The second advantage to the system of having the patient pay up front and then get reimbursed is that people by nature will think twice about going to the doctor if they know that they have to pay for the visit themselves – even if they know that most of the money will be reimbursed.  It’s sort of an instant-gratification-in-reverse idea, and helps to reduce over-utilization of health care.

For me, the most interesting part of the article had to do with the fact that the office visit in question was priced at $33.80.  Apparently, that was the entire cost of the visit, 70% of which would later be reimbursed by health insurance.  When was the last time you saw a total office visit charge that was less than $35?  My family has an HSA-qualified policy, so we pay for our own medical expenses until if and when we meet our deductible.  With Jay’s knee surgeries over the last couple years, we’ve had lots of office visits, both with the surgeons for consultations and follow ups, and also with the physical therapists.  The billed amounts have ranged from $63 to $150 per visit, with most of the visits in the $110 range.  Our health insurance policy pays for our son’s well child visits (all policies in Colorado have to cover well child visits before the deductible), but I’ve never seen an office visit charge of less than $100 on the EOBs we get after his check ups.

The cost of an office visit in France is significantly less than it would be here.  Figuring out why, and implementing some of the same strategies here, ought to be part of our health care reform efforts.  All of the effort we’re putting into health care reform seems a bit silly if we continue to pay two or three times as much for basic services as people in other developed countries.

I found Jason’s article in the Cavalcade of Risk, which he hosted this week at The Healthcare Economist.

How To Cope With Pain brings us a truly amazing video.  It’s a reminder to be thankful for all that we have, and for the things in life (like this video) that inspire us.  It’s well worth the five minutes it takes to watch it.

Amy Tenderich of Diabetes Mine shares a “would you rather…?” moment from her 9-year old daughter.  It’s a poignant reminder, seen through the eyes of a child, that all of the parts of our lives – even the bad parts – combine to make us who we are.

Kerri Sparling, of Six Until Me, has a very moving story about her pregnancy and how the online diabetes community has helped her along the way.  Kerri has put an immense amount of effort into getting her body ready for a baby, and it’s wonderful to know that things are going well for her and her husband as they expand their family.

The Hippocratic Oaf gives us some glimpses of life as a medical student, detailing interactions with patients and highlighting incidents that remind him to be grateful for his own life and health.

The rest of the articles cover a wide range of subjects, from the perspectives of patients, doctors, nurses, and policy makers.  Read on…

Dr. Val Jones, writing at Get Better Health, has written a very insightful article about how medical malpractice insurance premiums make it nearly impossible for primary care doctors to practice part time.  The premiums aren’t affordable unless the doctor is a specialist, or a full-time PCP.  She points out that our PCP shortage could be remedied by adding more part-time docs.  But in order to do that, malpractice premiums have to become more reasonable.  And in order for that to happen, we need tort reform.  Hopefully the lawmakers are listening.  Maybe if they’re trying to find a PCP in Washington DC they’ll notice the problem Dr. Val describes.

Health Business Blog’s David Williams brings us an interview he did with Dr. Henry Anaya of the VA, a research scientist working with HIV.  Dr. Anaya describes new rules at the VA that require less paperwork in order to give consent for an HIV test, and the benefits of a rapid result HIV test that is done with a swab instead of a needle, with results in 20 minutes.

Dr Rich, writing at The Covert Rationing Blog, gives us a very colorful depiction of the migration of cardiologists to other specialties.  It conjures up images of marauding Huns and defeated Roman Empires.  But in addition to the Western Civilization lesson, it brings up several good points about the territorial nature of specialists, the Medicare reimbursement cuts for certain cardiology procedures, and the options that are available for doctors seeking to replace lost income once the Medicare cuts take effect.

Lauren, from Novel Patient, describes her recent visit to a Sjogren’s specialist.  Instead of getting the answers she was looking for, she is now on a quest for a new diagnosis, as the specialist thinks there is an underlying condition.  While she’s in the midst of such a frustrating situation, Lauren manages to keep a positive outlook.  We wish you well Lauren, and hopefully the visit to Johns Hopkins will provide some answers.

Barb Olson, of Florence Dot Com, writes a very interesting article about a survey of 1000 non-profit hospital board chairs regarding the quality of care that their hospitals delivered.  Only 1% rated the quality of care at their hospitals as worse or much worse than a typical hospital.  But as Nurse Olson points out, it’s typical for people to overestimate their own positive attributes when self-evaluating (the Lake Wobegon Effect).  And in addition, the hospital board chairs generally weren’t well trained on quality measures, so it’s hard to expect them to have a clear understanding of what constitutes quality of care.  Good food for thought for people who are responsible for improving quality of care standards at our nation’s hospitals.

Clinical Cases and Images Blog has an article about a study showing that for married couples, having children has a positive impact on life satisfaction – and that the level of satisfaction increases with the number of children.  I know that our son has added a great deal of happiness to our lives, but I don’t think I’ll test this theory by having a dozen children!

Laika Spoetnik of Laika’s MedLibLog is making it easy for people to combine social networking with an interest in science and medicine.  She’s created Twitter lists pertaining to biomedical journals, medical journals, and scientific journals – making it easy for a person interested in one or all of those subjects to find up-to-the minute articles and commentary.

Dr. Jolie Bookspan, the Fitness Fixer, brings us a detailed post about how to look upward without placing strain on our necks.  I like the part about how our necks are not Pez dispensers – good visual image.  The article is a good reminder that we need to use proper form in all of our daily activities, not just while we’re at the gym.

Nancy Brown, PhD, of Teen Health 411, brings us some insight into what teens want when it comes to their relationships with their parents.  If we think back to our own teen years, I imagine we can all relate.

InsideSurgery has written about Dr. Nidal Hasan, the Fort Hood shooter.  The article delves into the responsibility that doctors have for their patients, and the moral obligation they have to seek help for themselves if they feel that they are being overwhelmed by their responsibilities.  In addition, the article address the fact that physicians who get their training paid for by the military have to expect that during their required years of service to the military, there may be a war, and they may be deployed.  Especially during times of peace, this is food for thought for anyone who would consider having the military pay for their training in return for military service.

Healthline’s Dr. Paul Auerback writes about how physicians who receive training in high-tech environments and then go on to work in settings with less technology often feel uncomfortable about their ability to provide quality care to their patients.  Most teaching hospitals are more technologically advanced then the average small town hospital or clinic where the doctor might end up working, so it might be advisable for the teaching hospitals to incorporate some low-tech training for their students, in order to better prepare them for situations where they might need to improvise in order to help a patient.

InsureBlog’s Hank Stern brings us a very interesting article about a British hospital that will no longer admit expectant mothers with a BMI of more than 34 (210 pounds for a 5′6″ woman).  The hospital’s labor and delivery unit is run by midwives, and not high-tech.  Because they have patients who want to delivery in a low-tech setting (which I can very much understand), they have no plans to make the facility more capable of handling complicated births.  In addition, one has to assume that there would be significant expense involved in making the hospital equipped to handle birth complications.  The ban on very obese mothers (the lower edge of obesity is defined as a BMI of 30) has to do with the higher risk of delivery complications associated with obesity.  I can understand the hospital’s position, but it seems that it would make more sense to go on a case-by-case basis, evaluating the mother’s health during her pregnancy to see if complications arise (for thin mothers, as well as obese ones).  If they do, it makes sense to have them deliver at a hospital that is better equipped to handle complicated deliveries.  It seems that this might serve their purpose better than a blanket ban on all mothers with a BMI over 34.

Dr. Catherine Busch of Child Psych explains the impacts of the mental health parity law that was passed last year.  The law takes effect on January 1, 2010, and will apply to group health insurance policies covering more than 50 employees.  Individual and small group plans are not required to comply with the law, and the law does not require policies – even for large groups – to offer mental health services.  If they do offer mental health services, the benefits have to be equal to the coverage offered for any other medical condition, but we might start to see policies discontinuing their mental health benefits all together under the new law.  Time will tell.

Eve Harris, writing at A Healthy Piece Of My Mind, gives us a clip of comedians Larry David and George Lopez discussing the results of an ancestry DNA test.  It’s lighthearted, but does make one wonder about the accuracy of direct-to-consumer DNA testing that claims to be able to scientifically determine our ancestry.

HealthBlawg’s David Harlow gives us an intro to what he calls Son of HIPAA – the new federal regulations that went into effect in September regarding protected health information and how data breaches are to be handled and reported.  As medical data is increasingly stored and transmitted electronically, these rules are both necessary and cumbersome, depending on your perspective.  David’s article is a good primer for providers and patients alike.

Allergy Notes explains that IL-33 is a newly-discovered marker of severe asthma.  In a study of people with mild, moderate, and severe asthma, along with non-asthmatic control subjects, those with asthma showed higher levels of IL-33 than those without, and the difference was especially pronounced in cases of severe asthma.

Elyse Nielsen, writing at AntiClue, details the information technology component of opening a new hospital.  One of the aspects that stood out for me was that we should work to eliminate multiple systems that serve the same purpose.  IT is the way of the future in medicine, and much has been said about the ability of technologically advanced systems to save health care dollars.  But this will be especially true if we make sure that our IT systems are as efficient as possible, with no redundancy.

Ryan DuBosar, writing at ACP Hospitalist, tells us about the results of a study that indicates that men with sleep apnea who are treated with nasal positive airway pressure (NPAP) improve their golf handicaps compared with control subjects.  Not surprising, since a better night’s sleep is probably linked to improved performance in nearly every activity.  But promises of a better golf game might make people more likely to be compliant with their treatment.

Laurie Edwards, writing at A Chronic Dose, reminds us all that unsolicited advice is rarely appreciated.  The H1N1 vaccine (along with the seasonal flu shot and pretty much any other vaccine you can think of) is a controversial topic, and it gets people fired up.  But each of us need to make our own decisions, for ourselves and our children, regarding whether to get the shot.  Our health care providers can be expected to weigh in with advice – that’s their job.  But no matter how strongly any of us feel one way or another about the vaccine, it’s not right to give unsolicited advice to other people, especially when we know nothing about their medical history.

Dr. Charles, of The Examining Room, has a very thorough article about Desiree Jennings, the Redskins cheerleader who was supposedly stricken with dystonia following a seasonal flu vaccine in August.  I remember seeing the clip on the news of Desiree, but hadn’t followed the story since then.  Dr. Charles’ article uncovers quite a few details that are worth reading.

ACP Internist’s Ryan DuBosar explains how easy it was for him to get the H1N1 vaccine.   He was able to get it at the county clinic without even standing in line – even though his baby’s pediatrician and his family doctor didn’t have the vaccine available at all.  It does seem to be pretty random in terms of where the vaccine is available and to whom.  In our own family, we have childless adults who have been able to walk right into their doctor’s office and get the shot, along with families with small children who were told they had to continue waiting.

Thanks to everyone who submitted articles for this edition of Grand Rounds.  They were a pleasure to read, and we’re honored to be your hosts this week.  Grand Rounds next week will be hosted by How to Cope with Pain.

Flickr Photo Credits:

• Thanksgiving dinner – CarbonNYC
  
• Leaf – ZedZap
  
• Thanksgiving drive – katmere
  
• Tree – OakleyOriginals
  
• Thanksgiving Turkey- xybermatthew

When Jay hurt his knee a couple years ago, an MRI was done prior to surgery.  We have an HSA qualified health insurance policy, and at the time our deductible was $3000.  So we paid for the MRI ourselves, and it amounted to more than a third of the deductible.  And that was after Humana reduced the bill to the network negotiated amount.  MRIs have helped to make medicine a much more exact science, but they are not cheap.

It seems that any system that pays physicians – directly or indirectly – to order additional testing will end up with excessive testing, adding to the overall cost of health care.  Even doctors with the best of intentions are likely to be swayed by the knowledge that they can boost their paychecks by adding a few MRIs here and there.

I believe that the number of tests a doctors orders should not impact his or her income.  And it seems that adding more medical imaging facilities in primary care offices will only increase our already burgeoning health care costs.

I found Stacey’s articles in Grand Rounds, hosted in trick-or-treat style over at Code Blog.

Hospitals are in business to make money, just like most of the other players in the health care industry.  And hospitals have boards of directors.  We know this, but do we know what they do, or who they are?  Dr. Roy Poses of Health Care Renewal has written an article about hospital boards that might make your blood pressure rise a notch or two.  The board he wrote about is comprised of 42 members, only 13 of whom are physicians.  Most of them have employment histories with the financial industry, and quite a few have conflicts of interest.  Dr. Poses floats the idea that board members (who are responsible for choosing new members) might be more interested in picking members who fit in with their exclusive social group than with finding members who are truly interested in keeping costs down and providing superior patient services.

Here in Colorado, Pete Coors – of Molson Coors Brewing Company fame – is on the board of the University of Colorado Hospital.  Other board members include the the vice-chairman of the Colorado Rockies baseball team, the wife of the mayor of Vail, and the owner of an upscale clothing store.  And that’s just one hospital.

In order to make health insurance premiums (the direct cost that consumers tend to notice) more affordable, we have to make health care more affordable.  Perhaps filling our hospital board of director rosters with a Who’s Who of the richest people in the city isn’t the best way to go about that mission.

I found Dr. Poses’ article in the Health Wonk Review, hosted last week by Hank Stern of InsureBlog.  Several new bloggers are included whose work I hadn’t read previously, so be sure to head over and take a look.

I was chatting with a good friend over the weekend about this issue.  She works in a women’s health clinic in Colorado.  The vast majority of her patients are uninsured, and the non-profit clinic is mostly funded with government grants.  My friend and her co-workers are aware that not all of their patients are in the US legally – the clinic doesn’t ask about immigration status.  Most of their patients are employed, working at low-wage jobs that don’t provide any sort of health insurance benefits.  Many of them are unable to pay the $5 fee that the clinic charges for most of its tests.  In that case, the fee is waived.  Some of the patients have no car, and get rides from neighbors to get to the clinic, sometimes coming from 40 miles away for treatment.

My friend’s job is to provide medical care to everyone who comes through her doors, and that’s what she does.   She sees them all as people, all deserving of care.  She had watched Obama’s speech, and the illegal immigrant issue seemed particularly pointless to her.  She mentioned that although there might not be provisions in the upcoming legislation to provide health insurance to illegal immigrants, there are already clinics like hers that provide health care to everyone – regardless of their legal status or lack of health insurance.

I can definitely understand the frustration that people like Joe Wilson feel about this issue.  We’re having a tough enough time providing health care for people who are here legally – adding illegal immigrants to the picture doesn’t make it any easier.  But how do you tell a person who is desperately ill that they can’t receive treatment because they aren’t in the right country (or because they don’t have health insurance, for that matter)?  I have to imagine that it would be tough for a dedicated health professional to turn away truly sick patients because they aren’t supposed to be here in the first place.  What if turning them away amounts to a death sentence?  Is that a fair price to pay for being in the country illegally?  Definitely food for thought…

Tom Emswiler’s article highlights the obvious problem – the fact that the number of scans jumped by such an astounding amount following the clinic’s acquisition of a scanner – and also details the physical risk posed to patients when unnecessary scans are ordered.  When my father was hospitalized a few years ago with serious peritonitis, several CT scans were done.  My family – and his doctors – agonized about the radiation exposure from the scans, but he was in a life or death situation at the time, and the risk of the scans seemed worth it.  The idea that any doctor would order more scans with personal financial gain in mind is unfathomable to me.

I like Tom’s idea for reimbursing physicians a set amount, regardless of what type of imaging is ordered.  Although the flip side there is that an unscrupulous doctor might choose to skimp on care in order to pocket the extra money.  I suppose there will always be doctors who put their own financial interests ahead of their patients’ needs – but I like to believe that they are a small minority.

Overall, it makes sense to pay doctors based on patient outcomes and evidence based medicine, rather than paying them for each specific procedure.  And after reading the article about the clinic that bought its own CT scanner, I think we need a clear delineation between the people who order expensive testing for patients, and the people who earn a living from performing such testing.  If the doctor owns the testing equipment, and also orders the tests, there isn’t a good way to eliminate conflicts of interest.  In cases like this, we need health insurance companies that deny claims.  But it’s hard to explain to patients that the health insurer is actually the good cop in that circumstance, working to keep health care costs in check.  The patients have a relationship with the doctor – not with the health insurance company – and when the doctor says an expensive test is needed, the patients tend to trust the doctor.  What they might not know is how much more money the doctor stands to earn if the test is completed.

I found Tom’s article in the Health Wonk Review, hosted last week by Jaan Sidorov at the Disease Management Care Blog.

In looking back over previous blog posts I’ve written, I’m pleased to see that I tended to use the terms “primary care physician” and “primary care doctors” rather than using the word provider.  I guess I was more PC than I knew.  What I tend to think of when I hear about any sort of primary care is “shortage”.  One way or another, we need to attract more medical students to primary care – by whatever name they prefer – instead of continually adding to the ranks of highly-paid specialists.

I found Dr. Brayer’s article in last week’s Tour de France-themed Grand Rounds, hosted at Captain Atopic.

I hope that lady doesn’t have to apply for individual health insurance anytime in the next few years.  She’s not in Colorado, but underwriters in most states will have trouble getting past three psychiatric medications being used concurrently, especially when one of them is used to treat bi-polar disorder.  There is no doubt in my mind that this lady needed some sort of help – she was upset enough to want to go to the doctor in the first place.  But it’s sad that mood-altering medications have become so ubiquitous (and so well-advertised) in our culture that people think of going to get drugs as the first step on the road to feeling better.

Pharmaceutical costs have played a major role in driving up health care costs over the years.  Many of the health insurance companies we work with in Colorado now require a separate pharmacy deductible to be met before copays kick in for drugs.  And then I read articles that describe how psychiatric drugs have become common-place in our society.  I think there’s a connection here somewhere…

Some ailments come out of the blue – like my father’s rare autoimmune disease that caused kidney failure and makes him highly dependent on medical care and dialysis (and health insurance)  to stay alive.  I’m no stranger to the acute need for health care that some people face.  But even a situation like my father’s involves a huge amount of patient responsibility.  True, he can’t heal his kidneys no matter what he does.  But he and my mother are diligent about his diet (the renal diet is extremely restrictive, and they follow it to the letter), his meds (he has to take a phosphate-binder at every meal since dialysis doesn’t remove phosphate), and his dialysis (every night he spends three hours hooked to the dialysis machine).  He has to limit his fluid intake, and avoid foods that are high in potassium and phosphate.  Life in general is a lot tougher for him than it was before all of this.  But the alternative isn’t very appealing, so he works to keep himself as healthy as possible.

Over the years, my parents have met lots of other dialysis patients.  Some are smokers.  Some drink five times as much liquid as they are supposed to, and rely on dialysis to remove the extra fluid.  Some aren’t compliant with their meds at all, and their labs are all over the board.  Some have other conditions that exacerbate their kidney failure, and aren’t compliant with their care for either ailment.

That’s not to say that the entire responsibility should be the patient’s.  People with serious medical conditions have to place a certain amount of trust in their doctors, and over the years my parents have come across numerous medical errors pertaining to my father’s care.  Doctors make mistakes, and some doctors are just plain bad (isn’t that the case in any profession?).  For the most part, the doctors my dad works with have provided good care.  But they aren’t – and can’t be – babysitters.  They can’t be there to say that perhaps it would be better to not have that cigarette or bottle of soda.  They can’t force their patients to take meds or avoid certain foods.  My parents make the trip to the University of Colorado Hospital once a month to see the doctor.  He gives my dad the tools he needs to be as healthy as possible, but it’s up to my dad to put those tools to use.

The concern I have with physician reimbursement based on patient outcome centers around patients like my dad. Nothing he does is going to bring back his kidneys.  He’s dependent on medical care indefinitely, despite all of his efforts to be as healthy as possible, and no matter what his doctor does.  Would an outcome-based payment system mean that doctors who treat chronically ill patients wouldn’t be reimbursed as well as doctors who treat people who can expect to fully recover from whatever illness they have?  Would doctors be less likely to take on chronically ill patients?  Yes, we should all eat kale, exercise every day, and take responsibility for our own health.  But what if we get sick anyway?  Doctors and patients are both responsible for patient outcomes, and any reimbursement reform should focus on both of those aspects.

I found the article about patient/doctor responsibility in Grand Rounds, hosted by Doc Gurley.  Check it out – it will remind you of childhood games of clue…

For the last two months of her pregnancy, my friend had weekly ultrasounds, and did more than her fair share of worrying.  When the baby was born, he was immediately taken from his parents and transferred to the NICU, where he was subjected to a range of tests.  He was not allowed to nurse for the first 24 hours after he was born.

Turns out that he’s perfectly healthy.  There are no issues with his intestines, and he was discharged from the hospital without surgery or the two week NICU stay that my friend had been expecting.

I was reminded of my friend’s story when I read this article by Marya at Healthcare etc.  Was my friend’s doctor practicing defensive medicine?  Probably.  Was she just trained to see problems, and thus spotted one that turned out to be nothing?  Whatever happened, it absolutely had an impact on the healthcare costs associated with my friend’s pregnancy and birth.  Eight extra ultrasounds and 24 hours of testing and monitoring in the NICU are not cheap.  She hasn’t seen the EOBs from her health insurance company yet, but I’m sure that the cost ended up being significantly more than it would be been without the looming fear of problems that hung over the last two months of the pregnancy. Luckily my friend has health insurance, so she won’t end up paying directly for the extra care.  But all of us pay for stuff like this in the form of higher premiums.

I found Marya’s article in last week’s technology-themed Grand Rounds, hosted at Medicine and Technology.