Friday, August 26, 2011

An Insurance Maze for U.S. Doctors -

A former colleague from Canada who practiced medicine with me here in the States never hesitated to make one thing clear to me: He couldn't wait to get back.

It wasn't the cultural life that he missed, nor was it the ex-girlfriend I always suspected he pined for. It was the medicine.

"It's different," he would say wistfully, without elaborating. "Practicing medicine is just different over there."

A study published this month in the journal Health Affairs made me think of my colleague again and offered one likely possibility for his return to Canada: There, he had more time to focus on his patients.

Researchers asked hundreds of physicians and administrators in private practices across the United States and Canada how much time they spent each day with insurers and other third-party payers, tracking down information for claims that were denied or incorrectly paid, resolving questions about insurance coverage for prescription drugs or diagnostic tests, and filing the different forms required by each and every insurance company.

Physicians in Canada, where health care is administered mainly by the government, did spend a good deal of time and money communicating with their payers. But American doctors in the study spent far more dealing with multiple health plans: more than $80,000 per year per physician, or roughly four times as much as their northern counterparts. And their offices spent as many as 21 hours per week with payers, nearly 10 times as much as the Canadian offices.

"The amount of time we spend on this is just crazy," said Dr. Sara L. Star, a partner in a three-physician pediatrics practice in suburban Chicago. "But each insurance company has its own language, its own set of rules and specific contracts with certain laboratories, hospitals, physicians and pharmaceutical companies."

And when those companies offer multiple "insurance products," the convoluted coverage grid acquires yet another level of complexity. Each "product" comes with its own unique permutation and combination of authorization requirements, rules for claims and list of approved prescription drugs.

Large practices often choose to outsource the job to firms that specialize in wading through the labyrinthine rules and regulations. Some hire several nurses or administrators to work exclusively with insurers, with each specializing in the arcane rules of a single insurer. But most primary care providers in this country — clinicians who are part of practices with five or fewer physicians — cannot afford to pay for additional help. Instead, they must make their way through the thicket of insurers and rules by themselves.

The complicated task inevitably gets in the way of patient care.

A young patient complaining of extreme fatigue, for example, might benefit from a $40 blood test that could confirm infectious mononucleosis in 10 minutes. But a doctor cannot order the simple test without first checking with the insurance company to see if it is covered and if there are any constraints on where the patient's blood can be drawn and the test run.

Tracking down answers often means phone calls with long periods on hold, digging up old patient information and even recruiting office workers to act as specimen couriers to other labs and hospitals in order to expedite results or save frail patients or harried family members the hassle of traveling to an "approved site" for a test or procedure. "If someone comes in with a sick infant who needs a test, we often eat the costs and draw the blood ourselves," Dr. Star said. "We aren't going to tell them to put that kid in a car seat, drive a mile to an approved lab, park, register, then wait in line."

Even more confusing are frequent changes in health care plans, particularly regarding prescription drugs. Every week, payers send physicians' offices notifications of changes in their list of approved medications, lists that run to hundreds of different drugs. The sheer volume of new information makes it impossible for doctors to keep up. "Physicians get into medical school because we can follow rules," said Dr. Marian Bouchard, a family doctor who practices with two other physicians and a nurse practitioner in Bristol, Vt. "But none of us can or want to follow the minutiae of a hundred rules at once, especially when we are trying to be present for our patients."

The authors of the study offer several recommendations to reduce the confusion and inefficiency of interactions between physician practices and payers. Not surprisingly, they propose simplifying the forms and procedures that add to costs without improving quality. "There are rules that really save money or improve patient care that health plans won't want to change," said Sean Nicholson, one of the study authors and an economist in the department of policy analysis and management at Cornell University. "But there are also a lot of things that don't matter that they could and should standardize."

The insurance industry, for example, could embrace a single set of universal standards to measure quality rather than the dozens that are currently used. They could adopt a uniform process of obtaining authorization for tests, procedures or consultations. And while widespread adoption of electronic medical records and changes in how doctors are reimbursed may eventually decrease some administrative burdens, the results of the study leave little doubt as to the costs now and in the foreseeable future for doctors and patients.

"We aren't saying that we should go to a single-payer system," Dr. Nicholson added. "But it's important to know exactly what all the benefits of the current costs are."

Wednesday, August 24, 2011

Deciding to Die, Then Shown the Door -

Armond and Dorothy Rudolph had talked about their plans for more than a decade. They had a mutual horror of a lingering decline in their final years. They'd joined an organization that supports the right to end life when illness or pain becomes overwhelming; they'd attended meetings and given both their children literature on the subject. They'd drafted advance directives.
"Their great fear was that they'd end up in a nursing home," their son, Neil Rudolph, told me. "That was hell for them, to have people waiting on them, to have no independence."
As it happened, the elder Rudolphs had a long and satisfying old age in Albuquerque, N.M., where they lived for 60 years; they gardened and volunteered with the Boy Scouts and served as leaders in their Presbyterian church. 

When their large house and gardens became difficult to maintain, they built a smaller one in a neighboring town, then moved again to a retirement community.
Mrs. Rudolph had nursed her own mother through four years of bone cancer, he said. "She saw her mother die a slow, wasting death. She felt pinned down for years, and she felt guilty about feeling pinned down. She didn't want that to be our experience."

"At that point, some health issues began to emerge," their son said. Mrs. Rudolph broke her hip and was in and out of rehab, suffering frightening episodes of delirium.
"Dad had a permanent catheter," said Neil Rudolph. "Physically and mentally, they began to go downhill." In October, they entered an assisted living facility called The Village at Alameda, thinking it would be their last home.
The Rudolphs faced increasing pain and debility. Mr. Rudolph, 92, suffered from spinal stenosis; Mrs. Rudolph, 90, had become largely immobile. Both showed symptoms of early dementia. So in January, they set in motion their plan to stop eating and drinking.
Current management would not comment beyond an e-mailed statement saying that when a resident "requires alternate placement, medical attention, or a level of care beyond the facility's capabilities, we have an obligation to notify a medical provider." Fundamental Long Term Care, the firm that owns the facility and more than 100 others in 14 states, did not respond to requests for interviews.
And the facility tried to evict the couple. The administrators, apparently on orders from the corporate legal department in Maryland, told the family the Rudolphs had to leave the next day.
As Neil Rudolph recalls the events, he protested that the couple — already on Day 4 of their fast — had nowhere to go. He also pointed out that their contract required 30 days' notice of discharge. The following day, administrators called 911, reported a suicide attempt and told the paramedics to take the elder Rudolphs to a hospital.
So much for the peaceful passage.
Voluntarily stopping eating and drinking — as the Rudolphs had learned from consulting with Compassion & Choices, the largest national organization working to expand end-of-life options — is a legal way to hasten death without drugs or violence, usually in about two weeks. In a survey of hospice nurses in Oregon, published in The New England Journal of Medicine in 2003, respondents reported that most of their terminally ill patients who had deliberately refused food and fluids had "a good death," with low levels of pain or suffering.
"They said, 'That's what we want to do,'" Neil Rudolph said, emphasizing that his parents' decision was hardly impulsive or caused by a bout with depression. He and his sister, Elaine Spence, and their spouses had come from Colorado to be with their parents and had called in a hospice organization. "We all discussed what it meant and whether they were sure," he said.
When his parents said they were, he helped them write a statement affirming their decision and then told the assisted living administrators about their plan.
Shortly thereafter, two emergency squads, from the Albuquerque Fire Department and Albuquerque Ambulance Services, converged on the scene. Neil Rudolph's wife called a reporter from The Albuquerque Journal, to whom the elder Rudolphs gave outraged and lucid interviews. The emergency crews soon called a doctor at the University of New Mexico's emergency medicine department, part of a consortium that consults when a 911 call brings a situation outside the norm — and this certainly qualified.
"They were stuck between divergent opinions and said, 'We need some guidance,'" recalled Dr. Drew Harrell, who was on call. He drove over to assist.
The standoff illustrates the legal tangle surrounding V.S.E.D., short for voluntarily stopping eating and drinking.
Under federal law, V.S.E.D. is indeed legal in every state, said Charles Sabatino, who directs the American Bar Association Commission on Law and Aging. "That a competent person can refuse any medical intervention, including tube feeding, has been recognized by the Supreme Court," he said.
It also is established in the federal Patient Self-Determination Act. Even a dementia diagnosis doesn't necessarily mean that someone lacks legal capacity to make that decision.
But, he added, "While the theory may be clean, the execution may get messy." Those who oppose the act for religious or ethical reasons (or fear of lawsuits) can throw up roadblocks.
New Mexico's Uniform Health-Care Decisions Act spells out an individual's right to stop eating and drinking, said Barbara Mathis, who helped draft the legislation and has taught at the University of New Mexico Health Sciences Center Institute for Ethics. "I would have been happy to go to court for no pay and get a temporary restraining order to keep the family from getting kicked out" she said.
It never came to that. Dr. Harrell spoke with everyone involved, including separate and lengthy bedside discussions with Dorothy and Armond Rudolph. "They were able to very appropriately and eloquently explain their wishes and what they wanted to have done," he said. "They didn't feel the need to go to a hospital. They detailed that they wanted control over their own end-of-life issues."
Reassured that they understood the ramifications of their decision, "I made a determination that our services were not needed," he said. The Rudolphs signed papers showing they had declined transport.
Worried about further conflict, their children transferred the Rudolphs to a rented house in Albuquerque and moved in themselves. Even with daily or twice-daily hospice visits, the round-the-clock vigil was exhausting — "but satisfying," Neil Rudolph said. "This was what they wanted, and we could help them carry it out." After slipping into unconsciousness, Mrs. Rudolph died first, 10 days after starting the fast; her husband followed the next day.
"They did find the dignified and peaceful death they both sought, but it's also a cautionary tale," Neil Rudolph told reporters in Denver last week.
He has launched a campaign with Compassion & Choices to inform people about voluntarily stopping eating and drinking. The organization is circulating a rider to assisted living contracts that states, in part, "Facility will respect Resident's end-of-life choices and will not impede any course of treatment, or non-treatment, freely and rationally chosen by Resident."

Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."

Cut Medicare, Help Patients -

MEDICARE is going to be cut. That is inevitable. There is no way to solve the nation's long-term debt problem without reducing the growth rate of federal health care spending. The only question is whether the cuts will be smart ones.

Smart cuts eliminate spending on medical tests, treatments and procedures that don't work — or that cost significantly more than other treatments while delivering no better health outcomes. And they can be made without shortchanging patients. There are plenty of examples; here are three.

Late last year, the Food and Drug Administration determined that the drug Avastin, which has serious side effects, is not effective for treating breast cancer. Astonishingly, Medicare declared it will still pay for Avastin — at a cost of about $88,000 per year for each patient.

Consider colonoscopies. The United States Preventive Services Task Force recommends not doing colonoscopies for most people over 75 because there is no evidence that they save lives in this population. Moreover, the risk of perforating the intestines rises with age. Yet Medicare pays for the procedure regardless of the patient's age.

Every year more than 1 million cardiac stents are placed in patients to open blocked arteries. Stents are essential immediately after a heart attack, but a 2007 randomized trial conducted at 50 medical centers in the United States and Canada showed that for patients with stable heart disease, stents do not reduce the number of heart attacks or save lives when compared with drug therapy. And they are substantially more expensive.

Because stents are more effective at reducing pain in some patients, the best practice is to start patients on drug therapy and insert a stent only for those who do not respond to treatment. Yet many patients who receive stents paid for by Medicare are either experiencing no pain or have not tried medication first.

The list of procedures Medicare pays for that are proven to have no benefit goes on and on. Cutting payment for these is not rationing. It saves money, but it also protects patients from the pain, stress and risks associated with unnecessary care.

Smart cuts can also be achieved through better coordination of patient care. One program, at the University of Pennsylvania, sends a nurse to visit older adults at home immediately after they have been discharged from the hospital. By reducing readmissions, the program saves $5,000 per Medicare patient. It also improves health outcomes. By assigning a nurse case manager to high-cost Medicare patients, Massachusetts General Hospital has reduced spending on these patients by 4 to 5 percent and also reduced mortality.

Group Health Cooperative in Washington State transformed its primary care practices in a pilot program by creating teams of doctors, nurses and pharmacists who work together, extending its regular office visits to 30 minutes and introducing "care coordinators" who follow up with patients after office visits, hospitalizations and procedures. After two years, quality of care and patient satisfaction improved; emergency room visits declined by 29 percent and hospitalizations by 6 percent.

Unfortunately, Washington is preoccupied with ill-conceived cuts. Three kinds of cuts got serious consideration in the recent debt limit negotiations, and are likely to resurface as the special Congressional committee tries to achieve $1.5 trillion in additional deficit reduction:

• Meat-cleaver cuts hack spending indiscriminately. Across-the-board cuts in payments to Medicare providers (which will kick in if the special committee doesn't come to an agreement) fall into this category. Cuts that fail to distinguish between high-value and low-value medical care would do more harm than good.

• Cost-shifting cuts don't actually reduce health care spending; they just shift costs from the government to the private sector. Increasing Medicare's eligibility age from 65 to 67, as Senators Tom Coburn and Joseph Lieberman have proposed and as the Obama administration reportedly floated during the debt ceiling negotiations, is a classic example. While raising the eligibility age would reduce government spending on Medicare, it would shift the costs to individuals and businesses. It would also increase the number of uninsured 65- and 66-year-olds, leading to worse health outcomes and making it harder for older Americans to find work.

• Penny-wise, pound-foolish cuts reduce current spending by a little but raise future costs by a lot. Raising co-payments for office visits and medications is a good example. Research shows that when older adults are charged higher co-payments, they reduce their primary care visits and use of prescription drugs. But the research also shows that forgoing this outpatient care leads to an increase in expensive hospitalizations.

THE sad truth is, Washington is never going to do a good job of making smart cuts to Medicare. Elected officials hate being blamed for directly restricting access to medical treatments — even when those treatments are proven to be worthless. Moreover, much wasteful spending occurs in situations where care that is appropriate for some patients is given to patients for whom it is inappropriate. It is impossible for Medicare to write payment rules that cover all such circumstances.

The responsibility for ending unnecessary medical spending needs to be placed in the hands of doctors and hospitals. This can happen only if we change our fee-for-service payment system. Today doctors and hospitals that develop new programs to keep patients healthy lose money in two ways. They spend money re-designing care and then, with fewer office visits and hospitalizations, the payments they receive go down.

The seeds of a solution lie in the accountable care organizations, medical homes and bundled payment reforms that were authorized by last year's Affordable Care Act. Accountable care organizations are groups of health care providers and hospitals that work together to treat patients. Medical homes coordinate primary care services. And bundled payments consolidate the many costs of an episode of care, like a hospitalization, into a single payment, incentivizing efficient delivery of tests and treatments. All of these reforms allow payments to be based primarily on the number of patients cared for and the quality of that care rather than on the volume of services provided.

To control Medicare spending and reduce the deficit, we need to stop paying for wasteful procedures, accelerate adoption of the Affordable Care Act reforms and empower doctors, nurses and hospitals to provide higher-quality and more efficient care. The path to smart cuts is clear.

Ezekiel J. Emanuel, an oncologist and regular contributor to Op-Ed, will be a vice provost and professor of medical ethics and health policy at the University of Pennsylvania beginning in September. Jeffrey B. Liebman is a professor of public policy at Harvard. Both were White House advisers.

Complaints Soar on Hip Implants as Dangers Are Studied -

The federal government has received a surge in complaints in recent months about failed hip replacements, suggesting that serious problems persist with some types of artificial hips even as researchers scramble to evaluate the health dangers.

An analysis of federal data by The New York Times indicates that the Food and Drug Administration has received more than 5,000 reports since January about several widely used devices known as metal-on-metal hips, more than the agency had received about those devices in the previous four years combined.

The vast majority of filings appear to reflect patients who have had an all-metal hip removed, or will soon undergo such a procedure because a device failed after only a few years; typically, replacement hips last 15 years or more.

The mounting complaints confirm what many experts have feared — that all-metal replacement hips are on a trajectory to become the biggest and most costly medical implant problem since Medtronic recalled a widely used heart device component in 2007. About 7,700 complaints have been filed in connection with that recall.

Though immediate problems with the hip implants are not life-threatening, some patients have suffered crippling injuries caused by tiny particles of cobalt and chromium that the metal devices shed as they wear.

Hip replacement is one of the most common procedures in the United States and, until a recent sharp decline, all-metal implants — one in which both the artificial ball and cup are made of metal — accounted for nearly one-third of the estimated 250,000 replacements performed each year. According to one estimate, some 500,000 patients have received an all-metal replacement hip.

One of the most problematic devices, the A.S.R., or Articular Surface Replacement, was recalled last year by Johnson & Johnson and accounted for 75 percent of the complaints reviewed by The Times. A precise count of failed implants reported to the F.D.A. is hard to come by because of the agency's overlapping reporting system, though The Times sought to eliminate duplicate reports about the same incident. Some complaints came from outside the United States.

Under F.D.A. rules, many all-metal devices were sold without testing in patients or without a requirement that producers track their performance. But in an unusual intervention, the F.D.A. in May ordered producers to study how frequently the devices were failing and to examine the threat to patients. Now, researchers say, producers face substantial hurdles in recruiting the hundreds of patients needed to conduct sound studies because of the lack of patient registries.

"They are grasping at how they are going to get this information," said Dr. Robert S. Namba, an orthopedic surgeon with Kaiser Permanente.

In addition, researchers are struggling to understand the tissue damage caused by the metallic debris. While some patients experience pain, other patients with the same damage have no pain, complicating decisions about whether to remove devices.

As problems and questions grow, most surgeons are abandoning the all-metal hips, saying they are unwilling to expose new patients to potential dangers when safer alternatives — mainly replacements that combine metal and plastic components — are available. Some researchers also fear that many all-metal hips suffer from a generic flaw. Current use of all metal devices has plummeted to about 5 percent of the market, though a few of the models are performing relatively well in select patients.

"It is like playing Russian roulette," said Dr. Geoffrey H. Westrich, an orthopedic surgeon at the Hospital for Special Surgery in New York, who has stopped using all-metal implants.

Dr. William Maisel, the chief scientist of the F.D.A. division that oversees medical devices, said he believed that producers would mount rigorous studies and find answers. But he acknowledged that it could take several years.

"There is not an existing infrastructure for studying this kind of information," Dr. Maisel said.

For many patients, it is too late. In 2008, Ann Morrison, a physical therapist from Newark, Del., received all-metal replacements for both of her hips. But Ms. Morrison, 50, soon experienced pain, rashes and inflammation.

Last year, the devices were replaced, but by then, she said, debris-caused tissue damage was so extensive that she now needs a brace to walk and still cannot work. She called the F.D.A.'s order for medical studies a "joke."

"We will be the little crash test dummies here until they figure out the health ramifications for us down the road," said Ms. Morrison, who has sued the DePuy division of Johnson & Johnson, which made her implants.

To conduct its analysis, The Times reviewed complaints filed with the F.D.A. from 2007 through this June for several implants, including the A.S.R. and the Durom cup, a component sold by Zimmer Holdings.

Typically, the number of complaints filed with the F.D.A. about a product understates a problem because while companies must file reports, doctors and patients do not have to. The filing volume for the A.S.R. and the Durom cup probably reflects a surge of lawsuits filed against their makers.

The Times review found some 7,500 complaints about the A.S.R., nearly 5,000 of them coming since January. In the case of the Durom cup, about 1,600 complaints were filed with the regulator from 2007 to this June.

Because complaints to the F.D.A. are not uniform, it is impossible to say how many adverse reports about all-metal hips have been submitted. For example, the Times analysis found some 200 complaints about an all-metal version of another DePuy device called the Pinnacle as well as 400 additional complaints that noted metal-related problems in Pinnacle patients. But the Pinnacle is sold in several versions, so it was not clear how many of the metal-related complaints were linked to the all-metal device.

A spokesman for Zimmer Holdings said the Times review was "in the ballpark" of the company's assessment of the drug administration's filings. A DePuy spokeswoman declined to disclose the number of A.S.R. complaints that the company forwarded to the F.D.A. She maintained that the Pinnacle was performing well.

DePuy, Zimmer and another producer of metal hips, Wright Medical, declined to discuss the study proposals they had submitted to the F.D.A. to comply with its May order. A fourth company, Biomet, said it had proposed mounting a study of 400 patients who received its devices that would draw in part on studies already under way. The F.D.A. declined to release producers' proposals, saying that they contained "confidential commercial information." The agency has until November to decide on the plans' adequacy.

In an effort to recruit patients, companies have recently contacted, researchers said, health systems like Kaiser Permanente and hospitals that operate their own implant registries.

Meanwhile, researchers say it may be a year before standard protocols are formulated that may be central to the future studies, like a uniform procedure to measure metallic ions in a patient's blood or how to calibrate diagnostic equipment to best detect tissue damage.