Health care - administrative incompetence

[kellyb]

¡Ai-yi-yi! . . .
In the UK (Your own source by the way)

In the US

So not only yearly mammograms in the US but MRIs for some rare women. Don't see this advised in the UK . . . I wonder . . . could it be . . .

COST-SAVINGS?

And even if that was true, according to the Supreme Court...

http://www.law.cornell.edu/supct/se...sion or erisa&url=/supct/html/98-1949.ZS.html

Herdrich argues that Carle’s incentive scheme of annually paying physician owners the profit resulting from their own decisions rationing care distinguishes its plan from HMOs generally, so that reviewing Carle’s decision under a fiduciary standard would not open the door to claims against other HMOs. However, inducement to ration care is the very point of any HMO scheme, and rationing necessarily raises some risks while reducing others.

 

[Rolfe]

My mom-in-law had two abnormal pap smears that the doctor didn't tell her about. He waved away her symptoms by telling her that they were related to menopause and put her on hormone replacement therapy. Then she gets a new job, new insurance and therefore a new doctor. The new doctor finds stage IV cervical cancer.

The new insurance company gets a hold of the old doctors records, calls her cancer a pre-existing condition. Months of phone calls, arguing, etc. They will consider covering her if she can get the first doctor to say he didn't give her the pap smear results. Maybe. Doctor bulks at this. More paperwork, more phone calls. The insurance company drops her. More paperwork, more phone calls, medicaid covers some of the cost.

Here's the fun part - Sister-in-law is infuriated. She calls every news station in California with this shocking story. They turn her down. Insurance company not paying? Nope, no story. This sort of thing is too common, it's not news. Maybe when they do a "High cost of insurance" special they'll call her. They never do.

Mom-in-law dies two years later. If she had lived, she would have been $300,000 in debt.

MIL worked for 35 years. She and her employees paid for health insurance during that entire time. She also paid taxes. When she got sick, she was on her own. Had she paid the same amount of money into the British model, she would have been helped. She may still have died but at least she wouldn't have wasted months on useless phone calls and paperwork.

That is a horrible, horrible story.

The first GP was negligent. What the hell was done about that? If he had been an NHS GP, he would have been in such hot water he wouldn't have known what had hit him. The patient would probably have sued, but even if she didn't the GMC would have been after him big time.

What the hell sort of practice was it where a GP could practise like that? In Britain, doctors have to pass re-validation examinations regularly and keep up their continuing education just to keep their jobs. Anyone who was even suspected of doing something like that would have been forcibly re-educated. And it's usual for people to see more than one doctor in a practice - in which case someone would almost certainly have picked this up.

But as you say, if this had been in the NHS, then not only would the doctor have been professionally lynched, the patient would have received whatever care could possibly be given, with money not even mentioned.

The idea that this sort of denial of care happens so often it's not even news is simply horrifying.

Rolfe.

 

[Tatyana]

This is simply not true. NICE decides the amount that cannot be exceeded to extend a person's life beyond a year.

Last year Britain’s National Institute for Health and Clinical Excellence gave a preliminary recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute, generally known as NICE, is a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness. The decision on Sutent did not, at first glance, appear difficult. NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year.

http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?pagewanted=1&_r=1

QALY isn't this big, bad, evil thing.

Search the New England Journal of Medicine (one of the medical journals with the best reputation and high impact rating) if you don't believe me.

They have some fantastic articles, evidence based articles, on the issues that the US is facing today.

They are also readily admitting the system is broken.




http://www.nejm.org/doi/full/10.1056/NEJMp1007168
Perspective
Legislating against Use of Cost-Effectiveness Information


In 1996, after 2 years of deliberation, the U.S. Panel on Cost-Effectiveness in Health and Medicine, composed of physicians, health economists, ethicists, and other health policy experts, recommended that cost-effectiveness analyses should use quality-adjusted life-years (QALYs) as a standard metric for identifying and assigning value to health outcomes.2

QALYs provide a convenient yardstick for measuring and comparing health effects of varied interventions across diverse diseases and conditions. They represent the effects of a health intervention in terms of the gains or losses in time spent in a series of “quality-weighted” health states. QALYs are used in cost-effectiveness analyses (termed “cost-utility analyses” when QALYs are included) to inform resource-allocation decisions: the cost-per-QALY ratios of different interventions are compared in order to determine the most efficient ways of furnishing health benefits. In contrast, other health outcomes are generally expressed in disease-specific terms, such as incidence of cardiovascular events, cancer progression, intensity of pain, or loss of function. Though useful for measuring the effects of particular treatments, these outcomes do not permit comparisons among diseases and conditions or between treatment and prevention.3



For the 'free-market' argument
http://www.nejm.org/doi/full/10.1056/NEJMp0911074


Table 1
TAnnual Cost of Expanded Insurance Coverage, According to the Amount of the Annual Premium. illustrates the most basic of these choices: the more generous the insurance policy, the fewer the people who can be covered with a given budget. It shows the amount that it would cost to cover a certain number of people with policies of a certain level of generosity (as indicated by the per-person premium).

We chose these values on the basis of the distribution of premiums for individual coverage in the employer-sponsored health insurance market today, using data for employers with more than 50 workers from the 2008 Medical Expenditure Panel Survey (MEPS) conducted by the Agency for Healthcare Research and Quality.1 The median premium was $4,200, the premium at the 25th percentile was $3,500, and the premium at the 75th percentile was $5,100. This dispersion reflects many factors besides the generosity of policies, including geographic variation and enrollee characteristics (although basing the analysis on premiums paid by larger employers mitigates the effects of these characteristics). One could also think of the less generous policies as reflective of the typical premiums of a decade ago (for example, the 25th-percentile premium in 2008 was similar to the average premium in 2000, which was $3,500 after adjustment for inflation).

http://www.nejm.org/doi/full/10.1056/NEJMsb0911104
Comparative Effectiveness and Health Care Spending — Implications for Reform

 

[Delscottio]

Bookitty thats an awful story, but theres a bit I am confused by- why did the MIL have to change doctors because of a change of insurer?

 

[Tatyana]

My mom-in-law had two abnormal pap smears that the doctor didn't tell her about. He waved away her symptoms by telling her that they were related to menopause and put her on hormone replacement therapy. Then she gets a new job, new insurance and therefore a new doctor. The new doctor finds stage IV cervical cancer.

The new insurance company gets a hold of the old doctors records, calls her cancer a pre-existing condition. Months of phone calls, arguing, etc. They will consider covering her if she can get the first doctor to say he didn't give her the pap smear results. Maybe. Doctor bulks at this. More paperwork, more phone calls. The insurance company drops her. More paperwork, more phone calls, medicaid covers some of the cost.

Here's the fun part - Sister-in-law is infuriated. She calls every news station in California with this shocking story. They turn her down. Insurance company not paying? Nope, no story. This sort of thing is too common, it's not news. Maybe when they do a "High cost of insurance" special they'll call her. They never do.

Mom-in-law dies two years later. If she had lived, she would have been $300,000 in debt.

MIL worked for 35 years. She and her employees paid for health insurance during that entire time. She also paid taxes. When she got sick, she was on her own. Had she paid the same amount of money into the British model, she would have been helped. She may still have died but at least she wouldn't have wasted months on useless phone calls and paperwork.

Holy crap, how sad.

I am so sorry.

 

[Shalamar]

¡Ai-yi-yi! . . .
In the UK (Your own source by the way)



In the US



So not only yearly mammograms in the US but MRIs for some rare women. Don't see this advised in the UK . . . I wonder . . . could it be . . .

COST-SAVINGS?

Could it be in the US... Doctors want more money for unneeded screenings?

 

[Rolfe]

I keep thinking the USA could be a lot more creative with the QALY.

Here, NICE decides how much a QALY is worth, and patients don't get much of a say in it. I sometimes imagine the USA could create a universal healthcare system in which a QALY was priced very much less than in the NHS, and anyone who wanted to spend more could then do so either out of pocket or through insurance.

Or the insurance companies could compete by marketing their products as providing up to a certain sum per QALY for the patient's treatment. You want the Rolls-Royce deal, sign up with X for up to $1M per QALY! It'll cost you though! Or Y might provide similar cover but for a lower premium. Or for a much lower premium, you could be covered up to $5,000 per QALY.

Maybe the government might mandate that everyone should have cover up to a certain sum per QALY, and subsidise that if necessary. Then people could choose to pay for better coverage if they wanted to.

Think of the possibilities! We could be saying, huh, here we are, everybody covered up to (what is it, about £20,000) per QALY, no choice at all compared to these Americans.

Look at what an opportunity is being missed!

Rolfe.

Just sayin'.

Rolfe.

 

[bookitty]

Running health care on the business model starts with the premise that some people are more deserving of medical attention than others. The requirements are simple - if you can afford it, you deserve it.

It totally ignores that fact that every society needs all of it's members. People who work low-paying jobs fulfill their functions as much as those who have or are born into wealth. The idea that the poor are somehow conspiring to get more than they deserve is not a new one. (See Welfare, panic over number of children born to recipients and A Modest Proposal by Swift, Jonathan)

But a civilized society understands that it needs street sweepers as well as doctors and that meeting basic needs - food, shelter, medical attention, education - for everyone is more productive and less expensive in the long run. If you don't educate the children of the poor, there is less chance that these children will better their station and provided needed tax revenue. If you don't see to the maintenance of health for your population you will spend more money on emergency care for issues that could have been dealt with in a simple fashion if caught early.

For some reason, the US is so enamored of the Horatio Alger model of success that they see little reason to try anything else. We're a nation of plucky newsboys pulling ourselves up by our bootstraps. If we don't succeed, we just didn't work hard enough and thus, the gutter awaits.

There's a sort of smug joy to these calls for responsibility, like a person watching a zombie movie and explaining (in minute detail) how they would do better. Mainly because there is zero possibility that they will ever meet a zombie.

 

[bookitty]

Bookitty thats an awful story, but theres a bit I am confused by- why did the MIL have to change doctors because of a change of insurer?

Her previous doctor wasn't in the new insurers network.

 

[bookitty]

That is a horrible, horrible story.

The first GP was negligent. What the hell was done about that? If he had been an NHS GP, he would have been in such hot water he wouldn't have known what had hit him. The patient would probably have sued, but even if she didn't the GMC would have been after him big time.

What the hell sort of practice was it where a GP could practise like that? In Britain, doctors have to pass re-validation examinations regularly and keep up their continuing education just to keep their jobs. Anyone who was even suspected of doing something like that would have been forcibly re-educated. And it's usual for people to see more than one doctor in a practice - in which case someone would almost certainly have picked this up.

But as you say, if this had been in the NHS, then not only would the doctor have been professionally lynched, the patient would have received whatever care could possibly be given, with money not even mentioned.

The idea that this sort of denial of care happens so often it's not even news is simply horrifying.

Rolfe.

The worst part was when the insurance company flat out told my MIL that she had probably just ignored the pap results. I would dearly love to see the statistics for people who have insurance who then ignore a cancer warning.

We had the basis for a lawsuit but after she died, we were too wrung out to do anything about. Keep in mind that she only had full time hospice for the last two week. Prior to that she had a nurse for 8 hours a day and we did the rest. It was hell.

 

[Delscottio]

Her previous doctor wasn't in the new insurers network.

Ithought that only extended to hospitals, I am a touch surprised at how US citizens accept these sort of restrictions to be honest. The whole healthcare debate seems so messed up that it confuses the hell ot of me.

 

[Uncayimmy]

That is a horrible, horrible story.

You may not be aware of this, but that's an improvement. Prior to the mid '90s, they could have excluded her at will. Now they are only allowed to look back six months and can only deny her if she's received treatment, diagnosis, or medical advice regarding the condition. It gives you a warm, fuzzy feeling, huh?

 

[Rolfe]

I just don't know how xjx388 can so smugly defend a system that can do this to people, and do it so often that the newspapers can't even be bothered reporting it, and at the same time dredge up such irrelevancies about the NHS to criticise.

He found an off-the-wall story about a woman who wanted even more, on top of the state-of-the-art cancer treatment she'd already been given. He then announces that the NHS doesn't fund life-extending treatment for breast cancer patients, with is a flat lie. And he still hasn't shown us evidence that the drug the NHS didn't think would do any significant good and therefore didn't fund, would have been automatically available to an American patient in the same situation.

He notes that alcoholics are unlikely to get a liver transplant on the NHS, and screams that this is "rationing". Without realising that alcoholics won't get a liver transplant in the USA either, for exactly the same reason, which is that a liver transplant is unlikely to be a success in someone who continues to abuse alcohol.

He notes that the NHS screens every woman between 50 and 70 for breast cancer, ever three years, free of charge. And screams that a failure to screen younger women, or screen every year, is cost-cutting. Ignoring all the evidence presented that the NHS regimen has it about right in terms of cost-benefit, and the US physicians may well be over-investigating women simply for the money.

At the same time, xjx388 is defending a system that repeatedly and systematically destroys people's lives in the way bookitty's MIL's life was destroyed.

Rolfe.

 

[Rolfe]

NHS Scotland has just initiated a bowel cancer screening programme. Kits sent to the patient's home, to be used in the privacy of one's own bathroom. Send back the completed kits in the pre-paid envelope provided. I did mine and got an all-clear letter back about ten days later, also saying I would be sent another kit in 2 years.

Soapy Sam threw his kit in the bin. It's a free country.

Anywhere in the USA doing anything like this?

Rolfe.

 

[Rolfe]

I used to think when the USA got itself sorted out, it would go down the insurance route - use insurance companies to deliver universal healthcare as some European countries do. I'm not so sure. The insurance companies seem to be a lot of the problem in the USA, and I suspect that any system that allowed them to continue being involved would see them continuing to milk it for all they're worth.

I also don't know how they would manage to implement a government-run healthcare system.

I think they're all ed, quite honestly.

Rolfe.

 

[Tatyana]

NHS Scotland has just initiated a bowel cancer screening programme. Kits sent to the patient's home, to be used in the privacy of one's own bathroom. Send back the completed kits in the pre-paid envelope provided. I did mine and got an all-clear letter back about ten days later, also saying I would be sent another kit in 2 years.

Soapy Sam threw his kit in the bin. It's a free country.

Anywhere in the USA doing anything like this?

Rolfe.

I would really like to know how things like community screening programmes are managed with so many providers.

According to the NEJM:

http://www.nejm.org/doi/full/10.1056/NEJMsb0911104

As examples, antihypertensive treatment, screening for colorectal cancer, and counseling for smoking cessation are all underutilized in the United States.21,22


Stukel TA, Lucas FL, Wennberg DE. Long-term outcomes of regional variations in intensity of invasive vs medical management of Medicare patients with acute myocardial infarction. JAMA 2005;293:1329-1337



McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635-2645

 

[Rolfe]

The kit just showed up on the post, with clear instructions. For breast screening, the usual form is just to send the woman a letter with an appointment already made, and a phone number to call if the time given isn't convenient. The records are centralised, so I guess a computer does it.

You don't have to participate, but everyone is invited and quite a lot of effort is put into encouraging as many people as possible to take part.

The USA doesn't seem to have any sort of public health system at all that could organise this.

Rolfe.

 

[Tatyana]

The kit just showed up on the post, with clear instructions. For breast screening, the usual form is just to send the woman a letter with an appointment already made, and a phone number to call if the time given isn't convenient. The records are centralised, so I guess a computer does it.

You don't have to participate, but everyone is invited and quite a lot of effort is put into encouraging as many people as possible to take part.

The USA doesn't seem to have any sort of public health system at all that could organise this.

Rolfe.

That is what I meant, how is it organised in the US.

For example, infants are screened at birth as they are in hospital, that one is quite easy to understand how it is done, but how does pre-natal screening work?

How does breast cancer screening work in the US?

 

[ServiceSoon]

I still can't wait to see XjX's explanation as to why we live longer for half the healthcare costs. Especially given her unsubstantiated claims of UHC rationing. It's been strangely absent so far.

Would it make sense if it was due to the nature of how the data is communicated? Lets take average life expectancy for example. WIki says the UK has a life expectancy of 79.4 compared to the US's 78.3. In the UK system everybody receives treatment. In the US 15% are uninsured and therefore don't receive proper treatment.

I wonder what would happen if you removed the bottom 15% from both the UK and US data? I'd bet a US nickel that the figures would reverse.

 

[kellyb]

Would it make sense if it was due to the nature of how the data is communicated? Lets take average life expectancy for example. WIki says the UK has a life expectancy of 79.4 compared to the US's 78.3. In the UK system everybody receives treatment. In the US 15% are uninsured and therefore don't receive proper treatment.

I wonder what would happen if you removed the bottom 15% from both the UK and US data? I'd bet a US nickel that the figures would reverse.

How are you defining "bottom 15%"?

I'm pretty sure the US infant mortality stats are affecting our life expectancy.
Here's the infant mortality situation in my city:
http://www.commercialappeal.com/news/2005/mar/06/special-report-infant-mortality-in-memphis/

The babies are buried with a backhoe, as many as eight at a time, in homemade pine boxes.

Like a giant steel hand, the machine's claw pats the soil as it covers the tiny coffins with dirt, tucking them in one last time.

Here at the Shelby County Public Cemetery, just outside the view of Memphis's gleaming symbol of prosperity, Wolfchase Galleria, this 30-acre burial ground for the poor holds 14,000 bodies - most of them infants in graves marked only by numbers.

Caretaker Robert Savage, a gentle man with an unthinkable job, toils week after week with a modern-day plague.

Memphis has the highest infant mortality rate among the nation's 60 largest cities. Babies here die at twice the rate of the national average.

An infant dies in Shelby County every 43 hours.

In 2002, the last year statistics are available, 202 babies didn't see their first birthday - enough to fill 10 kindergarten classrooms. By comparison, there were 122 homicide victims in the city and county last year.

"Some weeks it seems like they really stack up," said Savage, a gravedigger at the Shelby County Cemetery for almost three decades.

Several Memphis ZIP codes have infant death rates higher than scores of Third World countries. North Memphis' 38108, which includes the tattered communities of Douglass and Hollywood, is deadlier for babies than Vietnam, El Salvador and Iran.

Infant mortality is the barometer of a community's ills: poverty, pollution, crime, lack of education, access to health care and safe, affordable housing.

Would those infants count as part of the US's "bottom 15%"?