Although we could see it, we couldn’t get it out.  We tried briefly, but were afraid we would push it further in or that it would somehow wiggle it’s way into his sinuses, so we decided that the wise choice would be a trip to urgent care.

After our son’s finger incident last winter, he’s understandably wary of doctors, and as soon as we got out of the car at the urgent care clinic, he started saying “no doctor, no doctor”.  Hopefully he’ll remember that next time he thinks about sticking something in his nose.

We went to an urgent care that is part of Poudre Valley Health Systems on Harmony and Timberline in Fort Collins.  The receptionist greeted us, took our insurance card and id, and started filling out paperwork for us.  She asked us if we had attempted to remove the stone ourselves, and we told her what we had tried.  Then she mentioned that if we wanted to possibly save $140, there was one more thing we could try:  Hold his other nostril shut and blow into his mouth.

So Jay did just that.  And on the third blow, the rock came shooting out of our son’s nose.  We were thrilled – no need to sit in the waiting room at the urgent care facility, no need to subject our son to whatever instruments doctors use to extract stuff from toddler noses, and no need to pay for an urgent care visit (we have an HSA qualified policy with a $5000 deductible, so we’d have been paying for the whole thing).

We were in and out of the clinic in under five minutes, and it didn’t cost us anything.

A lot has been said about over-utilization of health care lately, and the need to reduce both cost and utilization in order to make our health care system sustainable.  But I wonder how many urgent care clinic front desk people would be willing to give out free advice like that, and how many would have just taken our insurance info and sent us in to see the doctor?

There are many reasons for the dramatic increase in c-sections over the last couple decades.  Too much medical intervention, a legal system that pushes doctors towards c-sections at the first sign of a hiccup in the birth, parental requests, ACOG’s recommendation against VBACs, etc.  Some have also pointed out that doctors make a lot more money for doing a c-section, and can do one a lot faster than it takes to wait for a laboring woman to give birth on her own.

It seems like that last one should be relatively easy to fix, if reducing the c-section rate is indeed a priority.  To make the math easy, let’s say that a surgical birth costs $20,000 and a vaginal birth costs $10,000 (these are completely random numbers.  The real numbers vary dramatically from one state to another, and from one health insurance network to another).  If we say that the goal should be no more than 15% c-sections, we can say that for 100 births there should be 85 vaginal deliveries (amounting to $850,000) and 15 c-sections (amounting to $300,000).  Add those two amounts ($1,150,000) and divide by 100 to get the average price of a delivery if we were to achieve a c-section rate of 15%:  $11,500.  In reality, the math would be much more complex than I’ve made it here, but the basics would remain the same.

Now that we have the average cost of delivery if no more than 15% of deliveries were surgical, that could become the standard payment for all births, regardless of whether a c-section were performed or not.  There would be no financial incentive for doctors to opt for c-sections, as they would no longer receive higher compensation for doing so.  The tough medical malpractice environment that OBs practice in would likely provide more than enough motivation for them to continue to do c-sections when there was a true medical emergency, despite the fact that they would know there would be no additional compensation for the birth.

The rising c-section rate is driven by a variety of factors, and obviously the problem needs to be confronted on many levels.  But it seems counter-intuitive to expect doctors to reduce their c-section rates when we’re paying them more to perform them.

It makes sense that as more systems become automated and computerized, claims get paid faster and fewer billing errors will be made, resulting in fewer denied claims.  But we still have a long way to go.  I mentioned yesterday that my mother broker her leg a few weeks ago.  In the emergency room, my sister made sure that my mother’s health insurance card was placed on file within an hour of my mother arriving at the hospital.  But in the weeks that have followed my mother has received EOBs from her own health insurance company as well as a company she had never heard of, and more from her previous health insurance carrier.  Apparently the clinic where she had a mammogram a few years ago is associated with the hospital where she was treated for the broken leg, and someone managed to attach her current claim to the health insurance she had at the time of the mammogram.  As for the health insurance carrier she had never heard of, a person in billing told her that it looked like someone just typed in the wrong code in the billing office and somehow the claims got sent to a random health insurance carrier.

In addition to EOBs coming from multiple carriers, my mother got ten EOBs in one day last week, half of which were from her current health insurance carrier letting her know that they had denied the claims for preventive lab work during her recent hospital stay (she has an HSA qualified policy with only basic preventive care coverage).  Turns out that someone in the hospital had accidentally coded the lab work that was being done as preventive care, and thus all the claims got denied and had to be resubmitted with the correct code.

The reason I’m mentioning this story is that it’s important to note that claim denial and delayed payment is sometimes due to simple billing errors (obviously in the case of my mother’s surgery and hospitalization, her lab work should not have been coded as preventive, and only her current health insurance carrier should have been billed).  As we continue to automate and standardize our health care reimbursement system, we should see fewer errors like this.

In 2004, my father was hospitalized for four months with serious peritonitis.  He had several abdominal surgeries and several abdominal CT scans.  At the time, my family questioned the radiation exposure from the scans, but the doctors told us that they didn’t have a choice – his situation was life or death at the time, and when weighed against an increased cancer risk 20 years down the road, the choice was obvious.  Luckily, there has been no repeat peritonitis, and my father is still cancer-free.

A few weeks ago, my mother was working on the roof of their house and fell off.  All she broke was her femur (a bad break, but not as bad as a neck or a skull, so we’re counting our blessings), but the ER docs needed to be sure nothing else was wrong.  The paramedics brought her into the hospital strapped to a backboard, and before they would take her off the backboard, they did a CT scan of her neck along with several x-rays of her broken leg.  We aren’t sure why the neck imaging was done with a CT scanner rather than an x-ray machine, but that was the option the ER docs chose.

I’m sure most families have similar stories.  CT scans are used so often that I think a lot of patients just expect to get one if they go to the ER or to the hospital with pain or a potential internal injury.  That’s not to say that they are bad – in a lot of cases, including my dad’s, they can help doctors save a patient’s life.  But we need to remember that they are absolutely not risk-free.

I like the idea of a radiation medical record that tracks a patient’s total exposure to imaging radiation over a lifetime.  If it’s easy for a doctor to glance at a computer screen and see that a patient has already had a significant exposure to radiation, the doctor might look for other options for the current testing needs.  As with many of the improvements that need to be made in our patient care system, tracking radiation exposure requires a more uniform, completely electronic medical records system that would allow data to be easily shared between one provider and another.

Advanced medical imaging is not cheap, and the fact that Americans have more of it done than any other country is likely a factor in our health care being so much more expensive than it is in other developed countries.  The realization that a couple decades from now, 2% of all cancers in the US might be due to CT scans we’re doing now ought to make both doctors and patients think twice before using them.

Health insurance companies could have an impact on the problem too, by increasing the review process needed before advanced imaging is approved.  If an ultrasound could be used instead of an x-ray, or an x-ray instead of a CT scan, we could be saving money as well as preventing future cancers.

Medical school in the US isn’t subsidized for the most part, and most of our new doctors are saddled with significant medical school loans.  Thus it makes sense that our doctors earn a bit more than they would in other countries.  But there is definitely too much of a gap between what a cardiologist earns and what a primary care doctor earns.

If we expect to get a handle on the shortage of primary care docs, we have to find a way to narrow that gap.   The PCP shortage is likely to become even more of a problem once the health care reform provisions kick in and millions of currently uninsured Americans become insured and presumably start to seek out more health care.  Unless we can make primary care more attractive to people in medical school, all of those newly insured people are going to end up seeing expensive specialists instead of PCPs, and the burden of paying for health care will only become harder to bear.

I am sure that the NHS has changed over the years, but my parents described how it worked in the 70s.  Basically, every resident had a doctor.  If you moved from one part of the country to another, one of your first errands would be to pick a new doctor.  You could choose whomever you wanted, as long as that doctor was currently accepting new patients (all of the doctors had a cap on the number of patients they could have at one time).  Then the new doctor would alert the NHS that John Doe was now his patient, at which point John’s records would be sent from his previous doctor’s office to the new one.  And the NHS would begin paying the new doctor to care for John Doe, and stop paying the old doctor.

Doctors in the system would get a specific amount of money for each patient on their roster, regardless of whether they ever saw the patient or not.  One patient might be very healthy and go to the doctor every few years for a checkup, but the doctor would receive the same amount of money for treating that patient as for treating another who needed constant care for a chronic illness.

I have heard lots of ideas on this subject, and have seen doctors who are offering concierge-style care (including some here in Colorado) where patients pay a set dollar amount each year to cover whatever care they might need.  Obviously our reimbursement system is far more complicated that a single-payer setup like the NHS; we have hundreds of different health insurance companies reimbursing doctors and hospitals for care.  But what if our doctors were reimbursed for our care regardless of whether we needed to see them or not?  I have a doctor I see for well-woman exams.  I consider her to be “my doctor”.  But she only gets paid for being my doctor if and when I make an appointment to see her.

Would paying doctors for the total number of patients they have provide an incentive for better care, and particularly for better prevention of chronic illnesses?  Not to discount the altruistic motivation that doctors have, but our current system rewards them for having sick patients.  A patient with diabetes or heart disease is a lot more valuable to a doctor than a healthy patient, because our doctors only get paid when we need to see them.  If doctors were paid for having healthy patients, would they be more inclined to focus on things like weight management, diet, exercise, stress-reduction, etc…. all the things that we know can lead to healthier lives but which don’t currently lead to incomes for doctors?

The problem with concierge-style medical practices now is the relatively large retainer fee that patients have to pay in order to join.  It’s really only available to those at the top end of the income scale, and generally not covered by health insurance.  But maybe the idea should get another look.  Maybe we should be looking at the idea of health insurance companies reimbursing doctors for keeping patients healthy, rather than just caring for us after we become sick.

Hospitals like Denver Health, where a large number of uninsured, indigent, and Medicaid patients are treated, will see millions of dollars in revenue from the fee system.  Hospitals that don’t currently treat many of those patients will end up losing money under the new law, although some of them may start to see more Medicaid patients as a result.

It’s no secret that hospitals in wealthier areas fare better than those in poorer areas.  In Colorado, a hospital in Highlands Ranch will see far fewer Medicaid patients than Denver Health.  There’s no way around that, since people are most likely to visit a nearby hospital, and demographically, there are fewer uninsured and Medicaid patients in wealthier areas.  But everyone needs access to medical care, regardless of where they live or how well funded their local hospital is.  The nice thing about the new hospital fee system is that it will help to level the playing field (at least a little bit) for hospitals in Colorado.  It will help the hospitals in poorer areas bear the brunt of treating so many uninsured and Medicaid patients, and will spread the cost around to some of the hospitals that treat mostly patients with private health insurance.

Obviously we have a long way to go, as the hospital fee system would still leave 650,000 people in Colorado without health insurance.  But it’s a good start.

Senate Bill 115 specifically addresses the medical needs of the people in Haiti, and was written to make it easier for facilities to donate unused medicine to be dispensed by licensed pharmacists working in disaster areas.  But I’m glad that the provision was also included to allow the facilities to transfer the medication to other patients as needed.  Ultimately, I’d like to see us reach a point where medication waste is virtually eliminated.  Tamper proof medication bottles that allow pills to be removed but not re-inserted, or a switch to only using blister packs for pills, could allow even partially used prescriptions to be returned to pharmacies for redistribution.  And with the cost of prescriptions becoming more of a barrier between patients and needed treatment, the destruction of perfectly good unused medication seems like a travesty.

One of the issues that Amnesty International addressed was postpartum care.  More than half of all pregnancy-related maternal deaths occur in the six weeks following birth, and yet most women aren’t seen for a postpartum checkup until the end of that time period.  The midwife we worked with for our son’s birth provided prenatal checkups at her office during the pregnancy, but once our son was born, she came to us for postpartum checkups.  We had six postpartum checkups in the first eight weeks following the birth, and for four of those visits, she came to our house.  The first postpartum visit was two days after our son was born.  We didn’t have to leave the house to take our son for checkups until he was over a month old.

The $3,000 that our midwife charged was quite a bargain, given all the service she provided.  If there had been a complication that required surgery or emergency intervention, she would have had to refer us to a hospital, but at least the problem would have stood a better chance of being caught than if I hadn’t had any postpartum care at all for six weeks after our son was born.  But in order to get that level of care, we had to pay for it ourselves (most individual health insurance policies in Colorado don’t cover maternity care, and the ones that do offer maternity don’t cover homebirths) and seek out a midwife outside of the traditional American maternity care model.

The Amnesty International report should be an eye-opener for a lot of people.  We spend a vast amount of money in this country on maternity care, and yet our results are quite poor compared with other developed countries.  Hopefully it won’t take two more decades to get back to the level of maternal death rates that we had in the 80s.

The RWJF article details a program that has helped to curtail MRI costs by simply having treatment guidelines pop up on the doctor’s computer screen when a test is ordered – the doctor can go ahead and order the test after reading the guidelines, but apparently many times they change their minds, since the program saved almost $6 million in testing expenses in 2008.

These sort of reminders are good for both doctors and patients.  Remember a few years ago when there was a public ad campaign to teach people that antibiotics are not effective against colds, and that overuse of antibiotics leads to antibiotic-resistant bugs?  Perhaps we need something similar for diagnostic testing and imaging.  An ad campaign that encourages people to wait a few weeks and see if their pain subsides could be a good reminder that we don’t need to incur thousands of dollars in testing expenses at the first hint of pain.

Part of the problem stems from the fact that equipment like MRI machines is becoming more ubiquitous in medical offices.  According to a study detailed in Health Affairs, MRI utilization is directly tied to availability – so if an office has MRI equipment on site, their patients are more likely to receive MRIs.  This makes sense, as the doctor has to recoup the costs of acquiring the machine, and also stands to make a nice profit from doing the imaging tests.

Perhaps this is where we should start.  What if we implemented a system whereby doctors could not be compensated for ordering medical imaging for their patients?  The imaging equipment could be strategically located throughout each city and state, but not in doctors’ offices, and not run by doctors who order the tests.  If a doctor were to have no financial incentive one way or the other, we could probably assume that imaging would only be ordered when it was deemed medically necessary, and we would expect to see roughly the same rate of imaging use from one doctor to the next.