The Hazards of Hospitals

Created by: Medical Billing and Coding

I tell people this stuff in the emergency room, straight up, when they want admission to the hospital and it's not indicated. A hospital, I say, is a great place to be if you're critically ill, and a terrible place to be if you can be treated safely at home, keeping you within your family, familiar surroundings, and the flow of your life.

There are no Dilaudid PCAs at home, though, so I lose that argument more often than not.

The trouble with blockbusters: expensive, crappy sequels

h/t My Strong Medicine:

April 20, 2011 — The 10 most prescribed drugs in the U.S. aren’t the drugs on which we spend the most, according to a report from the IMS Institute for Healthcare Informatics.

…

Out of the $307 billion we spent on drugs in 2010, we spent most of our money on the following:

Lipitor, a cholesterol-lowering statin drug — $7.2 billion
Nexium, an antacid drug — $6.3 billion
Plavix, a blood thinner — $6.1 billion
Advair Diskus, an asthma inhaler — $4.7 billion
Abilify, an antipsychotic drug — $4.6 billion
Seroquel, an antipsychotic drug — $4.4 billion
Singulair, an oral asthma drug — $4.1 billion
Crestor, a cholesterol-lowering statin drug — $3.8 billion
Actos, a diabetes drug — $3.5 billion
Epogen, an injectable anemia drug — $3.3 billion

What struck me was that with the exception of Epogen and (for certain indications) Plavix, every single one of those drugs is a variant on an older, now generic drug, which works for all intents and purposes just as well.

Crestor? Really? Nexium? Actos?

If you wanted to shave a quick $20 billion off the government’s healthcare costs, you could just announce that the VA formulary are now the only drugs Medicare or Medicaid will pay for.

When “Transformers 3″ comes out I will go see it, despite the fact that I’m shelling out money for a slight variation on a winning formula. But when the pharmaceutical industry is making its money off tired knock-offs, that’s more of a problem.

Making healthcare cheaper

Making healthcare cheaper is not, actually, a particularly difficult problem. It requires political will, not theoretical innovation. It can be arrived at via many routes, provided they observe a simple principle:

We must pay for health, not for sickness. For outcomes, not for methods. For the totality of a life, and not a particular crisis.

There are many ways in which this could be accomplished. A national health service, responsible for the health of the entire population, is one. A more market-driven approach would be to have a number of necessarily large healthcare organizations who would "bid" for patients, likely in lots, the contract for life-long health services going to the lowest bidder.

If we prefer to nibble around the edges of the problem first, there are a number of small, commonsense reforms we could implement. We could cut reimbursement for diagnostic studies and all procedures by 20%. We could require all Medicare and Medicaid recipients to fill out an advanced directive (we aren't going to tell them what to put in their advanced directive, only require that they have one).

Medicare could announce that it will automatically deny any claims by a physician who exceeds the census-adjusted rate of billing for a given code by more than 200%, excepting things like health maintenance or counseling. So if you, as an EM physician, order five times as many cervical spine CTs as your peers, Medicare will deny them all and require you to justify them one by one.

Medicare and Medicaid could carefully chose a subset of the best-validated, evidence-supported practice guidelines, and automatically deny any claims not in accordance with those guidelines.

Another money-saving and quality-improving device would be to rigorously limit the amount of documentation by health care professionals to the absolute minimum that can be shown to substantially improve safety and continuity of care. Fines for overcoding and fraud should be increased by orders of magnitude, forcing organizations to police themselves.

It is almost too obvious to say Medicare should only cover treatments which are effective. That this is a matter of some controversy cannot help but raise the question of whether Americans are, as a nation, too stupid to survive. A NICE-style board, calculating cost per DAYL, is the best way to calculate effectiveness. I would go a step further, and have too sets of calculations; one for people over the age of 60 with two or more chronic health problems; one for everyone else. Because we need to stop pissing away hundreds of thousands of dollars a case to no purpose but to torture some poor benighted soul for three or four weeks in the ICU. If you want that (and no one but no one who has seen it at the bedside and knows what it is wants it) you can pay for it yourself.

First principles

The conversation here will, by necessity and design, be fluid, unsystematic, and hopefully transgressional. That said, it will not be so amorphous that it stands for nothing; should not be so casual it becomes merely an online version of that popular medical bloodsport, bitching about our jobs.

These are the principles of what I am doing, whatever it is:

1. We are all in this together. There is not physician crisis, or nursing crisis, or patient crisis, or taxpayer crisis. We will not exalt one perspective at the expense of the others, as if the solution were only better training for residents or more nurses or better support for outpatients.

2. We are broken -- not in every way, not every time, but we are broken and we need to be whole. We will be whole when great healthcare is available to everyone at a reasonable cost, when compassion and good humor are ubiquitous, good communication a premise and errors as rare as your passenger jet falling out of the sky.

3. There will be no sacred cows, not private insurance or physician salaries or the autonomy of clinical decisions. There is a goal -- great healthcare for everyone, every time, at a reasonable cost. Anything that might get us a step closer to that is on the table.

A blog about medicine, American healthcare, healing and wellness

By now it's no secret that American healthcare is in the weeds. Some of its problems have been well described -- the funding crisis, the moral and practical challenge of the uninsured, the increasing recognition of medical errors and poor communication with and support of patients and families by their caregivers.

On the inside of the health system, where I and my colleagues are, all these problems are recognized, although some our obscured by the conditions in which we work (cost) and others by our work habits, our culture, and our self-protective rationalizations (few caregivers recognize how poor their communication with patients and families is, for example.) But also from the inside there are many more stress points that the public does not see. Care that sets out to be interdisciplinary and ends up fractured and confused. Reckless use of technology and medicine, often to patient's detriment, chasing the impossible dream of a work-up that takes no time, involves no exercise of judgment (which might leave it open to criticism), and misses nothing. The black hole of documentation which is swallowing giant swathes of time. And so on.

The mission of this blog is simple: we will confront the ways in which we, the American medical community, are broken, the way in which the country itself is broken as regards public health, medicine and law, and what can and is being done about it.