medical centers to be able to attract talented management. So am I bothered by CEO pay? Sure, but not as much in my industry as in say, finance, where CEOs who aren't making profit, and are hurting shareholders get rewarded with bonuses and golden parachutes. Brill seems to be upset that the industry is profitable and are CEOs are well-compensated. But this isn't so much a source of excess costs in healthcare as it is a source of excess costs in capitalism, and I don't anticipate that changing any time soon, nor do I think it's ultimately a good idea to nationalize or socialize the industry to make no profit.

This is too bad, because in an extensive, lengthy documentation of the absurdity of the hospital billing scheme, and anger at CEO pay, Brill's final recommendations hit many of the true sources of excess cost.

So how can we fix it?

Changing Our Choices
We should tighten antitrust laws related to hospitals to keep them from becoming so dominant in a region that insurance companies are helpless in negotiating prices with them. The hospitals’ continuing consolidation of both lab work and doctors’ practices is one reason that trying to cut the deficit by simply lowering the fees Medicare and Medicaid pay to hospitals will not work. It will only cause the hospitals to shift the costs to non-Medicare patients in order to maintain profits — which they will be able to do because of their increasing leverage in their markets over insurers. Insurance premiums will therefore go up — which in turn will drive the deficit back up, because the subsidies on insurance premiums that Obamacare will soon offer to those who cannot afford them will have to go up.

Agreed. In particular I find the financial conflict of doctors owning labs and radiology equipment, that they then can profit from ordering tests on, is very disturbing. It's been shown in the literature that this arrangement results in the physicians ordering more unnecessary tests, and demonstrates that it's an unacceptable conflict of interest that only increases costs.

Similarly, we should tax hospital profits at 75% and have a tax surcharge on all nondoctor hospital salaries that exceed, say, $750,000. Why are high profits at hospitals regarded as a given that we have to work around? Why shouldn’t those who are profiting the most from a market whose costs are victimizing everyone else chip in to help? If we recouped 75% of all hospital profits (from nonprofit as well as for-profit institutions), that would save over $80 billion a year before counting what we would save on tests that hospitals might not perform if their profit incentives were shaved.

We could save lots of money if we forbade various industries from making profit and taxed their incomes at 75%. But I don't think this is a viable suggestion in a capitalist society, and I believe that if we did increase competition in insurance, pharmaceutical, and other healthcare markets we could decrease costs. Socialism is not the answer, although Brill makes a compelling argument for a public-option as medicare's administration and pricing is highlighted in the article as a model of efficiency compared to the private insurers. I'd have no problem with expanding medicare as a payer. Next:

We should outlaw the chargemaster. Everyone involved, except a patient who gets a bill based on one (or worse, gets sued on the basis of one), shrugs off chargemasters as a fiction. So why not require that they be rewritten to reflect a process that considers actual and thoroughly transparent costs? After all, hospitals are supposed to be government-sanctioned institutions accountable to the public. Hospitals love the chargemaster because it gives them a big number to put in front of rich uninsured patients (typically from outside the U.S.) or, as is more likely, to attach to lawsuits or give to bill collectors, establishing a place from which they can negotiate settlements. It’s also a great place from which to start negotiations with insurance companies, which also love the chargemaster because they can then make their customers feel good when they get an Explanation of Benefits that shows the terrific discounts their insurance company won for them.

While I agree outlawing the chargemaster should be considered, I'm not really sure it will work. For one, yes, it is a fiction, it's not an actual source of excess costs like so many other problems described in the McKinsey report. And hospitals are in a bind. They can't charge what things actually cost, because insurance companies will still try to pay less. Hospitals know what their costs are, but it's nearly impossible to truly itemize a patient's stay, and take into account the exact time every physician doctor and nurse spent with them versus another patient, exactly how many disposable materials were used, as well as factor in all the other costs hospitals need to balance such as covering uninsured patients (most of whom never pay their bills), profit-losing divisions of hospitals and "mission" costs, as well as having a adequate nest egg at the end of the year to ensure adequate capital to expand as needed to meet demand, buy new equipment, and hire new staff. My guess as to what the chargemaster is accomplishing (and it is just a guess), is that it's a strategy that reliably returns a certain amount of profit on each hospitalization relative to patient utilization of specific services, while providing plausible deniability for what is ultimately overcharging the insured to subsidize the total costs of running their operation. It has to be inflated to cover all the costs of overhead, supplies, etc., that just can't be reliably quantified, and the fact that insurance companies will only pay a fraction of the final bill. The alternative would be to "bundle" costs so that hospitalizations for specific services cost a set amount, and hospitals then have an incentive to come in under that reasonable fixed price for the service. But then, you run into the problem of penalizing the hospitals that treat needier, poorer, sicker, older populations that cost more to treat, and will have poorer outcomes, readmissions, and complications.

It's a pickle. You want hospitals to have some measure of profitability - they provide a necessary service, employment, and pride to the community. But if you create profit incentives that put them in conflict with the community - like avoiding poorer, sicker, older patients, they won't provide the very service for which they exist.

I don't have a good solution to this problem. We need to own up to the costs of treating the difficult populations, rather than continuing to play the insurance shell-game. Hospitals have to treat people who are sick no matter what because of laws like EMTALA. EMTALA is an unfunded mandate, passed during the Reagan years, that doesn't specify how hospitals shall recoup their losses when someone can't pay, just that they have to provide care for sick people no matter what. The unwillingness to pay for the poor and the uninsured pushes even their primary care into the ER, and they present with more acute problems that earlier access to primary care could have managed more cheaply, raising the costs of their care, and foisting it on the hospitals - especially the non-profit, inner-city hospitals providing care to the most at-risk. They then have to figure out some way of spreading these costs back onto medicare and the insured and paying patients without attaching a rider to the bill that simply says, "paying for the sick and uninsured in your community -- $1200" (then you actually only have to pay only $200 for this service in reality because everything is inflated). I suspect the chargemaster, in its irrational and frightening way, is accomplishing this task. It's not pretty, but I'd love to hear suggestions to address the need of hospitals to provide universal health care without a funding source to do so.

Then Brill gets to the things which I agree the McKinsey report shows are our real sources of excess costs:

We should amend patent laws so that makers of wonder drugs would be limited in how they can exploit the monopoly our patent laws give them. Or we could simply set price limits or profit-margin caps on these drugs. Why are the drug profit margins treated as another given that we have to work around to get out of the $750 billion annual overspend, rather than a problem to be solved?

Just bringing these overall profits down to those of the software industry would save billions of dollars. Reducing drugmakers’ prices to what they get in other developed countries would save over $90 billion a year. It could save Medicare — meaning the taxpayers — more than $25 billion a year, or $250 billion over 10 years. Depending on whether that $250 billion is compared with the Republican or Democratic deficit-cutting proposals, that’s a third or a half of the Medicare cuts now being talked about.

We pay twice as much for our drugs as any other country, R&D is a BS excuse, and the inability of medicare to collectively bargain is anti-capitalistic and anti-market. How is it possible that in a capitalistic society a buyer isn't allowed to bargain for bulk purchase? It's just a wealth-redistribution scheme! And the proof is systems like the Veterans Administration, which is allowed to negotiate for lower prices, and does, typically paying about half as much for the same drugs.

Similarly, we should tighten what Medicare pays for CT or MRI tests a lot more and even cap what insurance companies can pay for them. This is a huge contributor to our massive overspending on outpatient costs. And we should cap profits on lab tests done in-house by hospitals or doctors.

I think that particular conflict of interest should be banned, but one must remember again that differing CT and MRI costs are largely a reflection of which hospitals have higher "mission" costs. It's not the CT in the suburb that costs medicare more, it's the CT in the inner-city.

Finally, we should embarrass Democrats into stopping their fight against medical-malpractice reform and instead provide safe-harbor defenses for doctors so they don’t have to order a CT scan whenever, as one hospital administrator put it, someone in the emergency room says the word head. Trial lawyers who make their bread and butter from civil suits have been the Democrats’ biggest financial backer for decades. Republicans are right when they argue that tort reform is overdue. Eliminating the rationale or excuse for all the extra doctor exams, lab tests and use of CT scans and MRIs could cut tens of billions of dollars a year while drastically cutting what hospitals and doctors spend on malpractice insurance and pass along to patients.

Tort reform may benefit but it's effects will take decades to see. It's almost impossible to adequately quantitate the cost of "defensive" medicine, and how it has inculcated generations of physicians to overtest, overtreat, and overspend on patients. Even if such changes were made, the paranoia runs deep within us. I agree it's costly, but it will take more than just removing the threat of lawsuits to generate more responsible cost-practices for physicians.

Over the past few decades, we’ve enriched the labs, drug companies, medical device makers, hospital administrators and purveyors of CT scans, MRIs, canes and wheelchairs. Meanwhile, we’ve squeezed the doctors who don’t own their own clinics, don’t work as drug or device consultants or don’t otherwise game a system that is so gameable. And of course, we’ve squeezed everyone outside the system who gets stuck with the bills.

We’ve created a secure, prosperous island in an economy that is suffering under the weight of the riches those on the island extract.

And we’ve allowed those on the island and their lobbyists and allies to control the debate, diverting us from what Gerard Anderson, a health care economist at the Johns Hopkins Bloomberg School of Public Health, says is the obvious and only issue: “All the prices are too damn high.”

If you throw in a ban on Direct To Consumer Advertising on Drugs, implementation of CPRS or a universal record standard for the EMR (not these medicare-gauging EMRs that for-profit companies are designing), and better end-of-life planning, data, and management, I think we'd go a long way to reducing costs. Brill's final recommendations hit the mark, but I'm concerned his obsession with the admittedly Kafkaesque chargemaster is a distraction. That's not the true source of the excess costs. Rather I suspect it's a way for hospitals to try to rationalize the redistribution of resources from medicare and the insured to cover their broader mission.

And one final petty complaint which as a surgeon I couldn't resist:

Steve H.’s bill for his day at Mercy contained all the usual and customary overcharges. One item was “MARKER SKIN REG TIP RULER” for $3. That’s the marking pen, presumably reusable, that marked the place on Steve H.’s back where the incision was to go.

No! The pen is sterile! We have to mark the skin after prep - the alcohol based preps we use will wash away most markings placed before sterile preparation, and iodine preps hide them pretty well too. Complaining about a lot of potentially "reusable" items is also just not going to fly in this modern world of MRSA and nosocomial infections.

denialism Mon, 02/25/2013 - 08:14

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The claim that the chargemaster is irrelevant was echoed throughout the article, with most hospital employees dismissing it with prejudice (essentially saying "No one pays that! (You rube!)"). I'm particularly referring to your argument above: " When someone who doesn’t have the power or expertise of the insurance company receives their bill (hospitals of course can’t send different bills to different kinds of customers right?) they end up paying more, or worse, think they have to actually pay the full bill, because they have fallen into this market without the tools or knowledge to navigate it."

But there were two examples that I would like to see addressed regarding people who didn't just "think" they had to pay because they were rubes. The first was the guy who had life-saving cancer treatment withheld until a check from his mother-in-law for $35,000 cleared and he advanced $7,500 on his credit card. The position that "the charges are just a basis for negotiations" becomes a bit more than that when you couple it "pay this or die."

The second example undermining the argument that the chargemaster is irrelevant is the case of the bus driver with the $9,400 bill for falling on her face. Bridgeport hospital sued her and at two court-required mediation sessions "wouldn't budge; his client wanted the bill paid in full." A judge knocked off $500, but that's it. How is that a basis for negotiations? She had a medical-billing advocate on her side - your suggested cure above - and still had to pay the full freight. These aren't the only two people in the United States to whom this has happened. Given that it does happen, the injustice of the chargemaster can't be dismissed with handwaving.

I would never dispute the injustice of it. But your comment demonstrates the exact problem I have with Brill's argument. Yes the chargemaster is awful! No, it is not the source of excess spending in US healthcare, but a reflection of a inefficient, broken system.

To the uninsured or those paying out of pocket, the chargemaster is unjust. I agree. I only dispute that the chargemaster is a major cause of excess spending in US healthcare. I don't think the data support that because most payers pay some fraction of it, and it represents a tool that hospitals are using in a bidding war against payers, not usually the uninsured. Getting sick without insurance is a tragedy, but it's not what is creating these high costs.

It is indeed unfortunate when an uninsured or an underinsured person gets caught up in this battle between the payers and the billers, and their inability to fight back doesn't mean they're rubes. Clearly, only those experienced with these billers - like the medical billing advocates - are particularly successful at negotiating the prices down, and even then, as you say, not always. For these folks it is tragic, and frightening, and painful. For those reasons I think it would be a great idea to get rid of the chargemaster, or at least allow hospitals to charge different kinds of patients different amounts - but as one of the administrators points out, they can not do this.

But the excessive costs? These have been studied extensively, and reports like the McKinsey report above begin to document where the excess billions that we spend each year are going. Most people are insured, most people aren't in the hospital getting subjected to these fees. Most of the costs are being generated by prescription drugs, overtesting and repetitive testing (defensive medicine), extremely expensive end-of-life care, ICU care, etc.

root cause - regarding sick people as a profit center.

"root cause – regarding sick people as a profit center."

Well, most people treated by doctors aren't "sick", much of what we do is prevention, monitoring, screening, and risk modification for our routine care. If you want government to own the medical system and employ all physicians, that's not necessary to reduce costs. Many medical systems throughout the world, including socialist paradises like France, Germany, and the Netherlands have for-profit hospitals and private physicians, only the state is the single-payer, or there is highly regulated insurance schemes like Germany's sickness funds or the Netherlands "insurance with social conscience". Not every universal system is state-owned or state run like Canada, UK or New Zealand. Most are mixtures of private and public enterprise, profit is still involved, and they still cost 1/2 as much as the US system. So no, the problem in the US isn't capitalism or profit.

I'll also tell you, I would probably not have dedicated 17 years of my life to training after college to get paid like a schoolteacher. As much as I like medicine and feel honored to be a part of it, medical school is expensive as hell, almost two decades of my life are now dedicated to training, and neither I, nor anyone else I know, is willing to do sacrifice such a large part of our lives for pennies. Maybe that makes us bad people, I don't know, but I'm doing this to become a highly-trained professional, not a missionary or technician.

Gamers nevertheless can not move for you to servers that are

Mark, I'm curious about how other countries avoid paying anywhere near the costs for healthcare that the US seems to. Looking at your first excess health care costs posts, I see you cited high administration costs, the lack of pharmaceutical price bargaining because of Medicare D, and the lack of risk sharing as particularly important. Are these alone enough to account for the discrepancy between costs in the US and elsewhere, or are there other factors at play in foreign systems?

I can see where administrative costs diverge if, say, the private insurance industry spends a good deal of money on paperwork and actuarial stuff to avoid insuring conditions with high risks of occurring (and probably the ones that most need to be paid for). Or, say, in hospitals and clinics that don't have electronic record-keeping, or really expand their administrative staffs. But is that what's going on here? Does the rest of the world really just have less paperwork and more limited role of private insurance (or none at all, like Canada or the UK)? It seems like it should be more complicated.

Also, not directly related to Brill's article, but about healthcare costs: Jon Chait points us to a wonderfulcherry-pick by senate Republicans about Obamacare. GAO published a report finding that the deficit goes up if the bill costs money but doesn't raise revenue... What are the odds of that?

Chronic pain patients caught in the middle of growing opioid abuse problem

lborkowski — Fri, 09 Nov 2012 14:23:14 +0000

Chronic pain patients caught in the middle of growing opioid abuse problem

by Kim Krisberg

This is the first in a series exploring the intersections between effectively caring for people living with chronic pain and the rise in unintentional poisoning deaths due to prescription painkillers. The series will explore the science and policy of balancing the need for treatment as well as the need to prevent abuse and diversion. This week's story provides a look at the field of pain medicine and the patients it cares for; next week's story will look at the educational and risk reduction approaches physicians are employing to address opioid addiction and overdose.

It took six years of going from doctor to doctor to doctor for Penney Cowan to finally receive a diagnosis for her chronic pain: fibromyalgia. Doctors had told her she'd just have to learn to live with the pain — a condition that some days made it hard to lift a cup of coffee. So when she decided to join the pain program at Ohio's Cleveland Clinic, she didn't have high hopes. She says she expected the effort to fail.

"Chronic pain never really goes away," Cowan told me. "What's difficult for people to understand is that it doesn't mean you'll have the same intense pain 24/7. You have good days and pain days. I felt so isolated and alone for those six years. People would say 'you look so good' and I would say 'you should be inside my body.' And it's not just the pain — it's the fear of pain that's awful too."

Fortunately, the Cleveland Clinic did help Cowan develop a set of skills, such as biofeedback training, to help her manage the pain. Eager to sustain the methods she'd learned and share them with those in need, Cowan began seeking out others in her Pennsylvania community also living with chronic pain. The effort eventually led her in 1980 to found the American Chronic Pain Association, which today offers peer support and education for people living with pain as well as for health care providers.

"I wanted to let people know they're not alone and that there's a way that they can work on helping themselves better manage their pain," said Cowan, who's the association's executive director. "We don't replace proper medical treatment...we share with them coping skills, we want to empower them to help themselves and become part of the treatment team. When it comes to living with pain, you have to be an active participant."

Managing chronic pain — like managing most chronic health conditions — often requires a multipronged approach and prescription drugs can be an effective part of the treatment puzzle. However, one of the most helpful categories of drugs — opioids — is now at the center of a growing diversion, abuse and overdose problem in the United States. The misuse and poisoning rate now associated with opioids is indeed alarming; but in the backlash and frenzy to find a solution, patients are getting caught in the middle. Cowan tells me that she's heard from chronic pain patients who say their doctors are no longer willing to prescribe opioids as part of their treatments. Others say their doctors will still provide a prescription, but their pharmacists won't fill it any more.

"Each person needs to be treated as an individual," Cowan said. "Right now, we're not seeing (people living with chronic pain) as trying to regain control of their lives, they're just seen as people seeking out drugs. That's not fair. No one wants to be in that much pain."

An emerging science

About 100 million U.S. adults are affected by chronic pain conditions — a problem that comes with a cost of between $560 and $635 billion annually in medical care and lost productivity, according to a 2011 Institute of Medicine report, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research." The report authors write:

Pain’s occurrence, severity, duration, response to treatment and disabling consequences vary from person to person because pain, like other severe chronic conditions, is much more than a biological phenomenon and has profound emotional and cognitive effects. Pain can be mild and easily handled with over-the-counter medications; it can be acute and recede with treatment; it can be recurrent over months or years; or it can be chronic and debilitating, requiring almost constant attention and accommodation.

The report goes on to say that "many shortfalls in pain assessment and treatment persist despite humanity's familiarity with pain throughout history," with much of those shortfalls related to gaps in policy, treatment, attitudes, education and research. When it comes to the science of pain management, "it's like a toddler, it's just walking," says Ylisabyth Bradshaw, an assistant public health professor at Tufts University and academic director of its Program in Pain Research, Education and Policy. Bradshaw said that while we know a lot about how to treat pain in an operative setting and at the end of life, chronic pain is still somewhat mysterious to researchers.

"We clearly know how to deal with both those types of pain better than we know how to control chronic pain," she told me. "That type of pain control has many more challenges. We can do a lot, but we can't predictably control chronic pain as well as we'd like."

For millennia, opioids have been used as an effective treatment for pain. Still, there's a great deal of difference in how individuals respond to different medications — "my biochemistry is different from your biochemistry," Bradshaw said. For comparison, she said, there isn't one type of breast cancer and therefore, people need different types of treatment. The same is true for pain, she said: "A drug that may help me could be no better than a placebo for you."

"We're beginning to understand this better and we predict that within the next decade or so we'll be able to type someone's biochemistry," Bradshaw said. "But right now, it's closer to trial and error."

Bradshaw said she doesn't think the health care community was prepared for the negative consequences that followed as more physicians embraced the use of opioids to treat chronic, persistent pain in the 1990s.

"As physicians, we strongly guard our ability to practice for our patients' benefit," she said. "We don't want the pendulum to swing too far back so that we under treat pain, but we want to be careful to help prevent overdoses, misuse and abuse. Clearly, opioids are a real hazard to many people, so figuring out how to reduce the risk is our big challenge now."

'Patients are getting caught in the middle'

The increase in opioid prescriptions has unfortunately coincided with an increase in drug-related abuse and unintentional poisoning. According to the Centers for Disease Control and Prevention, populations that are particularly vulnerable to prescription drug overdose include those who have multiple controlled substance prescriptions from multiple providers; those who take high daily dosages; and people living with mental illness and who have a history of substance abuse. More than half of those who abuse prescription painkillers say they got the drugs free from a friend or family member.

CDC reports that the drug overdose death rate in the U.S. — the death rate per 100,000 population — has more than tripled since 1990 and has never been higher. The public health agency reports that about three out of four prescription drug overdoses are caused by opioid pain relievers and that the "unprecedented rise in overdose deaths in the U.S. parallels a 300 percent increase since 1999 in the sale of these strong painkillers." Today, opioid pain relievers are involved in more overdose deaths than cocaine and heroin combined.

The situation is one many doctors feel ill-prepared to deal with, and an easy way to avoid the controversy is to simply stop prescribing opioids. This non-prescribing approach can be devastating for patients, said Edward Michna, an anesthesiologist at Brigham and Women's Hospital in Boston and an assistant professor at Harvard Medical School. For example, Michna said he recently heard from a patient who is living with severe rheumatoid arthritis and who had an opioid prescription to treat pain. When her physician recently took a leave of absence, the rest of the medical practice refused to refill her prescription.

"Right now, I have patients who complain that they go to the pharmacy and they feel that people are making judgments against them," said Michna, who also serves on the Board of Directors for the American Pain Society. "I think certainly in the primary care community, which currently prescribes over 70 percent of opioids, there's a growing fear because of the obvious misuse and abuse. Access to care is being restricted, especially in under-served areas. Patients are getting caught in the middle."

Michna told me that the science of pain management has a long way to go, noting that even though pain is the most common reason people seek out a doctor's help, the amount of resources spent on understanding pain and its treatment is quite small. (According to the American Cancer Society, less than 1 percent of the National Institutes of Health budget is spent on palliative care research.) Adding to the issue, Michna said pain management as a specialty is still in its infancy and because there's no "real definition" of what makes for a pain physician, the "practice is all over the place."

"You can say you're boarded in pain management, but other that that it's like the wild, wild West," Michna said.

Michna noted that there are no long-term studies on long-term opioid use to treat chronic pain; he added that such research is sorely needed and will likely have to be funded at the federal level.

"Certainly, opioids are a major part of the treatment of pain, especially acute pain, but the question is whether they are effective long term, and we don't really know in what subpopulations of the chronic pain population they're most appropriate (for long-term use)," he said.

In fact, it's only been in recent years that "we have a general agreement that pain is a disease itself," said Lynn Webster, who's been practicing pain management for 30 years and is president-elect of the American Academy of Pain Medicine. Webster told me that as a result, there's a fragmented approach to the treatment of pain, and physicians don't have one solid set of standards to guide their approach.

Webster cautioned that what's being lost in the overall dialogue on the rise in unintentional opioid poisonings are the equally tragic consequences of not treating chronic pain, noting that as high as half of those living with chronic pain have suicide ideation. He said there's no question that patients are having a more difficult time accessing pain treatment as well as finding a doctor willing to treat their pain.

"There are consequences for not treating pain as there are consequences when we prescribe opioids to somebody at risk for addiction," Webster said. "The problem of prescription drug abuse and the problem of treating pain will require a broad coalition of people — it will require the regulatory community, medical community and legal community to jointly come together to solve this problem. No one group will be able to solve this problem by themselves."

For more on the science of pain management, visit www.ampainsoc.org or www.painmed.org.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for the last decade.

lborkowski Fri, 11/09/2012 - 09:23

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On issue that technology could help image a pill dispenser that is refilled and sealed at the pharmacy. To get a pill you put your thumb on a reader and the pill appears, if the time is right. This makes the selling and misuse more difficult. Of course we do need to continue the idea that if a patient is terminal who cares about addiction.

For example, Michna said he recently heard from a patient who is living with severe rheumatoid arthritis and who had an opioid prescription to treat pain. When her physician recently took a leave of absence, the rest of the medical practice refused to refill her prescription.

That's bloody criminal. If I were that patient, I would be complaining as high up the ladder at Brigham and Women's as possible.

My husband has been turned away from doctors since his dr had her license pulled. He has had good pain relief with methadone for 20 years. Now no one will help him since new drug laws in WAstate went into effect. He needs to find a real dr. before he just decides death is the only solution for his pain. He needs to do physical work. Somebody has to know of a doctor in the lynnwood, edmonds, bothel, everett, seattle area.
We need help before it is too late!

I think that idea for a mini machine, even a new computerized pill bottle top for dispensing daily meds is excellent! I have often wished for one, as chronic pain many times also comes with poor memory, sometimes I will hurt and can't remember if I took my pain pill or not nor when. With a thumb print scanner I would be more at ease, knowing I will not run out early either due to myself or others. Also I have hidden numerous pills while sleepwalking, and have no clue where I put them. Sometimes they are found weeks later, sometimes never found. My family has seen me do this! This solution seems like it would be a simple and effective way to stop diversion and abuse, plus create more jobs in technology and ease not just the chronic pain suffers mind, but dr's, Pharmacists, DEA, everyone concerned with it now! A very uncomplicated solution.

I suffer with fibromyalgia and on May 27, my doctor told me he had to wean me off of my prescription pain killers because of the reclassifying laws now enforce. I don't know how the FDA can do this to patients that suffer chronic pain. I'm thought of moving to another state but from what I'm reading its nation wide. Anyone know a doctor that will take new patients in the Lafayette, Baton Rouge, New Orleans area?

I've been through everything this article discribes and more. I've dealt w/doctor problems, Rx problems, and almost more gauling Pharmacist problems (some how these chemist seem to think that PhD = MD; thes ass monkeys need to be shut down; or medical problems are complex enough. I too was at the dawn of a working combination when a pharmacist got in the middle and the next thing I know my dr. ( a visiting fellow from china dropped me like a hot rock). The Pain management dept just let my doctor "fire" me. Never even new this was possible. I finally found a new primary care (the doc of the afore mentioned era dumped me amidst th rx confusion sighting he would not risk his license for me or anyone..... even though that primary care had known me over 20 years and always claimed he would have my back. That is not someone covering your ass in battle. Make no mistake, the new fed policy has turned this into an us vs them scenerio. The hardest part is defining who is really with us, "the patient."

I'm at the end of the rope and the end of my money and my government will not assist me in any way (something I never wanted to ask for in the 1st place.) I'm 45 and the only reason I push through the hellish pain of life is I don't want my kids discovering my body after I finally end the pain. So here I am caught between bureaucracy and hell.
This is the world I fought through disability for, earned my degree for. I had known I would never have married; I drug my family under with me. The vitriol I feel for this new era is immeasurable.

When do we come first again?

I had been seeing my Pain management Doc for 13 years. Last appointment I had at end of May they gave me a drug test. It came back Positive for THC and Adderall. I personally didn't think it was a big deal since THC is legal to use for medical use in over half of the states in US. Second this Doctor had previously prescribed me the Adderall that I had used. The problem per my Doc office was that the adderall hadn't been prescibed in previous 12 months. He had prescibed it for years and it was my choice to stop use. I had quite a few left over so when I felt I needed to use adderall again I used the pills I had left over instead of getting a new script filled that I didn't need. I swear in the 13 yrs that he had treated me, no one ever said you can be kicked out of his care for doing this. My doc would have put me back on it anytime if I had asked, but I didn't know. So after 1st drug test in 13 years they dropped me. Obviously it was him doing CYA. I'm just venting and letting others know of what can happen. I wish the medical system put as much work into their patients as they do covering themselves from Gov. Agencies.
Best of Luck to those of us suffering from Chronic Pain

My family dr. informed me recently that with the new drug laws he would no longer be able to write prescriptions for pain meds. and I would have to go to an authorized pain clinic. It cost me $65.00 a month to see the dr. and get a monthly prescription. Now I go to a pain clinic where I'm treated like a criminal, don't get proper meds., and it costs $200.00 per visit (cash) . I ask you, how are the new drug laws and the D.E.A. helping me with a crippling disease?

stopping compassionate physicians appropriately alleviating patient suffering is apparently an issue the D.E.A.... I dispute the number of suicides we will be seeing.

It is miserable to be in chronic pain, the way pharmacies view you like a junkie... We can invade countries half way across the world - but use Government resources to regulate a problem like this? No way. I'm 50 and cant stand due to an arthritic spine. Shake my head. I will most likely euthanize myself in the next few years, without pain meds, I am a burden to a family I love more than life itself.

Prayers of pain free days to all who suffer. God bless.

I know how you feel I live with chronic pain every miserable second of my life an when you try to get your script filled the pharmacist acts like he's the decision maker something needs to be done life is to short to deal with this

I have had chronic pain for several years and tried not to go down the road of narcotics use since as a nurse I was very familiar with how these patients are often unfairly treated by the medical community and uneducated family and friends. My pain has kept becoming more severe until I was praying every night that I would not wake up the next day frequently thought about suicide. I was able to find a compassionate doctor to treat me but the way I have been treated by other members of the medical community including other doctors caring for me because I am now on these medicines has been worse than anything I imagined. I have also recently learned from an MRI just prior to starting strong meds is that I have extensive loss of grey cells in my brain. Why is that important? Look up grey matter loss and chronic pain on google scholar. Lack of adequate pain control has been documented now for several years to cause damage to the brain including extensive loss of memory, damaged ability to learn new information and abnormal connections in the parts of the brain controlling emotion and affect. In other words, among other things your depression is likely physically caused in the brain by the damage. I wonder what would happen if multiple patients started filing malpractice suits against doctors for inadequately treating their pain resulting in brain damage? I'm not a fan of malpractice lawsuits but I bet it would change things quickly. In the meantime perhaps we can all write our congressman to make them aware of these problems and the burden that onerous laws are having on adequate treatment..

Recently diagnosed with RA..been suffering with pain on and off for two years...I am being passed back and forth to doctors..nobody wants to deal with my pain issues...I have taken everything recommended to no avail..I believe I am a responsible patient/person having had a business for 23 years, raised four children by myself...I am not granted pain relief for a bout of RA on the hip that's affecting my ability to function..once again passed to another doctor that I can't see for a month and a half because they are overwhelmed...I really want to crawl up and die sometimes....

While the concern is always raised about those who are overdosing with self inflicted poisoning, little is said about the thousands of pain victims who have been iatrogenically poisoned in the rush to provide an "alternative" to opioids: I speak of the thousands who have been inoculated with contaminated medications, most often steroids used in performing epidural steroid and joint injections for pain. Indeed some of the doctors who do injections have publiclty portrayed themselves as providing the "only alternative" to opioids for chronic pain! The ongoing saga of horror for those indirect victims of the war on drugs remains largely hidden from public discussion. Their story needs to be told as part of this discussion. They are the ones poisoned by the medical profession in its rush to use an "alternative to opioids," its rush to profit (huge dollars are paid for these procedures), and the doctors rush to escape the wrath of DEA and medical boards (many doctors have been driven from business for prescribing opioids, but not one for wrongfully or fatally injecting a patient.)

I have chronic pain due to Lyme disease. Shortly after contracting Lyme, I tore my quadriceps muscle simply cling stairs, and have developed arthritis in most of my joints. Docs don't believe in chronic Lyme anymore than chronic pain. Thankfully my primary care doc has no problem giving me all the pain meds I need until I can get into the VA pain clinic( I'm also being medically retired because of all this BS) but she is away on maternity leave and her sub just told me yesterday he was "uncomfortable" prescribing "such a high dose" of oxy and Vicodin, so now I don't know what I'll do until my regular doc comes back. At least I don't have problems at the pharmacist. He knows I'm military and at least according to the press, were all hopped up on pain meds and antipsychotics so he doesn't hassle me. I'm just afraid of what's going to happen in the future. My pain situation is almost guaranteed to get worse. Until I can convince som doc that I need long term antibiotics, I'm only going to get worse. I'm stuck in two medical BS issues.
I'm sick of it. I just want to feel better!

Early surgically induced menopause..at 25 years old, resulting in advanced osteoporosis and diffuse spinal and joint pain in early 40s..Fibromyalgia, though exhausting doesn't compare to being diagnosed w/erythromalagia, a rare vascular arterial disease, affecting my feet..and beginning to attack my hands. Withholding any medication that helps me have any degree of quality of life seems to go against the "first do no harm" slogan of that so called "oath".

Much research is still needed as the medical community endeavors to balance the fine line between effectively managing a patient's chronic pain and protecting them from the danger of opioid addiction. Recognizing that each patient requires an individual treatment plan is key.

This article, written nearly four years ago and if anything, the problem has only worsened.
Here's the problem, the federal govt decided several years ago, there is no such thing as "chronic pain," and further, only terminal patients may have pain medications. On Long Island, they began in Suffolk County, marching gustapo style, into pharmacies, demanding computer print outs of all physicians prescribing pain medications. They then visited these doctors threatening them with everything from loss of licenses to prison time. Wah Lah, eventually there are NO pain management practices remaining.
And now, several years later, politicians are trying to give good rationale WHY Heroin use in Suffolk County has grown to epidemic proportions. I have witness ELDERLY people, on walkers for God's sake, in the streets looking to "score" anything they can to relieve their pain.
There are many, MANY disease entities and post traumatic events, which cause horrific, debilitating, intractable pain for which there simply are NO alternative treatments.
Yes, the DEA has been very successful putting nearly every pain management practice out of business in this county. The "unintended consequences"? Heroin use has become epidemic AND, the numbers of adult suicides in this country has increased exponentially.
Great job!