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.

I can see both sides of this issue, but with all of the technological advances we’ve made over the last decade, it seems that something as simple as communication between hospitals and health insurance companies regarding patient admissions should be a simple, electronic process by now, with no clerical errors or staffing issues involved.  If astronauts can update their status on Twitter from the space station in real time, we should be able to devise a system that allows for instantaneous notification for health insurance carriers when an insured is treated or admitted to a hospital.

What if our health insurance ID cards came with barcodes that could be scanned in the doctor’s office or hospital, immediately allowing the office staff to see our benefits, how much of our deductible still needs to be met, and any exclusions on our policy?  Then admission and treatment data could be transmitted directly to the health insurance carrier, without the need for phone calls or extra staff.  Rather than having different scanners and transmittal systems for each insurance carrier, it would make sense for this to be a standardized system, with one system that would be able to transmit data to all of the  major health insurance carriers.  This isn’t a far-fetched idea – think of credit card processing systems.  Visa, MasterCard, American Express and Discover are privately-owned companies that are fiercely competitive with each other.  Yet a store owner does not need a separate processing system for each card.  When you pay at the gas pump with a credit card, the processing system can identify what type of card you’re using, transmit the data to the correct company, check to make sure you have available credit on your card, and authorize the transaction, all within a few seconds.  Visa doesn’t have to wait around for 24 hours before they find out that I bought some groceries today.

There has been a lot of talk about bringing our medical information system into the 21st century lately, and this battle over notifications is a perfect example of how the health care industry is lagging behind a lot of other sectors in terms of electronic data storage and transmission.

This is a great idea, and hopefully will one day become a reality.  Cost comparison for medical procedures is difficult at best, and sometimes impossible with our current system of proprietary rates.  People who have comprehensive health insurance that only requires a copay at the doctor’s office and a deductible for more comprehensive procedures, might not be aware of the vast differences in pricing from one hospital to another - even under the same health insurance policy.  People with high deductible, HSA qualified policies are probably more interested in the actual cost of care, but likely find it difficult and cumbersome to shop around in our current system, especially if they are already sick and in need of care.

A statewide database of prices would be a great step forward in terms of transparency.  If people could look at two hospitals in the Denver metro area and see that one is charging 50% more than another for the same procedure, it would at least be a good starting point for a discussion about value in health care.

It makes sense that a cost comparison database might have to focus on relatively straight-forward procedures that can be priced with a reliable degree of accuracy across a large number of patients.  But more complicated procedures (which presumably vary in price from one patient to another, based on potential complications) could also be included by looking at a hospital’s history of such procedures and average charges.  Or the procedures could be broken down into their components (for example, the anesthesiologist’s fees, the operating room charges, the inpatient medications, etc).  The way I see it, the more procedures, details, and hospitals that are included in the database, the better it will be.

It’s hard to have an effective dialog about costs and cost-control when the average person has no idea what the costs actually are, and no realistic way of finding out.  EOBs are great, but they only come after a person has received treatment, and thus aren’t particularly useful in terms of comparison shopping.  Kefalas’ bill would be a good step towards transparency in health care costs, and I hope it is well received.

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…