Fee-for-service quick and dirty

In my holiday fervor, I forgot some key points. Doing a quick lit search brought up this lovely paper from 2008 “Health care reimbursement: Clemens to Clinton” by John T. Preskitt, MD. (John you and I should just settle down and raise a family we are perfect for each other). The answer to my stutter about when fee-for-service originated? It evolved along with Medicare, and was recognizable by the late 1950s. Managed care brought it into full flower.

One more point to be made. A crucial drawback of fee-for-service: profiting from mistakes. If you are thoughtlessly administered a drug you are allergic to–and now you’re needing all the care someone in anaphylaxis gets–you and your insurance will be billed for the privilege. Mistakes happen. Medicine is human. But failure should not be rewarded with money.

Pull quote from Preskitt’s article, which I am nicknaming “Ghosts of insurance past”

Managed care was supposed to create a system that would contain costs while simultaneously increasing the quality of care. Our traditional fee-for-service medicine had led to health care inflation because it encouraged caregivers to maximize the number of procedures they perform, ignoring preventive care. Doctors and hospitals were not paid to keep patients well; they were paid to treat them when they were sick.

Why out-of-control costs matter

Complexity. From how you get insurance (THREE MORE DAYS FOR MARKETPLACE PLANS) to who the emergency department treats to the non-communicating EMRs that create a chorus of fax tones ringing out across this great nation of over-paying under-served… well it ends like this: envelopes.

Cramming up your mailbox. Every medical service, every brick and mortar facility, every radiologist in his/her darkened bedroom reading films in memory foam slippers, is going to send to a separate bill. And this is why you still have a checkbook. Because even within the same organization, let’s say a fictional system called ANOVA that I visit for one scan, get 3 bills (physicians group, facility, and radiologist), then I go again in 3 months for the exact same thing. None of my six account numbers will be the same. Cram that in your electronic bill pay.

Here, loves, are my preventative health costs since October. Cancer screenings, with no expensive imaging like CT/MRI. Just doc visits, PAP pathology, and a radiology bill for who knows what that is? $12? I’m leaving out my $400 surprise colposcopy. But, VACCINE PLUG: get your son/daughter an HPV vaccine and the his girl/she may never know the surprise cervical pinch of colposcopy. It is a terrible thing to surprise a woman with. (I was too old, to not a virgin at 26 when vaccines became available).

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Don’t feel bad for me. Maybe set me up one of those gofundmesoIcanaffordfollowupcancersurveillanceandhaveayearlypapsinceI’msexuallyactive. Not a big draw on that?

Alright then. Just pay attention as policy, which people seem to be more averse to than illness itself, is being made. Taxes (for a few) may be losing their place on that short list of inevitability, but mortality my loves, endures.

CVS-AETNA merger (I told you so, mom)

The things going on in corporate health care these days. Woo! It’s like my own personal Boiler Room. Our care system is at the point in its spring cleaning when all drawers have been dumped on the floor to sort out the junk for donation, the cleaning products are strewn about, and there’s a half-built really expensive organization system that refuses to fit together. Here come the tears because HOW IS IT EVER GOING TO GET BETTER!

I get the pleasure of interviewing corporate executives, medical directors, and patients all doing the work of trying to straighten this place up — it gives me a great deal of faith that it will in fact, get better. It is going to be messy.

Today’s Upshot by Austin Frakt gives a superb sum-up of the why and what for of Sunday’s $69 billion merger. Two pull quotes below. Dust off your macroeconomics text books, it’s vertical integration in the land of the free (who pay an average of $10,000 a year on health needs). Consolidate. Cut middle men. And as always, gather ye customer base while ye may.

The CVS-Aetna deal would be just another of the many recent mergers across business lines in health care. Insurers are buying or partnering with health care providers. Health systems are offering insurance. Hospitals are employing physicians. Even Amazon is jumping into the pharmacy business in some states. This may be part of the motivation for CVS to buy Aetna — defensive jockeying to maintain access to a large customer base that might otherwise begin to fill drug prescriptions online.

One source of optimism: Research shows that coordinating pharmacy and health benefits has value because it removes perverse incentives that arise when drug and nondrug benefits are split across organizations. When pharmacy benefits are managed by a company that’s not on the hook for the cost of other care, like hospitalization, it doesn’t have as strong an incentive for increasing access to drugs that reduce other types of health care use. That could end up costing more over all.

As a postscript, I know the first thing that comes to mind when seeing “billion dollar merger” is monopoly. We hate those. With intact heavy regulation, however, monopoly is not at the top of my nightmare list for the health care industry. What is? Corporation as person, with all the legal rights of, and free from the deterring power of class action legal suits. That keeps me up.

Why gun violence research has been shut down for 20 years – The Washington Post

Lamenting the absence of studies has been a part of our post-massacre what-can-be-done for a number of years and a larger number of mass shootings. But what could research do to get us out of these dire straits?

Scientists, lab coat-ed spreadsheet fillers, create the data that uncovers the truth. I’m not sure if you’ve heard yet but truth is a powerful thing. Evidence is the pointy triangle on which change is leveraged.

Traffic deaths, often sited by gun lobby as even with gun deaths, get a healthy amount of study. The Federal Transit Administration gave out 7 million in grants to advance transportation safety.  Research is done, evidence is collected, and regulations (seat belts, which I find sexy) are put into place. The auto industry isn’t going to make those crumple zones, laminate that glass, put in that little switch that turns your passenger airbag on and off so a tiny seat occupant is not killed by its deployment, out of the goodness of its heart.

To make industry safer, we need regulations. To make regulations, we need evidence. To make evidence, we need research.

The gun industry has put an impressive chill on learning anything about the safety of firearms. The 1996 Dickey Amendment, legislating that no research may advocate gun control, has been reauthorized every year by Congress. Data quoted in the aftermath of mass shootings is culled from CDC databases that collect cause of death information. CDC numbers tell us that guns are killing people in epic numbers. But epidemiological data alone does not a policy make.

Source: Why gun violence research has been shut down for 20 years – The Washington Post

No more free birth control, says President

That’s right. I was pretty stoked about the Affordable Care Act requirement that birth control to be 100% covered by all insurance plans. What a great thing! To not have to pay more for health care simply because you have a uterus! To make accessible the means of controlling when you will have children, thereby increasing your chances of advancing your education and career, making you, a uterus-haver, more able to pursue the dream of being an independent and self-sufficient citizen-contributor.

Allegedly the pres. wants to put a stop to abortions. Presumably the fewer abortions the better?  Since free birth control provided by the ACA became available the number of abortions per capital dropped to its lowest level since data collection began at Roe v. Wade.

MAKE UP YOUR MIND.

This is abysmal health policy. Terrible public policy. Bad economic policy. And its perfectly in tune with the administration’s regard for women. NONE.

Friendly neighborhood sick person weighs in on health care debate.

When I used to freak out about losing my health insurance/access to care, not being able to afford medicine, I always pictured my parents losing their house to pay my medical bills. It was the greatest loss imaginable. In the past months my catastrophizing has changed. Now, my mother won’t sell her home, cash out her retirement. I fantasize about dying from lack of care. If my cancer comes back, if I can’t keep my job, if I lose my insurance and I can’t afford to get treatment–I won’t seek care. I’ll die of my illness.

If anyone every told you I’m stubborn they weren’t lying. I indulge this fantasy of martyrdom to my hard-hearted country.

I need to express the psychic weight that the debate over who deserves what coverage burdens me with. Watching the monetary value of my continued American existence up for debate just a few miles from where I live. I cost healthy people too much. My debility or poverty disqualifies me, abdicates rights I thought were mine… life, liberty, something else… but yea, life. Not that.

In my hospital we have special education high school students working as volunteer helpers. Not everyone welcomes them. They are different people and require a slight adjustment in communication. They require accommodation.

They came to the hospital to work with assistance of a career coach and the support of our unit manager. They are kind and interesting, alike to most young people. Tremendously helpful, alike to most young people. Restocking supplies, lending a hand to grab a wheelchair or a drink for a patient, going to the waiting room to track down someone’s elderly family member who won’t answer a cell phone. They complete tasks that keep everyone in the unit moving forward. Days that I’m swamped, they keep me afloat.

The myth of the productive citizen baffles me. I’ve met a lot of people. Strangers coming out of anesthesia tell me dark secrets. No one conforms, not all the time. We are a big interdependent mess. To define productive and make it the measure of value is a terrible effing idea. This ideal of a completely independent working class American is at the core of the repulsive rhetoric I see daily.

What we are capable of is influenced by what we are told we are capable of. The political dialogue, a demoralizing debate over who is worthy of access to care, corrodes the potential of the precise people that have renewed American greatness again and again. The striving poor, immigrant, person of color, victim of circumstance. The young. Mounting arguments to deny the very poorest, the sickest, the youngest among us the scant safety net of Medicaid and strip us of legal protection to not be discriminated against due to sex and preexisting conditions, is undeniably passing judgement on who deserves healthcare. These groups of people, my people, have no chance to acquire health insurance without the protections set in place by Medicaid and the Affordable Care Act. To be without insurance is to be without access to care. The message is this: you are uncared for. To be perfectly clear, you are left for dead.

The health care debate is deeply personal. The abandonment of my cause, my cause being the pursuit of a productive and healthy life, by so many of my fellow Americans. My president, my representatives.

Since my diagnosis at age seventeen I kept my lupus a secret from most. A learned behavior from my father who shared the same diagnosis. He came of age in this country, a sick person in a time before the Americans with Disabilities Act. The fear of being found out, losing out on educational opportunities, jobs, insurance.

I lied on my college applications. I lied on my job applications. I’m not sure if you’ve noticed, but there is a box to check for “I may require reasonable accommodations” i.e.–I have a disability. NOPE. Nope. Per dad’s advice, cross that bridge if you come to it. You don’t need accommodation. You can pass. I can pass for healthy. I’ve never had trouble getting a job.

But I was ashamed. Sneaking around in the shadows will do that to a body. Fearful of being judged as burdensome. A waste of the world’s resources.

To experience the birth of the Affordable Care Act and its protections after a labor so long and fraught was elation. Immense validation. I was hearing from the highest office in the land that my worth, my potential, was not degraded by chronic illness. It’s no coincidence that it was in those heady days I returned to school and became a nurse. I chose a challenging career in a field of service. I was pushed, encouraged to dedicate myself to progress personal and political. In no small part because of the leaders of my country put all the chips on the table to codify the belief that health care is a human right.

Since the ACA passed, I’ve checked the “accommodations” box. When I go to an appointment, I don’t lie. My coworkers no longer think I am hitting the dentist’s office monthly. I can pass, but I need everyone to know what a disability looks like. Which is, in my opinion, human. The messages that came from President Obama, from my representation, from advocacy groups all over the land made me feel like it was okay to exist as I am.

Permission to exist is a powerful thing. It isn’t hyperbole to say that the Affordable Care Act is my own civil rights legislation.

It despairs me to hang on as the pendulum swings against it. But hold on, it matters. Keep saying it, no matter how ridiculous it feels to say, children and women and the sick and the elderly all deserve equal protection under the law. Our nation, and me, well… our lives depend on it.

PS- Somebody make me a bumper sticker that says “KEEP YOUR HANDS OFF MY OBAMACARE”

A few words mustered on AHCA

I want to credit the journalists, academics, and my fellow healthcare providers who continue to write in this inhospitable-to-truths environment. I don’t know how you do it.

I’m hotter than a billy goat in a pepper patch. I can’t put it together. I can barely speak.

On this blog I’ve made the turn from facts to feelings in the last 100+ days, likely because facts seem to have suffered a fatal blow in this unrecognizable version of the world.

Here’s my feeling: I just left CancerCon (post in process), a group of many hundred sparkling, talented, mutually supportive young adults with cancer. Every last one of them contributing and (this is my bottom line) not any less human than before they got sick. THROUGH NO FAULT OF THEIR OWN. I’m one of those hundreds.

The Affordable Care Act was my civil rights legislation. Its “replacement” is the repeal of my and my legion of patients hard fought and nightly worried over civil rights. To adequate care. To freedom from unnecessary physical suffering and premature death and disability. Freedom from fear of sinking ourselves and those who love us into destitution to pay for our care. That’s all I have for now.

Am I less than my healthy counterpart? Is my humanity so easily disregarded by my country?