Letters to the Editor is a periodic KHN feature. We welcome all comments and will publish a selection of those that are relevant. We will edit for space, and we require full names.
Among the stories that have drawn comments and responses are Susan Jaffe's piece examining the costs of hospital "observation care" and Phil Galewitz' article on virtual doctor visits. Here's a sampling:
The story $18 For A Baby Aspirin? Hospitals Hike Costs For Everyday Drugs For Some Patients (Jaffe, 4/30) drew the following comment:
Mike Alkire, COO of the Premier Healthcare Alliance, Charlotte, N.C.
As the article, "$18 For A Baby Aspirin? Hospitals Hike Costs For Everyday Drugs For Some Patients" points out, many patients look at a hospital bill only to go into sticker shock. What the article doesn't include is an explanation for why costs are so high.
The culprit is our reimbursement structure.
Public programs do not fully pay for the cost of care. … A Premier study of 323 hospitals identified $1.82 billion in annual losses for cardiac or orthopedic procedures. In one case, valve replacement surgery cost the hospitals $14,500 more than their Medicare reimbursement – per case!
Unable to absorb losses, the bill gets passed to commercial insurers and individuals who pay out of pocket. And it's only going to get worse as our population ages and more Americans call Medicare and Medicaid their insurer.
The only way to avoid these costs to make limited dollars go farther and to tackle the big-spend areas [is] to improve efficiencies and eliminate waste. Consider the example of medical devices, such as pacemakers, artificial knees and spinal discs. … These devices are chosen and ordered by physicians, but they don't pay for them – hospitals do. The result is that price is rarely factored into the decision of which device to use. As long as this remains the status quo for payment, hospitals that want to reduce the expense and lower the bill - for all of us - are completely handicapped.
But solutions may be on the way. Last year, Medicare announced a program that would allow for "bundled" payment. The approach would require providers to bid as a team for fixed price reimbursement, including those that require pre- and post-hospital care such as heart surgery or hip and knee replacements. In this way, Medicare is injecting price sensitivity into a market that traditionally has lacked it. ... And it's been proven to work. A heart bypass bundled payment demonstration saved $42.3 million, or roughly 10 percent of expected costs, and reduced patients' insurance costs by $7.9 million while improving care and lowering mortality rates.
This is what the future needs to look like. … There are answers to the cost question out there. But we need to deploy these solutions in a much more systematic way.
Readers also commented on Insurers Embrace 'Virtual' Doctor Visits (Galewitz, 5/6).
Dr. Irvin Zeitler, Jr. President, Texas Medical Board
Ron Hammerle, chairman and CEO, Health Resources, Ltd., Tampa, Fla.
The Texas Medical Board would like to respond to the May 6 Kaiser Family Foundation/USA Today article by Phil Galewitz, "Insurers Embrace 'Virtual' Doctor Visits."
Texas Medical Board rules absolutely allow telemedicine. In general, two models are addressed, each for a different situation: either from a patient's home or from an established medical site. Patients can access health care via telemedicine (video conferencing with a live feed) from their homes. The basic requirement for an in-home evaluation is that the patient must be a patient previously seen in person either by the physician or PA with whom the patient is teleconferencing or by another physician [to whom] the patient [has been referred] and the referral is documented in the medical record. Once that initial diagnosis is made in person or at an established site, the patient may receive follow-up care for that pre-existing condition via telemedicine in their homes.
In addition, the doctor can treat pre-existing patients in their homes for new symptoms as long as the patient is advised to see a physician face-to-face within 72 hours if the symptoms do not resolve. Patients who live a great distance from a physician can access telemedicine via an established medical site, which can be a nurse's station in a public or private school, a volunteer fire department, an EMS station, a residential or institutional care facility, or even a pharmacy. The key criteria are the availability and presence of a patient site presenter who is a licensed or certified health care professional, such as a nurse, emergency medical technician (EMT), or pharmacist; and sufficient technology and medical equipment to allow for an adequate physical evaluation.
The article includes a nurse practitioner diagnosing a pediatric patient's high fever over the phone, and a physician identifying a respiratory illness without looking at the patient's nose or throat. The implication is that a physical exam is unnecessary. We at the Texas Medical Board could not disagree more strongly. The TMB is working to educate doctors on these and other rules through its outreach program. More information about Texas' telemedicine rules can be found here.
When the telephone was first invented, retail pharmacies were among the first to install the technology in their stores -- and physicians were among the first to adopt its use. Today, despite global advances in telecommunications, medical imaging and information technology, some medical societies and state licensing boards are resisting "telemedicine," arguing it is not in patients' best interest. One suspects other motives and interests are really involved.
At some point in time, the business community and governmental units, each faced with healthcare costs that have historically risen at three time the CPI, will decide that such professional protections are neither in their interest nor the public's. Medically uninsured patients are already voting with their phones and feet.
One reader offered the following response to Insuring Your Health: Some Insurers Paying Patients Who Agree To Cheaper Care (Andrews, 4/26).
Dr. Geraldine McGinty, chair, Commission on Economics, American College of Radiology
As a provider of diagnostic imaging services and chair of the American College of Radiology Commission on Economics, I strongly disagree with the observation in "Some Insurers Paying Patients Who Agree to Get Cheaper Care" that "For simple diagnostic lab and radiology procedures, choosing providers based primarily on cost is probably fine."
With the increasing complexity in the array of imaging tests that are available for accurate diagnosis and surgical planning, it is more important than ever that the appropriate imaging test be employed for a particular clinical problem and that those services be of the highest quality possible. The consultative relationship that a referring physician, whether a surgical specialist or a primary care provider, develops with the physicians at the imaging facility is essential to this process.
Advanced imaging procedures, (CT, MRI, PET, and Ultrasound) should only be performed at facilities subjected to a robust accreditation process such as those of the American College of Radiology. We strongly object to a process whereby the patient is steered to a particular provider over the recommendations of their personal physician solely on the basis of cost. This interrupts the physician-patient relationship and may actually lead to repeat testing when the initial examination ordered is not the most appropriate, not performed at a high quality level, and or not performed to address the particular clinical issue.
ACR Accreditation assures quality and safety -- for equipment and personnel. These factors are still paramount -- particularly when dealing with matters of health.
One reader offered a different perspective in response to Dr. Otis Brawley: 'The System Really Is Not Failing… Failure Is The System' (5/1).
Mary Riley, San Diego
I understand [Dr. Brawley's] point but would like to suggest that this MD also needs to provide some reasonable effort to identify what is working about our health care system.
I have survived cancer. Prior to diagnosis I rarely went to the MD except for regular check-ups, and did what I could to stay healthy. I completed a triathlon four days before receiving my diagnosis. I did triathlons, maintained a normal weight throughout my life, avoided red meat and ate organic food. I still got cancer at a relatively young age. My point is that there are people that do everything they can to stay healthy and still get very sick.
My genetic makeup predisposed me to getting cancer -- not my lifestyle. I had lymphoma. The health care system worked well for me. I did go to a National Cancer Institute designated hospital and underwent treatment. I honestly think it is very wrong to NOT state that there are areas where our current health care system is working and I was lucky enough to experience this. There are good doctors and good institutions delivering health care and we need to recognize this. We need to inspire confidence where it is deserved.
Meanwhile, the story, Community Health Centers Under Pressure To Improve Care (Galewitz and Monies, 4/17), led readers to comment on the care provided at the facilities and to question some of the comparisons that were included.
Dora Harris, Saginaw, Mich.
Robert J. Hodgen, CEO, Upper Valley Community Health Services, Inc., St. Anthony, Idaho
Health centers mean so much to our urban population. I must agree, without our centers so many of our patients would fall through the cracks. When our patients come into the center, they bring the total package. We become the doctor, the social worker, the therapist and, a lot of times, the counselor. There are times when they just need someone to listen. Over the years we have come to realize we have become a part of their family. That's a great feeling to have that kind of relationship with your patients. For some of us, we've seen 3 generations come through our doors. Our care is needed and appreciated. I love what I do and who I serve.
Thank you for an informative article on CHC's. I'm sure it will be used to sensationalize the shortfalls of safety net health care, but that would be a gross misinterpretation of the message. You have clearly outlined the challenges we face in providing health care for the underserved; no money, no transportation, poor diets, lack of health literacy, superstition, fear of deportation, self-destructive behaviors, mental illness, etc. Comparing care for this population to a national average seems a bit unbalanced but the results are outstanding, given the challenges of increasing demand and diminishing resources faced by CHCs. What would be the results of a comparison of children of poverty with a national average in education or housing? I hope this message is understood by all your readers.
In response to Medicare To Tie Doctors' Pay To Quality, Cost of Care (Rau, 4/15):
Dr. Arthur Kim, Austin, Minn.
I admit that this is an enormous task to rein in the cost escalation, and many bright people with expertise are making contribution to resolve this matter with utmost sincerity. However, at the end of the day, "Physician Value-based Payment Modifier" would cause physicians to avoid "sicker and complicated" patients to maintain their "quality score." Blaming and "finger pointing" will be common occurrence between doctors. Also, implementation of this new method in 2015 is too early. The payment modifier should go through a trial period in a pilot project with participation of various stakeholders.