Medical Malpractice News and Views


Welcome to our blog where we discuss current issues in medicine and law. We welcome your comments.

Just Fill Out These Forms – Hospital Edition.

November 28, 2022

If there was ever a situation of more uneven bargaining power than being asked to fill out hospital forms while lying on a gurney in the emergency department, I cannot think what it could be.  And yet that is precisely when the hospital asks you to fill out pages and pages of forms with closely spaced legal mumbo jumbo that can have huge legal and economic consequences down the road.  You are in no position to get up and leave.  You are in no position to refuse to sign.  So you do what you must; you sign, usually without even reading the forms.

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The hospital knows you are coming.  It may not expect you personally, but it knows patients will be arriving every day needing vital medical treatment.  The hospital wants to be ready for you.  It wants to be ready to deliver good medical care to you, but it also wants to place itself in the strongest possible position to get paid and to defend itself in the event someone makes a mistake and it gets sued.  That is why it has had lawyers prepare detailed forms and why it insists you sign them before it will admit you to the hospital.

The hospital forms are often pretty much alike from hospital to hospital.  Hospitals compare notes.  Their attorneys compare notes.  They read the court cases and change their forms to take advantage of whatever the law allows them.

One of the things the hospital has thought of that you probably have not is who is this person who is providing care to you?  He or she is wearing a name tag.  It may or may not have the hospital’s name on it.  While it may be news to you, the person may not be a hospital employee at all, even though the person is dressed like all the other hospital employees.  If all goes well, you never have to care about whether the person was employed by the hospital or not.  However, if things go wrong and the person injures you, the hospital may inform you that it is not legally responsible for the person it sent to care for you.  Depending on how badly you have been hurt, this may make a big difference in how much money you can recover to compensate you for your injury.

There are lots of people in a hospital who are not actually employed by the hospital.  In the emergency department, the doctors very often work for an outside company that the hospital has hired to work in its emergency department.  Their name tags may or may not alert you to that fact, although there are good reasons why you don’t spend much time examining those name tags while you are lying on your back in pain.  Depending on the hospital, it may hire doctors to see you during the time you are admitted.  These people are called hospitalists.  They don’t do anything other than see patients in the hospital.  The radiologists who review the x-rays, CT’s and MRI’s performed in the hospital are usually not hospital employees.

The hospital may call the emergency department doctors, hospitalists, and radiologists “independent contractors” and take the position that they are not hospital employees.  Were you to walk into any other business in town and be waited on by someone who gives every appearance of being an employee of the business, the law will usually treat that person as an employee, even if the business claims that it was just someone it hired but who wasn’t technically an employee.  The law will hold the business responsible for any mistakes the person makes that cause you injury.  Here is where the hospital’s forms come into play.

Buried deep in the fine print in the admission forms, the hospital will inform you that not everyone who provides you care is a hospital employee and that you should not assume that they are.  Even if you are able to find that sentence, you may not understand it, but the courts will enforce it against you anyway.  The courts also won’t care that you didn’t have much choice when presented with these forms.  This means that the hospital is not legally liable for the mistakes of these people and doesn’t have to pay for them.  Since the hospital usually has many millions of dollars of insurance coverage and the “independent contractor” does not, this can make a big difference, if you are badly injured.

There are lots of other hospital-favorable provisions in these forms.  Among other things they make you promise to pay, in the event your insurance company does not.  They may make you agree to arbitrate certain disputes, instead of going to court over them.  You agree that the hospital may take pictures of you and that the pictures will belong to the hospital and not you.  You agree to have certain information shared.  You give your consent to the treatment you are going to receive, and, if you are in the hospital to deliver a baby, you give consent for the baby to be treated as well.

There is not much you can do about these forms.  The best you can do is read them and ask questions, but you are going to have to agree to what the hospital wants or leave and go on down the street.  Under the best of circumstances, that is a problem and, even then, the next hospital will hand you similar forms to sign.  Just be aware that these are important forms and will be binding on you, even though you never really had a chance to refuse to sign them.

 

Posted in Doctors, Hospital Negligence, Hospitals, Informed Consent, Lawsuits, medical errors, Medical Malpractice, medical mistakes, Nurses |

Our Broken Health Care Delivery System.

November 21, 2022

Next time you are visiting someone at the hospital and have a few minutes to spare, take a drive through the doctor’s parking lot.  If you live in a major metropolitan area, you will see luxury car after luxury car.  In areas more remote from the big cities, there will be nice cars, but probably not as many really expensive ones.  What does this have to do with our broken health care delivery system?  Well, pretty much everything.

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In order to afford those fancy cars, doctors must make a lot of money and many of them do, particularly the specialists.  Not so much for the family care doctors or the pediatricians.  So chalk up part of the problem to high fees charged by segments of the doctor population.  Not to be outdone, hospitals have very high “sticker prices” for their services, off which they offer discounts to some people and some insurance companies.  Tough luck, however, if you are forced to go to a hospital that is not “in network.”  You are likely going to get soaked.

Another part of the problem, and there are many parts, is how we pay for our health care.  In most cases, we pay for our health care by the service performed.  This is the “fee for service” model.  The more a doctor or hospital does for you, the more you are charged.  There is a built-in incentive to do more to get paid more.  There is also an incentive to divide a service up into as many parts as you can and to bill separately for each of them.  This may be where the airlines learned to charge separately for food, drink, bags and leg room.  In the fee for service model, the emphasis is on the service performed as opposed to the result achieved.  Under the current system, no one really cares if the service results in a cure or not.  There should be an incentive for getting your patient healthy and keeping her healthy.

Hospitals are also extremely secretive about how much they charge.  Probably no business in America has as many different charges for the same service as do our hospitals.  Not only do they have different charges for the same service depending on who is doing the paying but the differences can be huge.  In a recent blog post, I discussed the case of a woman who had a breast biopsy for which the hospital charged $18,000.  For patients with no insurance, the hospital charges only $1,400 for the same biopsy.  Hospitals don’t want you to know what they charge.  They consider their price list to be a trade secret.  However, without knowing what the hospital charges, consumers cannot make rational decisions about where to go for hospital care.  Our capitalist system relies on rational decision making to keep prices down and to encourage efficiency.  Hospitals gum up the works on purpose.

Drug companies play a big role in our broken system.  They have enormous financial power and have been very effective lobbyists.  For decades, Big Pharma has prevented Medicare from negotiating the price of drugs that it covers for seniors.  That changed recently but only for some drugs and the change is to take place over a period of years.  The drug companies also game the patent system to keep prices high.  They virtually conspire with the insurance companies to keep prices high, which allows the insurance companies to charge higher premiums.  We have, and will for the foreseeable future, pay more for the same drugs than anyone else in the world.

The health insurance industry makes big profits from the current broken system and has no interest in seeing it change.  Every time reform is suggested, the health insurance companies start the scare tactics to convince Americans that the health care apocalypse is just around the corner and they can kiss their doctor goodbye, if any changes are made.  It has been a quite successful tactic for them.

In spite of the success of the Affordable Care Act, there are still many living in this country who have no health insurance or whose insurance is terrible.  For obvious reasons, these people don’t go to the doctor very often.  By the time they show up at the hospital, they are often very sick.  Under federal law, the hospitals are required to accept them as patients and to provide to them the care they need.  When they cannot pay the bill, the amount of their bill is added to the bills of all of us who do have health insurance so as to keep the hospital from going broke.  Those who think that having people without health insurance is no concern of theirs don’t understand the situation.  They are paying for the uninsureds, whether they realize it or not.

As regular readers of this blog know, we pay more for health care in the United States on a per person basis than any other country in the world.  Do we get the best health care in the world for all that we spend?  Not by a long shot.  By any objective measure of health care outcomes, such as infant mortality, life span, obesity, etc., we are way down on the list of successful countries.  We are not just way down on the list, we are dead last.  It is no coincidence that we are also the only industrialized country that does not have universal health care.

Our broken health care delivery system traces its roots to price and wage controls put in place during World War II.  Health insurance became a fringe benefit that could be used to attract workers when wages were frozen.  From there the system just kept on moving forward and creating companies with huge financial stakes in preserving the status quo.

Only Congress has the power to wipe the slate clean and to create an efficient system of delivering health care to our citizens.  Sadly, with the degree of partisanship we are currently experiencing, we are unlikely to have the bipartisan majorities needed to make the necessary changes any time soon.  Even if bipartisanship were to suddenly spring up, the lobbying power of the doctors, insurers, drug companies, and hospitals would make real change hard to come by.  Guess we are just going to have to live with it for a few more decades.  Maybe our grandchildren will do better.

Posted in Doctors, drug companies, Fee for Service, General Health, health, Health Care Costs, Health Insurers, Hospitals, Medical Costs, medical ethics, Medicare, Obesity, Secrecy |

Medical Malpractice and Quadriplegia.

November 14, 2022

Over the years, I have handled a number of cases in which the patient successfully underwent surgery only to become paralyzed in the hours and days after leaving the operating room.  In each of these cases, the patient should not have been paralyzed.  In each of these cases, the nurses or the surgeons, or sometimes both of them, failed to do their jobs and the patient was left with a lifetime of paraplegia or quadriplegia.

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The spinal cord is like a superhighway through the body.  Like a superhighway, it is a critical piece of infrastructure.  It carries messages from the nerves to the brain and messages and instructions from the brain to the nerves and muscles.  It is protected from trauma by the bones of the spine and by a tough, fibrous sheath.  Medical errors can overcome that protection and damage the spinal cord.  The closer to the head the damage occurs, the more messaging to and from the brain is lost.  Damage to the spinal cord in the lower back can cause paraplegia, the loss of the use of the legs.  Damage in the neck can cause quadriplegia, loss of the use of both the arms and legs.

The two main ways the spinal cord can be damaged by malpractice are through direct trauma during a surgery on or in the vicinity of the spinal cord and compression of the spinal cord after surgery due to the formation of a blood clot.  Malpractice during surgery is almost always the exclusive responsibility of the surgeon.  Post-operative compression due to the formation of a blood clot involves the nurses and may or may not involve the surgeon as well.

Time and space do not permit me to detail all the ways in which a surgeon can directly damage the spinal cord during a surgery.  It depends on the nature of the surgery, its location, whether or not hardware is being used as well as a number of other factors.  Suffice it to say that some cases of spinal cord damage during surgery are unavoidable while others are completely avoidable.  Each case must be examined on its own merits.  While paralysis may be a risk for all surgeries in and around the spinal cord, the fact that paralysis occurs during such a surgery does not mean that the paralysis was not the result of negligence.

Post-operative paralysis is a much easier case to make.  It should not happen.  While post-operative bleeding may cause the formation of a blood clot (hematoma), which compresses the spinal cord, any resulting paralysis will develop over a period of hours and will cause signs and symptoms, which an observant nurse will see and report to the surgeon.  If the nurse is doing her job, the developing problem will be recognized early enough for surgical intervention to preserve spinal cord function.

You would think that the nurses assigned to care for patients who are recovering from surgery on or near the spinal cord and who are at risk of developing paralysis would be among the best the hospital has on staff.  You would be wrong.  In many of the cases I have handled of post-operative paralysis, the nurses were inexperienced and poorly trained.  Why are these nurses entrusted with such important care?  In one of my cases, the nurses saw the developing evidence of paraplegia and deliberately ignored the order of the doctor to call her immediately, if they saw any of the signs they were seeing.  These night shift nurses testified that they discussed it among themselves and decided that the loss of sensation, motion, and strength was not really due to developing paralysis and that there was no reason to call the doctor.  By the time the surgeon arrived in the morning and discovered his patient was paralyzed, it was too late to fix the problem.

Any time a patient is paralyzed while in the hospital, an experienced malpractice lawyer should be asked to review the records.  If there was no malpractice, the lawyer can reassure the patient and life can go on to the best extent possible.  If, on the other hand, malpractice was a cause of the paralysis, the lawyer can advise the patient about the options that are available.

Posted in Blood Clots, Doctors, Hospital Negligence, Hospitals, Lawsuits, medical charts, medical errors, Medical Malpractice, medical malpractice cases, medical mistakes, Medical Negligence, medical negligence lawyers, Nurses, Surgical Errors |

Some Helpful Medicare Enrollment Information.

November 07, 2022

It is only early November and I am already sick to death of the advertisements trying to get me to enroll in a Medicare Advantage plan and I still have a month go before the open enrollment period ends.  Every celebrity in an advertisement these days tells me I need to get what I deserve.  Grumpy Marge needs to be persuaded to call the number on the screen.  These ad campaigns must be working as the number of Medicare eligible Americans enrolled in Medicare Advantage plans keeps increasing every year.  As of 2022, almost half of the eligible Medicare beneficiaries are enrolled in a Medicare Advantage plan.

If you remember nothing else, remember that there is no free lunch and that the extra benefits you are being offered in an advantage plan are going to be offset by savings somewhere else so that the insurance company running the advantage plan can make its profit.

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The puzzle image here is a good one for our purposes because Medicare can be very confusing, even for the sophisticated shopper trying to figure out what is the best coverage for her.  There is an alphabet soup of Parts A, B, D, F, G and so on.  What are they and what do they do?  If I want to enroll in an advantage plan, what are the trade offs?  What must I give up?

I recently received a link from a private company that brokers health insurance.  Their web site explained all of the different types of Medicare coverages available in Arizona and provided some data for the largest companies offering Medicare Advantage plans here.  They also provided links to other sites with helpful information.  Here is the link I received.  It is definitely worth a look.

On the subject of Medicare Advantage plans, the site for which I gave you the link says there are four main types offered in Arizona.  The first and most common is the HMO model, in which, in return for extra benefits, you give up the right to choose any doctor who accepts Medicare.  You must have a primary care physician (PCP) in the HMO network and cannot see a specialist without a referral from your PCP.  If your PCP decides you can see a specialist, it will usually be someone in the HMO network.

Next are the Preferred Physician Networks.  Under this model, the care you receive from a physician in the network will cost less than care from a doctor outside the network.  There are other types of Medicare Advantage plans offered in Arizona as well.

As the site points out, the best Medicare Advantage plan for you depends on what is most important to you in terms of costs, availability of providers, and ease of access.  Arizona had 122 Medicare Advantage plans for sale in 2022, however, not all of them are available in all parts of the state.  When comparing plans, you should consider cost, availability of physicians and hospitals, deductibles, co-pays and coinsurance, coverage area, out-of-pocket costs, and benefits.  It can be quite a daunting task but can have a big effect on your pocketbook and on your access to health care.  Good luck.

 

Posted in Doctors, Fee for Service, health, Health Care Costs, Health Insurers, Medical Costs, Medicare |

BOO! It’s Halloween and the Scammers and Fraudsters Are Out.

October 31, 2022

Of course, the scammers and fraudsters are out every night.  It pays to be careful so you don’t end up as one of their victims.  Scammers are always refining their scams so you may see new tricks.  Here are some of the things you can do to protect yourself.

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If you didn’t initiate a conversation on line or on the phone, assume that the “person” on the other end is a scammer and act accordingly.

No matter how attractive you may think you are, handsome men and beautiful women are not sitting at their computers just waiting to fall in love with you.  At some point they are going to need money for a medical emergency or are going to ask for an intimate picture of you.  They may have already sent you an intimate picture of the person they claim to be.  These people are scammers.  There is no medical emergency.  Intimate pictures may be used for blackmail.

Never give private information out in response to a request that you did not initiate.  Scammers can make texts you receive or emails you receive or phone calls you receive appear to come from legitimate sources.  Just because the caller ID says that the IRS is calling does not mean it is the IRS on the line.  In fact, the IRS says that they never contact taxpayers by phone so if the IRS pops up on your caller ID, it is almost certainly a scammer calling to warn you that your bank account is about to be seized unless you immediately send someone some money.

If you want to respond to an inquiry you did not initiate, DO NOT use the phone number or link provided to you by the person contacting you.  Scammers have set up web sites that look exactly like that of your bank or credit card company.  The person answering your return call to the number they give you will pretend to be the business you were trying to call.  ALWAYS look up the phone number or web address yourself using a trusted source and follow up that way.

NEVER EVER give personal information over the phone or on line, if you did not initiate the contact.

Another good piece of advice I saw recently pointed out that scammers want to make you afraid as that may cause you to lower your defenses.  The advice was that, if you get a message that makes your hands moist and clammy, assume the message, no matter what it is or who it claims to be from, is from a scammer.

On your cell phone, send all unknown callers to voice mail.  There is a button for that.  Do not respond to text messages that appear to be intended for someone else or have otherwise been mistakenly sent to you.  Such messages are often just a way for the scammer to confirm that your number is a live number or to engage you in a conversation or both.

Sometimes scammers prey on older people by calling and pretending to be a young relative who is in a jam or in jail and needs some money fast.  “Gramma, it’s me, your favorite grandson.  Please help me, Gramma.”

Some scammers call or email at night or on the weekend and pretend to be your boss who needs you to send some money immediately to resolve some emergency.  Verify before sending any money to anyone for any reason.

You may receive an email from a friend who is out-of-the-country and has had his or her wallet stolen.  They are embarrassed to ask but need you to send them some money so they can get home.  Don’t do it.  You will usually find that the scammer somehow compromised the address book of your friend and sent identical emails to everyone in it.

Even if you are not asked for financial information, be wary of giving any information.  Scammers can sell medical information or other identification information.  “Hi, this is Doctor (mumbles) office calling.  We are updating our records and just want to confirm your Medicare number.  Will you please read it to me?”  Give that and you may find that someone has used your number in a fraud against Medicare.

You may read this and think it can’t happen to me.  It can and does happen to sophisticated people.  All it takes is one little slip and you can become a victim.  Be alert and be careful, not just on Halloween night, but every day and very night.

 

Posted in Fraud, Medicare |

You’re Not Listening To Me.

October 24, 2022

Medical diagnosis and its evil twin, misdiagnosis, are profoundly influenced by the physician’s ability to effectively listen to the patient.  There are great diagnosticians and some doctors who are not so great diagnosticians.  The great ones almost always say the same thing, “If you listen to the patient, she will tell you all you need to know.”

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There are many trends in medicine which discourage physicians from listening to their patients.  Probably the most important of these is the press of time.  Doctors are being pushed by economics to spend less time on each patient visit.  The less time there is for a visit, the less time the doctor has to listen to the patient.  Maximizing the number of patients a doctor sees in a day may be a good way to maximize income but it is a terrible way to deliver good medical care.

Many doctors have personality traits that make it difficult for them to be good listeners.  Tops on that list is a lack of patience.  They want to cut to the chase.  They interrupt the patient when the patient is trying to tell them what is wrong.  They ask questions early, which tends to cause them to form a diagnosis before they have heard all the facts.  Once a diagnosis has entered the physician’s brain, his or her hearing becomes selective and they tend to hear those things that support the diagnosis and discard those that don’t.  They don’t value the patient and the patient’s perception of what is wrong.  After all, who went to medical school?

Patients play a role in poor communication as well.  One article I read advanced the position that patients sometimes act like hostages.  They are reluctant to speak.  They are reluctant to contradict or to challenge the physician/captor.  They feel powerless and dependent on the physician.

Failure to listen results in dissatisfied patients who conclude that the doctor does not have the time for them, that the doctor does not care about them as persons but only as patients, and that their fears and concerns are valueless.  The trust that is such an important part of a good physician/patient relationship is hard to create when there is a failure to listen.  Failure to listen also increases the chances for a miscommunication.  Doctors need to hear all that their patients have to say.

To its credit, the medical profession recognizes the problem with listening to patients and has tried to change its ways.  Article after article in professional journals or presentations at seminars urge doctors to engage in active listening.  An active listener doesn’t just listen, she engages with the patient.  She is in the moment and giving the patient all of her attention.  No multitasking.  No writing or typing on the computer while the patient is speaking.  She does not interrupt.  She interprets what she has heard and repeats it back to the patient.  She watches the body language of the patient and avoids body language on her part that might suggest disinterest or being closed to communication.  These are the keys to good communication.

As a patient, don’t be a hostage.  Insist that the doctor listen to you.  If the doctor is impatient or for any other reason, won’t listen to you, find another doctor.  You owe that to yourself.

 

Posted in Doctors, Fee for Service, medical charts, medical errors, medical ethics, medical mistakes, Medical Negligence, Misdiagnosis |

Our Hospital Pricing System Is Insane.

October 17, 2022

I recently wrote a post about how our health insurance system is making the delivery of health care worse than it should be.  Here is another horror story for your files.

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There are two variables in health insurance plans that can greatly impact what you pay for medical care.  They are the deductible and the co-pay.  The deductible is the amount of medical bills that you must personally pay each year before your health insurance plan will even begin to pay.  A plan with a low monthly premium but a large deductible may prove to be very expensive in the long run.  The co-pay is the amount of each bill, after you have met your annual deductible, that you must pay.  It is expressed as a percentage, for example, 80-20 means that you must pay 20% of each bill after the deductible has been satisfied.

The poor patient in our horror story had a $6,000 annual deductible, of which only a small portion had been satisfied by the time she felt a lump in her breast.  She had a family history of breast cancer and was justifiably concerned about the lump.  After a mammogram, she was told she needed a biopsy, which was scheduled to be performed at a local for-profit hospital.

Our patient attempted to find out in advance how much she was going to have to personally pay but no one at the hospital would tell her.  They claimed that the price would depend upon what size biopsy needle they needed to use when they got in there and a number of other factors that could not be predicted in advance of the procedure.

She went to the hospital’s patient payment estimator and found that the average price of a breast biopsy for people with no insurance was $1,400.  She then did a Google search, which suggested the price might be as much as $3,000.  She was reassured by both of those prices and figured she would pay less because she had insurance.  Poor, naive patient.

After the biopsy, she got both good news and bad news.  The good news was that the lump was not cancerous.  The bad news was that the hospital billed the biopsy and related charges at very close to $18,000.  Her insurance paid a negotiated price of almost $8,500.  The patient was required to pay over $5,000, which was the balance of her deductible.

So how does a price vary from $1,400 for those with no insurance to $18,000 for those with insurance?  The price should be the price, unless your insurance plan can get a lower price for its customers.  It should never be more for insured patients.  The idea that you should have to pay a huge premium because you have insurance is ludicrous.  Welcome to the fun house of American hospital pricing.

Under a fairly new rule, hospitals are required to disclose their prices for a number of routine services they provide.  Hospitals fought to prevent the creation of this rule for years.  They don’t want the public or the health insurance companies to know how much they are charging others.  Now that the rule is finally here, many hospitals are just ignoring it.  Even among those who have disclosed some prices,  they have refused to disclose the prices for their most expensive procedures.

Using the available data from those who have made the disclosures, a group of researchers compared prices for both insured patients and uninsured or cash paying patients.  They published their results in one of the journals of the American Medical Association.  They discovered that what happened to our poor patient was not unusual and that very often hospitals gave a better price to uninsured patients than they did to patients who had health insurance.  The important takeaway from all this is that, if you have a high deductible health insurance plan and may have to pay much of a hospital bill out of your own pocket, ask about the hospital’s cash price before letting your insurance company pay.  You may save yourself quite a bit of money.

 

Posted in Fee for Service, Health Care Costs, Health Insurers, Hospitals, Mammogram, Medical Costs, medical ethics, Secrecy |

More Evidence Medicare Advantage Plans May Not Be A Good Deal

October 10, 2022

It is that time of the year again.  The Medicare Annual Enrollment period runs from mid-October to early December.  That means that the airwaves are full of celebrity spokespeople encouraging everyone who is Medicare eligible to “get all you deserve.”  By that they mean that you should enroll in a Medicare Advantage Plan and get “more” benefits than traditional Medicare provides.  It is true that most Medicare Advantage Plans offer benefits that Medicare does not and that they do not charge their members for those additional benefits.  How can they afford to do that?  The simple answer is that they rigorously control the benefits their members can use in a way traditional Medicare does not.  They may also require co-pays and other out-of-pocket expenditures.  The phrase, “There is no free lunch,” applies here.

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Those companies that offer Medicare Advantage Plans are doing so, not out of the goodness of their corporate hearts, but to make money.  They accept Medicare eligible patients and receive money from Medicare for each of those patients.  At the end of the year, they get to keep the difference between what they received from Medicare and what they had to spend on their members’ care.  There is a great incentive to keep the amount they spend on member care to the lowest possible number.

Medicare Advantage Plans keep their expenditures down in a number of ways.  They may limit the doctors their members may see to a network of doctors with whom they have negotiated favorable prices.  If your doctor or your favorite hospital is not in their network, you cannot see your doctor or go to your hospital without incurring additional charges.

The plans may also require that before you go see a specialist, the visit be approved by your primary care physician.  Reducing specialist visits is a time-honored method for HMO’s and similar organizations to keep costs down.  You may think you need the opinion of a specialist but, if your primary care physician, who is paid by the plan, does not agree, you don’t get to go.

In recent news, a new plan tactic has been discovered.  Medicare permits its beneficiaries to have up to 100 days each year in a skilled nursing home or in a rehabilitation facility.  Medicare Advantage Plans must also give their members that same benefit.  However, they are allowed some leeway in deciding when it is no longer medically necessary for their member to remain in the facility.  Recent investigations have found that some plans are telling their members to go home when the professional staff at the facility believes that the patient needs more care and that it would be unsafe to discharge them to home.  The response of the Medicare Advantage Plan?  Go home or appeal our decision and run the risk of being on the hook for several thousand dollars, if you lose the appeal.  The appeal is made within the advantage plan and many believe that the appeal process is weighted in favor of the plan.

Investigators for the Inspector General of the Department of Health and Human Services, which administers Medicare, found that nursing home care was among the most frequently denied forms of care by advantage plans.  The investigators also found that traditional Medicare would often have covered the denied nursing home care.

Medicare Advantage Plans may be right for you but they are not right for everyone.  Before you give up the freedom of traditional Medicare for an advantage plan, see what is covered and what is not.  Are your doctor and your favorite hospital in the plan’s network?  What are the services you are likely to need in the coming year and how much will it cost to receive those services through the plan?  How will your overall expenses under the plan compare to your expenses with traditional Medicare?  Are you willing to live with restrictions on your ability to see specialists without prior permission? There is lots to think about before making the choice to leave traditional Medicare.  Whatever you do, don’t allow yourself to be swayed by celebrity endorsers.  Do your research before you make your decision.  If you find yourself in a plan you don’t like, you will be stuck there until the next Medicare enrollment period rolls around.

Posted in Doctors, Fee for Service, Health Care Costs, Health Insurers, Hospitals, Medical Costs, Medicare |

Developments in Type 1 Diabetes.

October 03, 2022

Nine years in and counting.  It has been nine years since my then 3 year old grandson was diagnosed with Type 1 diabetes.  At the time of his diagnosis, I assured his anxious parents that relief was on the horizon.  Medical science was working feverishly to find both a cure for Type 1 diabetes and mechanical treatments that would more closely replicate the natural processes of the pancreas and keep blood sugars in a normal range.  While medical science continues to work feverishly on these two fronts, a really good solution seems still to be just out of reach.

What is diabetes? | CDC

Success in treating Type 1 diabetes is a holy grail for many companies and researchers.  There are an estimated 2 million people living with Type 1 diabetes in the United States today.  Approximately 200,000 of them are under 20.  The incidence of Type 1 diabetes is increasing for reasons that are not entirely clear.  It is estimated that by 2050 there will be 5 million people living with Type 1 in the United States.  Selling insulin to these people is already a huge money maker for Big Pharma.  Developing a cure would bring untold riches to the successful companies.  Developing an insulin pump which can effectively replicate the function of the cells that produce insulin and regulate blood sugar levels would also be a huge money maker.

Type 1 diabetes is an autoimmune disease.  For some unknown reason, the body’s immune system decides that the cells which produce insulin are a foreign invader and attacks them.  Insulin is a hormone that is essential to the body’s ability to use glucose to produce the energy the body needs in order to operate.  When enough insulin producing cells are destroyed, the body does not have enough insulin to survive.  Sugars in the blood reach out of control levels and, if insulin is not provided from the outside, the patient dies.  A little over 100 years ago, there was no outside source of insulin.  A little over 100 years ago my grandson would be dead by now.

There are two somewhat competing avenues of research for the treatment of diabetes.  The first is biological and seeks to restore the ability of the body to make insulin.  This avenue faces substantial obstacles created by the very process that caused the diabetes in the first place.  Any new insulin creating islet cells transplanted into the patient will be attacked by the immune system as were the original cells.  At present, islet cells are taken from a donor pancreas but there are not enough donors to supply everyone.  Anyone receiving such a transplant must take immunosuppressants for the rest of their life to protect the transplanted cells and immunosuppressants present problems of their own.  In spite of the use of immunosuppressants, the average life of an islet cell transplant is about two years.

Researchers are experimenting with novel ways to obtain islet cells for transplant and to protect them from destruction by the immune system.  Notwithstanding their best efforts, they appear to be quite a ways away from the time when a successful therapy can be rolled out to the public.

The second avenue of research and treatment is more advanced.  It is mechanical in nature.  It seeks to create what has been called “the artificial pancreas.”  The FDA has approved and companies already sell insulin pumps, which automatically deliver small amounts of insulin over the course of the day.  There are also sensors on the market that measure blood sugar and report it directly to the pump.  At present, the FDA has been unwilling to approve a pump that can take the data from the sensor and, using an algorithm, determine on its own how much insulin to deliver and when.  The greatest concern is that the pump might malfunction and deliver too much insulin, which causes a condition called hypoglycemia, or low blood sugar.  If blood sugar drops too low the patient becomes unconscious and can die.

The other failing of today’s pumps is that, unlike the human body, they can only deliver insulin.  In a non-diabetic, the body senses blood sugars and delivers insulin as blood sugar rises.  If blood sugar drops too low, the body will release stores of glucose to maintain appropriate levels.  The ability to sense the need for and to deliver glucose is a great defense against dangerous hypoglycemia.  Today’s pumps do not deliver glucose and will not in the foreseeable future, although some talented programmers have hacked insulin pumps to allow them to independently regulate blood sugar levels using both insulin and glucagon.

There is constant progress in the research and development of a cure and in the creation of an “artificial pancreas.”  In fact, the Wall Street Journal recently reported on a new pump being given fast track status by the FDA.  The pump does not need to be told how much insulin to deliver but makes the decision on its own and monitors the blood sugar levels.  That device may be approved in the next year or two.

If you, like me, have a loved one with Type 1 diabetes, you will continue to watch the developments and hope for significant breakthroughs.

 

Posted in drug companies, health, Medical Costs, Medical Devices, Type 1 Diabetes |

Thanks to Health Insurance Health Care Is Getting Worse.

September 26, 2022

In the United States, we already pay more than any other developed nation for health care, but have poorer outcomes in major categories of care, such as infant mortality, life expectancy, obesity levels and rate of suicide, just to name a few.  Of course, there is one significant difference between us and the rest of the developed world; we are the only ones without universal health care.  This has two important consequences, which will continue to plague us and which will likely lead to a continuing decline in our quality of care.  First, many of our citizens do not have access to health care, until they are desperately ill and hospitals are required by law to accept and treat them.  Second, health insurance companies take a huge chunk out of our health care spending as their cost of doing business and profit; money that could be better spent providing care.

Daring Women Doctors: Physicians in the 19th Century | PBS

If you have health insurance and think that the plight of the uninsured is no concern of yours, you are sadly mistaken.  Adults and children without health care cost society a lot of money.  Preventable illnesses or medical conditions may keep lower wage workers off the job and injure productivity or put them on government-paid disability.  Preventable illnesses may keep children out of school or they may go to school and infect other children.  As noted above, when people get sick enough, hospitals must accept them as patients and treat them until their medical emergency is over.  Someone must pay for that treatment and it is not likely to be the uninsured patient.  The cost of their care is added to your hospital bill and mine.  Since we are going to pay for it anyway, we should be looking for ways to keep people healthy as it will cost us the least in the long run.

The profit motive does not belong in health care and yet it is front and center.  Under our health insurance system, doctors treat patients and then send bills to the insurance company.  Each treatment and condition must be coded for billing purposes.  Doctors offices employ teams of people, not to treat patients, but to handle coding, send bills, and resolve billing disputes with the health insurers.  The bureaucratic paperwork necessary to run our health system takes up billions of dollars each year, even before the health insurers take their profit.

The health insurance companies are in business to make money and, according to Wall Street, they are very good at it.  One of the ways they make money is by controlling the care doctors provide their insured patients.  If the health insurer does not think the treatment was medically necessary, it refuses to pay.  If it thinks the doctor spent too much time with the patient, it refuses to pay.  If it thinks that the treatment was not covered by the mish mash of provisions in its insurance policy, it refuses to pay.  Doctors should not be forced to make treatment decisions based on whether the health insurance company is going to agree that the patient needed that care.  Doctors should not be forced to deny or limit needed care for fear of not being paid.

The corrosive effects of our health insurance system are all around us and getting worse.  Doctors spend less and less time with patients because health insurers limit the amount they pay for an office visit.  Everyone in medicine knows that listening to the patient is the best way to figure out what is going on.  It is the very foundation of diagnosis.  If the doctor has no time to listen to the patient, misdiagnosis, the most common form of medical malpractice, is more likely to occur.  Patients do not receive the treatment they need when the doctor cannot take time to listen to the patient.

Another key to good care is the quality of the physician/patient relationship.  The more trust the patient has in the doctor the better.  The better the doctor knows the patient and her medical history, the better care the doctor can deliver.  Health insurance cares nothing for the physician/patient relationship.  If your employer or you change your health insurance company, you can probably say goodbye to your doctor as you will be forced to use a doctor in the new insurance company’s plan and your doctor may not be among those on the list.  If you choose to remain with your doctor, you can count on paying extra for out of network treatment.

The corrosion raises ethical questions for doctors.  Faced with the risk of underpayment or no payment, the doctor is tempted to fudge the coding in billings to increase the chances the insurance company will pay for a treatment the patient needs but for which the insurer would not pay, if it knew the true story.  Forcing doctors into this ethical dilemma is bad for the doctors and for their patients.

As long as our health insurance system remains in its present form, health care is going to deteriorate.  Costs will go up.  Co-pays and deductibles will increase.  Doctors will be squeezed more and more.

Our health insurance system is virtually immune from meaningful change or regulation.  The problem is national in scope and requires a national solution.  We have a Senate in which nothing gets done without 60 votes.  Health insurers are veterans of the lobbying wars.  They have lots of money and know how to spend it to make sure they have the votes to prevent any threats to their profits.  You might as well get used to health care that gets worse each year while at the same time costing more each year.

 

 

 

Posted in Doctors, Fee for Service, health, Health Care Costs, Health Insurers, Hospitals, Medical Costs, medical ethics, Misdiagnosis |