Now it just so happens that Kagen – who is also a Doctor – will be in Massachusetts this month and there is an event at The Precinct Bar and Restaurant in Somerville’s Union Square for him. It’s on Sunday, March 21st from 6 – 8 and Congressman Capuano is one of the sponsors of the event.
Kagen is a frontline Democrat in a swing district. He was first elected in 2006 in an upset, and he already has seven Republicans running against him. If the GOP defeat Kagen and take back this seat, it’s going to spell trouble for people who want progressive leadership in Washington DC. Hope you can come down and meet Kagen and make a contribution to his campaign.
(Full Disclosure – Kagen is a client of The Campaign Network in Boston, who I consult with.
Please share widely!
because then you could refuse products you didn’t feel you needed. If told I needed Tylenol, I could choose not to buy the $140. Tylenol, instead I would send my daughter to the store and pick up a bottle for $5.00 and give it to myself. You could also question the need for tests and refuse certain ones if you didn’t think they were necessary (of course after discussing with the doctor).
So here’s a question:
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p>If you know you’re going in for a procedure, and that you will have any amount of pain management afterward while still in the hospital, why not ask what the options are ahead of time — aspirin, acetaminophen, etc., and in what unit measurements (mgs). Then, come in with a brand new bottle of each possibility. Might cost you $20 at CVS for all of ’em.
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p>Put them next to the bed.
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p>Now, instead of the nurse serving you up a $40 pill, you find out what you’re supposed to have and use your own supplies.
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p>Is this Kosher? I’d think it is. It’d lower costs for both the patient and the insurance company — but lower the revenues for the clinic or hospital, who would have to adjust costs to make up that revenue elsewhere. That’s fine by me: the price of services in hospitals ought to more closely reflect the cost of those services, not be a wild mix of cross-subsidies.
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p>As for tests, you may find you’re in a tougher boat — the doctor may not be willing to diagnose you if you refuse a test. After all, the doc may be on the hook for a poor diagnosis, and it’s harder to make a correct diagnosis when the information is more imperfect.
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p>Saving money on OTC pain medication (and other OTCs) at hospitals isn’t going to “fix” health care but, like climate change and energy, there isn’t likely to be a single fix but rather a long series of small fixes, each incrementally improving the situation.
You’ve just wreaked havoc with the business model of the suppliers who contract with the hospitals to provide such medications — you’ve taken away the low-cost high-markup medications that are their bread and butter.
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p>It’s an excellent idea.
When checking out nursing homes for my Dad I made a point of looking over the latest inspection report from the state. A number listed the “violation” of patients having their own bottles of Tylenol or Motrin. What if someone takes the wrong amount while under the hospital’s roof. Can I bring my prescription, controlled substance, migraine medicine? (It’s good stuff.) My Dad was actually told he could not have a couple cans of Ensure in his room because they were considered to be “meal replacements”. He could however hade 10 pounds worth of assorted candy worth half a million calories.
there is the potential for confusion, for combining self-medication with meds from the hospital, etc. That’s why I asked.
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p>But look, if the doc wants you to have 600 mg of ibuprofen, it doesn’t matter if it’s 3 200mg tablets from OTC or 1 600mg pill from the pharmacy. Same drug, same amount.
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p>As long as its the nurse who always opens the bottle and serves it up, does it really matter?
As long as you want to be sure to keep the right to sue the hospital, doctor, and nurse for a bazillion dollars when something goes wrong.
If I get around to it, I’m going to write a post on regulatory failures, cases where well-meaning regulation can have negative consequences.
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p>I’m unsure what the effect of Kagan’s suggestion would be, so I’d like to see how it would operate in the wild. Several thoughts come to mind:
So I can imagine this having lots of different effects, but I don’t know whether the good will outweigh the bad. Potentially, of course, by a lot, but these things can have unintended consequences.
that those overpriced aspirin pills help to offset the huge losses from serving non-insured and underinsured patients.
are probably steeply discounted by insurance companies, they probably pay only $5(guesstimate, haven’t been hospitalized in years) of the actual charge, the rest is taken as a “discount”. However, a self pay customer, one who is most likely middle class, who can’t afford insurance but does not qualify for a state subsidized plan will have that charge remain on their bill. And if they don’t pay it, it will go to collections or they will charge it on a credit card.
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p>Many of those inflated charges really only affect self pay individuals.
when my wife went in for surgery @ MGH in ’04 the bill from the hospital for her 30 hour stay was north of $30,000. BCBS paid around $10k. An interesting scenario to say the least where the “man in the middle” (not the poor who would never pay dime one) or the insured are the ones getting stuck with the bill at the end of the night.
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p>That being said, what has been going on recently with small businesses in MA and their health insurance premiums is that they’re the ones given the tab.
… one of the things that is peculiar about healthcare as a product is that we don’t tend to question it – we don’t tend to overrule the doctor. So the concept of empowering the will of the health care consumer is a bit weird given that it’s one of the products we are least likely to question as consumers.
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p>All that isn’t to say that the Doctor really is always right nor that people would do well to shop around their diagnoses in order to be an intelligent consumer. But I put much more faith in MEDPac and comparative effectiveness study. I doubt we’re going to change this aspect of ‘trust the doctor’ in health care very much or that changing it a lot is necessarily a good idea. So with the consumer helpless to be much less informed about their health care as the doctor, I think focusing on the doctor / provider, his or her practices and the availability of information for him or her, as well as tweaking the payment system so that they are more inclined not to incur ‘treatment waste’. This is exactly where Kaiser and Mayo have made great strides and that’s without MEDPac or comparative effectiveness.
… reading: The Fed.
I like this idea as a stop-gap measure.
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p>In the longer run, because health is simply not something that can be priced in any rational way, no market-based approach to health care is ever going to work in a sustainable way.
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p>We need government-sponsored single-payer health care, and the resulting delivery system must also encompass pharmaceutical supplies. The cost differential should go in the other direction — the medication offered by the hospital should always cost less (and be priced lower than) the same medication offered in the local CVS. This is because the government-operated plan should always buy in much larger bulk and obtain correspondingly lower volume discounts from the supplier.
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p>Some things can be rational — which is to say, we can encourage a competitive marketplace for some components of health care. Medical devices is a great example.
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p>What’s the market for used crutches? There generally isn’t one — every kid who gets hurt playing soccer ends up with a new pair of crutches. It turns out that since insurance covers most/all of the cost, there’s just no market for used crutches.
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p>This is dumb. We’re not talking about re-using things which ever get blood/puss/scat/germs on ’em. We’re not talking about dialysis components (to which research has shown that new outperforms used-and-cleaned). We’re talking about wood and a little foam and a bolt and wingnut. Yet we don’t reuse.
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p>Another example is pills, one MCRD was fond of bringing up. Lots of pills follow the following path:
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p>Factory in big bottle to hospital pharmacy
hospital pharmacy to small bottle to room in hospital
small bottle in room in hospital to toilet
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p>If a patient doesn’t consume every pill in the bottle (no longer needed, doctor changes Rx, patient dies, whatever), the contents get tossed in the toilet. Ibuprofen is cheap but not all drugs are.
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p>With all these “reuse” issues, there is overhead cost. The material has to be re-collected and then inspected (crutches for cracks, pills to ensure they’re the correct pill). Things may have to be cleaned. Still — I suspect that there are plenty of cases where we could drive down cost by using traditional market pressures — virtually identical items (new v. used) with vastly different costs.
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p>At the end of the day, this is all crazy. We have no idea where the real costs in medical care are, or where the real waste is. We’re proposing little fixes to bits, with no engineering sense of order of magnitude. What percent of pills go down the toilet? What percent of medical cost in hospitals is pills taken in-building? What percent of medical costs is medical cost in-hospital? Are we talking 0.1% of overall cost? 0.01%? 0.0001%? I have no idea, and the same applies to lots of these issues. .0001% is real money, but it will do almost nothing to solve the problem when costs are growing by 5-25% per year.
It seems to me that the irrationality I mean plays a large part in why the absurdities you describe exist.
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p>Trading off used versus new for pills a parent gets for their child is not the same as the same trade-off for a passenger-door crank mechanism.
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p>It seems to me that a large part of the problem is relying on patients (customers?) to use market mechanisms to select care — that’s really what I mean by “irrational.”
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p>If the providers and pharma suppliers were paid directly by the government, they could then compete on the basis of who could deliver the same care, and market mechanisms would work. Similarly, insurance providers could morph into businesses who competed on their ability to transfer funds with the least overhead and the least mistakes.
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p>If a child is sick or injured, and the parent believes that a procedure, test, or medication has even a small chance of helping, then I don’t think a market-based mechanism will ever successfully allocate resources on a sustainable basis. The value of the child’s life is essentially infinite, and therefore the parent will simply demand the procedure, test, or medication regardless of its price.
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p>Meanwhile, I suspect (I don’t have the data either) that an enormous portion of the 5-25% annual growth in cost is driven by a closed-feedback loop where the insurance company and provider both profit from delivering more and more tests and “preventative care” visits — all justifiable by “medical necessity” because they are shown provide a marginal but real benefit. Such tests and procedures are profitable (in the current system, until the ponzi-scheme costs kill it). Because they take a known time and can be scheduled far in advance, they make much more effective use of resources. That’s why the lead time for even an urgent dermatology visit is so long (often far in excess of six months), while once you’re in, the followups are easy to schedule at convenient (for the provider) weekly intervals.
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p>The patient is left holding the bill (either directly or indirectly through their employer, insurance company, or both). Because the value of life is infinite, the value of even that marginal improvement is also essentially infinite (look at the reaction to suggesting the annual prostate exams or breast exams are not cost-effective). My engineering guess is that those factors dominate the terrifying increases we’re seeing.
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p>I think they’re endemic to a market-based approach to allocating health care. That’s why I think single-payer is the only approach that will work. In fact, I think the currently-unfolding collapse of the health care system is exhibit A to show that market-based mechanisms sometimes fail.
Market dynamics would work if the system was open/transparent. Try this to reduce costs. Have every hospital and docotor produce a fee schedule. Hospital A charges 1500 for an mri and hospital B charges 800$. Then allow insurance companies to incentivize helathplan members to choose between the two hospitals. Choice A costs 100$ for a co-pay and choice B cost nothing. Lets see what consumers decide. If my hunch is right we will see the following: 1. Consumers save 100$ 2. Insurance company saves $600 3. Hospital B delivers more care thus increasing the ROI on that MRI. 4. Hospital A develops a strategy to win back mri patients by reducing their costs or delivering mri’s that people want to pay $700 more for. Am I missing something here?
and I’m not arguing that you’re wrong… but there is a concern that some hospitals will “whip” patients through on tests like these — what happens when Choice B gets a reputation for not doing a good job — not getting the images quite right, being slow to get them to the doctor, etc… how do you manage a situation like that? Dunno.
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p>As far as testing goes, I understand the value of being able to do tests “in house” if you’re a big hospital, but I’ve always been surprised that there aren’t mega-testing centers in medium and large sized metro areas. MRI machines are expensive — so you want to use them all day, every day to get your investment back ASAP. A large testing center, open 6am – 10pm 6 days a week could process lots of MRIs — and therefore drive down the cost. This isn’t just true of testing — it’s true of medical offices themselves. Get a group of dentists together to cover 6am – 8pm six day a week dental and their overhead is way lower because they see more patients with the same number of chairs, square feet of office, computers, etc.
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p>But again, we’re chasing cost reduction without knowing their impact. How much cost in medical care do these sorts of things add, and how much could be saved by implementing these recommendations? Without knowing that, it’s really hard to know what’s worth pursuing and what’s worth holding off on because the returns are lower.
… tests has been pretty standard for a long while now. See Quest Diagnostics in Cambridge.
I’m just surprised that they’re not bigger… so big that there’s a Coke and a Pepsi of all testing, and that they’re processing oodles of tests and images and samples day and night and weekends.
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p>Only time I’ve been to Quest was to do a pre-employment drug test. I’ve never been asked to go there for any of my broken bone X-Rays or MRIs — I was always sent to a local so-called mom & pop shop for X-Rays, and a clinic for MRIs, and neither struck me as a particularly efficient allocation of resources.
that you download a series does on NPR’s Planet Money podcast, from last fall, that covers EXACTLY this dynamic, and explores why the MRI costs so much more here than it does across the street.
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p>I would link it, but I get it through itunes. Extraordinarily worthwhile use of time and ipod space.
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p>www.npr.org/money is the program’s website, but I don’t think they put the podcasts there.
The MRI in a separate testing facility has to pay for the real estate, the cost of the machines, and the techs to run them. The MRI in a hospital, like the aspirins and everything else in a hospital, has to fund the operation of the hospital.
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p>Hospitals give out a lot of free services. They need to stay solvent somehow.
Hospitals were never meant to be run as profit centers. The small labs are.
was pretty good. Still reluctant to get too excited about it without a public option. However, insurance stocks are down as the speech ended, so that is a clear sign it’s a fairly good plan for the American people.
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p>HUMANA
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p>WELLPOINT
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p>UNITED HEALTH
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p>CIGNA
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p>MERCK