Summary: “A respected group of cancer specialists developed a chemotherapy program for a breast cancer patient,” David Belk writes over at The Huffington Post. “But then her insurance company denied the claim, so the cancer center stuck her with a bill three times as large as what they would have required from the insurance company.
Summary: We’ve written a lot on prescription drug pricing; here’s our prescriptions page. Consumer Reports took up the topic recently: “Millions of Americans have been hit with high drug costs within the last year. In fact, a recent Consumer Reports National Research Center poll of 1,037 adults showed that a third of those who currently take a drug said they experienced a spike in their prescription drug prices in the past 12 months — anywhere from just a few dollars to more than $100 per prescription. According to the American Society of Health-System Pharmacists, big price jumps can be due to anything from a product shortage to a change in your insurance coverage. And in rare instances, manufacturers may raise prices simply because they have no competitors also selling the medication. … Our poll shows that most people just fork over the money. Only 17 percent comparison-shopped to see whether they could get a better deal. If you have a standard insurance co-pay, it might not occur to you to shop around. But sometimes the price you’d pay out of pocket … might be less than your co-pay. … Case in point: Metformin — used to treat type 2 diabetes — sells for just $4 for a month’s supply, or $10 for a three-month supply, at stores such as Target and Walmart, while a co-pay for a month’s worth averages about $11. And if you do decide to pay out of pocket, the prices retailers charge can vary a lot. To find out what various retailers were charging, we had secret shoppers check prices for five common generic drugs at stores around the country, including chain drugstores, big-box retailers, supermarkets, and independent pharmacies.” “Tips for Finding the Best Prescription Drug Prices,” Consumer Reports.
Summary: Medical record-keeping is broken. In the attempt to get from paper records to fully electronic ones, medical records companies have taken the opportunity to make competing products, which has made for complicated problems: records are still full of errors, they cannot be transferred easily between providers in many cases, and as a result the old problems still (sort of) exist and yet are compounded by new problems. Some of the benefits of accurate, timely records: better communication among providers, fewer errors, fewer duplicate tests and better care overall. The results of inaccurate, slow records: bad communication, more errors, more duplicate tests and worse care overall. So this piece from my acquaintance Peter Elias, a doctor from Maine, originally posted on The Health Care Blog, grabbed my attention.
Summary: “People worry a lot about their health-care costs, such as the share they pay of their health premium or the size of their deductible,” Drew Altman, president and chief executive officer of the Kaiser Family Foundation, wrote in The Wall Street Journal. “But they tend to have a harder time getting their heads around the measures experts use to talk about the national health-cost problem, such as health spending as a percentage of gross domestic product, or the rate of increase in national health spending, or the difference in per capita health spending in the U.S. vs. other countries. … There is good news for those who want to understand more. The Bureau of Economic Analysis (BEA) has made a real contribution to making health spending more comprehensible by analyzing health spending and price growth by common diseases and diagnoses such as cancer, heart disease, diabetes, and even the common cold. Doing that makes the problem of health-care costs much more understandable for everyone, and it can help direct the attention of policymakers, health professionals, and health-care institutions to where health-care dollars are going.” Drew Altman, “The Diseases We Spend Our Health Dollars On,” The Wall Street Journal.
Summary: “Small rural hospitals called critical-access hospitals have in recent years been performing more and more inpatient orthopedic surgeries, even as their overall stays decline, a Journal analysis of Medicare billing records shows,” Christopher Weaver, Anna Wilde Mathews and Tom McGinty write in The Wall Street Journal. “Inpatient joint-replacement surgeries covered by Medicare rose 42.6% at the hospitals from 2008 to 2013, far outpacing the growth of those services at general hospitals. The trend reflects financial incentives built into the way Medicare pays the nation’s roughly 1,300 critical-access hospitals—generally isolated facilities with 25 or fewer beds—experts say, but it has troubling implications for patient safety. Many studies suggest that patients generally get better results when their procedures are done at hospitals that perform them frequently.” Christopher Weaver, Anna Wilde Mathews and Tom McGinty “New Risks at Rural Hospitals,” The Wall Street Journal.
In the same issue of The Journal:
“Due to an obscure bit of regulatory wording, Medicare patients pay far more out of pocket for outpatient care at … critical-access hospitals than they would for the same care elsewhere, according a Wall Street Journal analysis of Medicare billing records,” Melinda Beck and Christopher Weaver write. “For example, Medicare patients who had colonoscopies at critical-access hospitals had copays of $840.22 on average in 2013, more than three times the $270.53 average copay at general hospitals, according to the Journal’s analysis. Copays for outpatient hernia surgery averaged $1,926.60 at critical-access hospitals, compared with $562.52 at other hospitals. For bunion surgery, Medicare patients paid copays of $2,272.56 on average at the small rural hospitals, compared with $780.79 at other hospitals. The reason is buried in a 1997 law that created the critical-access designation to help small, struggling hospitals. Under the program, Medicare pays such hospitals more than it pays general hospitals, using a different formula. The law also set the Medicare copay for outpatient care at qualifying hospitals at 20% of hospital ‘charges,’ as the facilities call their list prices. At most hospitals, patients only pay 20% of the rates Medicare sets for outpatient services, which are generally much lower than list prices.” Melinda Beck and Christopher Weaver, “Comparing Costs for Outpatient Care,” The Wall Street Journal.
© 2013 Ron Cogswell, Flickr | CC-BY | via Wylio
Summary: We are often invited to share our expertise in crowdsourcing, as I did as a co-author of a recent “How-To Guide to Crowdsourcing” for the Tow Center for Digital Journalism at Columbia University. While there is, strictly speaking, no rulebook for how to do this, there is an evolving community of practice and some shared ideas. Among the great places to check out current practices in crowdsourcing is the Crowd-Powered News Network that was founded by Amanda Zamora and her colleagues at ProPublica. In the process of putting together our crowdsourcing projects, I’ve come up with a few ideas that I’m putting out here as a resource. Others are sharing theirs, too, on the CPNN group and elsewhere.
Summary: “When Valeant Pharmaceuticals International ran a TV ad after this year’s Emmy Awards broadcast featuring actor Mario Lopez promoting its new antifungal toe treatment, Jublia, the spot drew some barbs,” Cynthia Koons and Robert Langreth write in Bloomberg Business. “But it’s also lured plenty of curious consumers who heeded the company’s invitation to visit the drug’s website for savings. There they found an online coupon that promised no out-of-pocket costs for eligible patients. That’s a great deal for consumers, because the prescription medicine costs more than $1,000 for an 8-milliliter bottle. It’s an offer many of their insurers would prefer to refuse. Jublia’s marketing tack is part of a high-stakes game of chicken in which insurance companies raise copays on some drugs to as high as $100 to discourage their use, only to see pharmaceutical companies pick up the tab for those copays — seeking to leave insurers on the hook for the balance, often in the hundreds and sometimes thousands of dollars per monthly prescription. ‘It is a brilliant marketing strategy’ on Big Pharma’s part, says Adriane Fugh-Berman, an associate professor of pharmacology and physiology at Georgetown University, who’s been a paid witness in lawsuits against some drug companies. She calls the practice an ‘insidious’ way to circumvent insurance companies and employers who increasingly are trying to get patients to share the pain of soaring drug prices. Valeant didn’t respond to requests for comment. In 2015 the pharmaceutical industry will spend an estimated $7 billion — up from just $1 billion in 2010 — to hand out coupons and discount cards to cover some or all patient copayments for drugs from fibromyalgia pain treatments to brand-name diabetes pills, according to data from IMS Health Holdings.” Cynthia Koons and Robert Langreth, “That Drug Coupon Isn’t Really Clipping Costs,” Bloomberg Business.
Summary: “As anyone who needs insulin to treat diabetes can tell you, that usually means regular checkups at the doctor’s office to fine-tune the dosage, monitor blood-sugar levels and check for complications. But here’s a little known fact: Some forms of insulin can be bought without a prescription,” writes Sarah Jane Tribble on Kaiser Health News. “Carmen Smith did that for six years when she didn’t have health insurance, and didn’t have a primary care doctor. She bought her insulin without a prescription at Wal-Mart. … Smith, who lives in Cleveland … said: ‘The clerks usually don’t know it’s a big secret. They’ll just go, “Do we sell over-the-counter insulin?” Once the pharmacist says yes, the clerk just goes to get it, Smith says. ‘And you purchase it and go about your business.’… There are two types of human insulin available over the counter: one made by Eli Lilly and the other by Novo Nordisk. These versions of the medicine are older, and take longer to metabolize than some of the newer, prescription versions; they were created in the early 1980s, and the prices range from more than $200 a vial to as little as $25, depending on where you buy them.” Sarah Jane Tribble, You Can Buy Insulin Without A Prescription, But Should You?” Kaiser Health News.
Summary: Childbirth is the most common reason for hospitalization. Here’s a chart from the federal Healthcare Cost and Utilization Project showing the number of hospital discharges in 2013 for various reasons. The reasons are categorized by ICD-9 code; I collected all the childbirth-related diagnoses from the top 25 discharges at the top of the spreadsheet to show just how many there are.
Summary: “Health insurance can be confusing. Take the Affordable Care Act…. Health insurance companies spent a lot of money lobbying to make sure they’d profit from the eventual system,” David Belk writes over at the Huffington Post. “They were so successful, in fact, that a frequent criticism of Obamacare is that it’s just a ‘giveaway to the health insurance industry.’ Yet, one of the major emerging challenges to Obamacare is that health insurance companies are now reluctant to participate. In fact, they’ve even spent millions of dollars trying to defeat the ACA. So, why are they opposing this supposed gift to them? You could try asking the insurance companies, but don’t expect a clear answer from them. Creating confusion appears to be part of their business model. Still, most of the big health insurance companies file financial statements each year, and these financial statements can give us clues that might explain their behavior. Before we jump into their financial statements, let’s first take a moment to understand the insurance business. Insurance is a bet you make with a large company that something bad will happen to you. It’s a strange bet, because both you and the company hope you’ll lose. Just to make sure you’ll lose, insurance companies hire high-priced financial talent to guarantee their odds of winning; they know exactly how to rig the game. So imagine my surprise when I started analyzing insurance company financial records and found that the big insurance companies have spent years getting out of the commercial health insurance business. This explains why they’re rejecting Obamacare: it turns out the last thing they really wanted was millions of new commercial customers to insure.” David Belk, “The Obamacare Paradox: The Real Reason Health Insurance Companies Don’t Like the ACA,” The Huffington Post.