Archive for July, 2010

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Are You a DIY Traveler/Patient?

Dorothy Jeffress
Friday, July 30th, 2010

Dorothy JeffressOnce upon a time, most people traveling outside the US depended on a travel agent and some were only comfortable when they were part of an organized tour.    Finding top hotels or out of the way adventures was best left to experts. Travel guides available at bookstores, though often outdated, were gripped in sweaty hands, consulted like BIbles.

Now I can plan a trip at the last minute, securing deals on flights and interesting places to stay. Does anyone still use a travel agent?  And I am guided by virtually real-time reviews from fellow travelers rather than reports from someone who gets paid commissions by the industry or who visited the location months or even years ago.

I was reminded of this evolution to do-it-yourself (DIY) travel…when I heard several health care experts suggest at the Campaign for Better Care program this week that advocating for reimbursement and provision of professional care coordinators is their #1 priority… vitally critical for the success of health care reform outcomes.

Really?  If the rest of the marketplace can teach us anything it is that more and more services once provided by professionals are now in the hands of everyday folks.  Online banking, brokering stocks, real estate financing, and yes, travel….more and more of the detail work – gathering options, weighing trade-offs and making choices – has been embraced by consumers.  Why, in a time of growing health care costs and complexities of diagnosis and treatment decisions – would adding a layer of paid professionals to navigate the system for us likely be a killer app?

While I applaud those who understand how difficult it is for patients and caregivers to organize many providers, medications, tests and treatment regimes, particularly for those with chronic condtions, I am skeptical that handing these tasks off to another busy professional is the best answer. Yes, there are undoubtedly some who will not be able to manage to pull all the pieces together.  They are already ill; they are frail; they lack knowledge and skills, and they will need such help.

But I suspect this number is modest.  Rather, it would be modest if providers and institutions and health plans made it possible for the vast majority of us to find and use good evidence and resources and guidance and real person reviews. 

We have made the transition from laypeople dependent on experts to competent users of online information in other domains.   And we have shown a remarkable ability to make use of the transparency afforded in other industries to make choices that satisfy us.  The proposal to provide us with a health care “nanny” sends a signal that there is little need to participate in finding and making good use of our care.  And it sends a message to clinicians, insurers, hospitals and laboratories that they are not accountable to us.

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Keeping an Eye on Insurance Rate Hikes

Trudy Lieberman
Thursday, July 29th, 2010

Trudy LiebermanState insurance regulators who basically decide what we all pay for our health coverage are not known for being super-transparent.  Actually, it’s just the opposite.  Last week, though, the California Department of Insurance went on the offensive, setting up a new service to alert the state’s consumers when their carriers have filed for changes in premium rates, up or down.

That means if WellPoint, the state’s mega-insurer, tells regulators it wants another increase for the policies it sells to individuals, those policyholders will be among the first to know about them.  All consumers have to do is sign up here for an e-mail alert that will tell them what their carriers are requesting.  “We want as many people as possible scouring these rate filings to ensure they are mistake-free,” says California Insurance Commissioner Steve Poizner.

While there may not be much consumers can do (short of canceling their coverage) if, say, WellPoint asks for another 39 percent increase, they can act as important sentinels for what’s happening in the marketplace.  Last spring it was consumer outrage that alerted the press and the politicians in Washington that the rate requests were too high for them to pay.  L’affaire WellPoint sparked a national backlash against the insurer that helped push the health reform bill to the finish line. And in California, it invited further scrutiny of their rates that resulted in the carrier withdrawing its request and going back to its computer models for a redo. Regulators found that the company had made mistakes in calculating its rates.  Earlier this month, Anthem Blue Cross, a WellPoint subsidiary, filled new rates in California calling for increases of up to 20 percent for individual plans although on one insurance policy the rate increase might be closer to 25 percent.  The new increase will affect about 600,000 people who have individual policies.

To review:  These are the policies people buy on their own when they don’t have coverage from the government or employers.  Premiums are high and companies may still turn down applicants who have pre-existing health conditions. That will change in 2014, but for now sick people may be out of luck. Rate hikes of any size are important because those in the individual market have to shoulder the increase themselves; there’s no one sharing the premium cost.   A monthly increase of $300 hurts the pocketbook, as one Californian found out when Anthem raised his rate when he turned 50.  Companies are allowed to factor age into their premiums and will be able to do that even when health reform takes effect.

I hope lots of folks in California sign up for the new e-mail alert service and that regulators in other states follow California’s lead.  In some states, consumers cannot challenge rate increases through the regular hearing and appeals process.  California’s move gives them a voice in the process.

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Why Ask if You Won’t Help Me

Dorothy Jeffress
Wednesday, July 28th, 2010

Dorothy JeffressIn a recent iHealthBeat post, Steve Findlay talks about a provision in the new “meaningful use rules” for health information technology issued by DHSS.  Findlay noted that nothing seems to have moved the needle on people completing advance directives. He expressed hope that this “can now be rectified if hospitals embrace the optional (menu set) meaningful use objective that promotes recording the existence of an advance directive in a person’s EHR. It’s a start.”

Hmm.  Hasn’t the requirement to ask each patient if they have an advance directive been part of the JCAHO standards for years?  And how has that been working?

Here’s my experience with this measure in real life:

Last fall I was suddenly admitted to a local hospital for testing and observation.  While in the emergency room over several hours, I was asked by two separate members of my care team: “Do you have an advance directive?”  When I later reached my hospital room, another clinician asked: “Do you have an advance directive?” Three times I was asked this one simple question…three times I said “no.”  There was no explanation for the question provided by any of the team. In just one instance, I was offered sample information about advance directives.  Although I indicated I would like to have it…no information was ever provided.

Nothing about this promoted anything but a bit of idle curiosity and pique on my part. Given all the other scary things that were going on during this intake evaluation, why did they keep asking me this specific question?  And then why once answered, did they ask the same question over and over again?   Would they have been satisfied if I had said “yes, but it’s at home?”  What if I had had the foresight in the midst of my crisis to bring a copy – would it actually be included in my record?  What if I had an outdated advance directive entered in the system – would this question have been asked in the first place?

I was reminded of the box I mindlessly check off at my local pharmacy, indicating that I am declining individual counseling by the pharmacist about my prescription.  Nothing in the process encourages me to seek information in this public setting; nothing suggests doing so might be worthwhile 

Neither recording the existence of advance directive in my hospital record nor documenting that that I waived consultation by a pharmacist really supports or facilitates my active participation.   Rather, each one bluntly attempts to align an ideal (people should complete and share advance directives with health care providers; make it possible to get experts’ advice at the point of Rx dispensing) with what appears to be a “teachable moment.”

After the first inquiry about my advance directive in the emergency room, with no discussion or assistance offered, this stopped being a meaningful opportunity. When filling in a box is the desired outcome, those in charge learn very quickly how to achieve that goal.  All those good intentions and the multiple steps that it takes to actually influence people’s behavior merely get in the way.

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Who’s Got My Back?

Jessie Gruman
Tuesday, July 27th, 2010

Jessie GrumanLast week The New York Times published a front-page feature about how diagnosing breast cancer “can be surprisingly difficult, prone to both outright error and case-by-case disagreement over whether a cluster of cells is benign or malignant.” The article goes on to discuss how advances in imaging present serious challenges to pathologists, particularly with borderline breast lesions, for example, resulting in both over-treatment & under-treatment.  It recounts the stories of women who unnecessarily underwent surgery and radiation treatment as the result of what appears to be some combination of ambiguous findings and pathologist error.

What does this report mean about the diagnosis of other irregularities and malignancies, breast and otherwise?  Do I need to seek a pathology second opinion? Can I trust a negative mammography report?

This article comes a couple months after another front-page feature in the NYT about the danger of poorly calibrated radiological equipment that has delivered dangerous – in some cases fatal – doses of radiation.  Loose regulation and monitoring resulted in devastating injuries to a number of people across the country.

Guess I should be checking up on that too when next I’m scheduled for radiation – Hey!  I wonder if this lax attention extends to X-rays and MRIs?

It comes two days before the Journal of the National Cancer Institute published a study showing that the relevant major peer reviewed journals published information required for a physician to prescribe and monitor new cancer therapies  was included in only 11 percent of the articles on cancer treatment in articles appearing between 2005-2008.  http://www.ncbi.nlm.nih.gov/pubmed

Well then, where does my doctor get the information she uses to treat me?

And all these news reports drop into a constant stream of new revelations that pharmaceutical companies are hiding data showing that commonly used drugs pose serious health risks…the past few months the focus has been on Avandia, but that is only the latest in a long series of disclosures about new and old drugs.

What do you make of this?

The uncertainty and risk are probably the same as they have always has been. They’re only now being measured and documented and reported on.  Even so, when I view these reports cumulatively, the self-interest of each of the players – health plans, doctors, safety monitors, pharmaceutical companies – is evident.  Conversely, these reports reveal how the responsibility of each player for the safety and health of the public is of lesser concern to them…but more, apparently, to us.

Because by implication, once we know about these deficits and dangers in health care, it is our responsibility to track them carefully and then try to reduce them for ourselves and for those we love. We have to do the research, get the second opinions, and double-check every treatment plan, every drug prescribed, every X-ray machine and every pathology report or we risk adding injury to our illness. We have to ask these questions and resolve disparate answers.

Is there an alternative response?  This is a heavy lift for most of us.  Who has got our backs?

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