Category Archives: Payment Reform

Left Behind: Why Excluding Residents from Delivery System Reform Hurts Us All

Several weeks ago, I was fortunate enough to attend a meeting at the Association of American Medical Colleges (AAMC) on a new mandatory payment model for joint replacement. I was the only resident physician among the more than 70 health professionals at the meeting. What I learned is that for most trainees in medical school and residency, little time is spent understanding the nuances of health care finance or practice management. Continue reading Left Behind: Why Excluding Residents from Delivery System Reform Hurts Us All

The Price of Certainty in the ICU

Originally posted August 10, 2015

By Tom Peteet, MD

Mr. J was as close to a typical sixty-year-old patient as possible, wary of doctors and selective in when he took his blood pressure medications. On a sunny Thursday, he woke up nauseated and called an ambulance. During evaluation in the emergency room, his blood pressures reached atmospheric levels (nearly 300 systolic). He began seizing, which soon stopped; he was transferred to the ICU. As the admitting resident, I dutifully went through the potential causes of his elevated blood pressure: medication noncompliance, surreptitious cocaine use, and even the zebra diagnosis of a pheochromocytoma. As for the seizure, I held firm on the diagnosis of PRES, an acronym for posterior reversible encephalopathy syndrome, an under-diagnosed condition of abnormal blood flow to the brain in the setting of high blood pressure.

Mr. J was on course for a typical hospital admission. We would run a battery of tests, determine a singular diagnosis for his problem, and send him home on treatment. The hospital would be reimbursed for his coded diagnoses of hypertension, PRES, seizure, and he would have close follow-up with specialists.

If Mr. J was a typical case, our discussion of costs and appropriateness of testing was not. Despite a resurgence of “cost consciousness” within medicine, the word cost rarely comes up in the ICU. Much of the discourse around cost and of the Choosing Wisely campaign is an effort to avoid unnecessary tests in clearly defined circumstances. However, Mr. J’s case shows us that the vast majority of clinical decisions live in a gray zone of appropriateness. On rounds, the question came down to this: Does he need a brain MRI and angiography (MRA) to “prove” he has PRES? The clinical history seemed to support the diagnosis, and the study could potentially offer limited prognostic information. Also, in the highly improbable scenario the patient did have a small stroke, we would see it on the MRI. What is the value we place on this minimal increase in certainty? According to the Healthcare Bluebook, the cost of both studies is $1,206.

Taking a step back, I wondered about our zeal to “prove” a diagnosis. Physicians so frequently frame clinical questions around diagnostic proof that we forget this is not the only way. Why not frame clinical questions around appropriateness, cost, or even risk-benefit to the patient? Context matters. In settings like the emergency room or ICU, ruling out the worst is highly valued. If Mr. J continued to be stable after a few days, the diagnosis would be PRES by exclusion, and we would all save time and money.  Similarly, in one month, if he remained fine, his primary care doctor would not rush to get an MRI. But Mr. J was in the ICU, we needed an answer, and a test offered us the psychological boost we needed.

Mr. J walked out of the hospital five days later on a different regimen of blood pressure medications. He thanked the staff profusely, who in turn, felt they provided excellent care. Each actor behaved rationally: the patient and clinician to get a diagnosis, and the hospital to generate revenue. The system, however, behaved irrationally, to the cost of the public and also the patient. Despite a confirmed diagnosis of PRES, Mr. J will follow up with two specialists to verify the results of other rare causes for high blood pressure, again generating revenue, visits, and a minimal gain in certainty.

As a physician in this structure, I struggle to maintain hope, as thoughtfulness contradicts rationality. For Mr. J, I pushed against getting the MRI because I valued diagnostic utility and system costs over diagnostic accuracy. The system pushed back. The neurologist highly recommended the test, the ICU attending changed over, and the fellow “needed to rule out a mass.” Considering the cost and appropriateness of each test is hard work, and too great a task for one person. While I am skeptical of top-down change, I take solace in the ability of clinicians to think complexly: to weigh accuracy alongside cost, risk, and benefit. In the gray areas of medicine, we as clinicians would do well to ask and wrestle with the question, “What is the price of the certainty we seek?

Peteet photoTom Peteet, MD, of Massachusetts is one of the winners in the 2015 Costs of Care Essay Contest. He practices in Boston, where he contemplates the price of certainty in his surroundings.

The Costs of Cancer Care

Originally posted August 3, 2015

By Holly Woodcock

I’m a nurse and a patient. My story starts out during Thanksgiving of 2009 when I was diagnosed with colorectal cancer at the tender age of 47. Stage IIIB. Metastatic but curable, they told me. After three surgeries, hospital stays, blood work, traveling, chemotherapy for six months, all the follow-ups with physicians, CT scans, the medications needed at home, I’m still paying.

As a consumer, it’s really enough to make a head spin. As a nurse, I’m aware of hospital costs. I know it’s expensive. Expenses add up fast as $100 co-pay after $100 co-pay are requested with every doctor’s visit, every clinic visit, and every X-ray visit. Cancer didn’t take into account all the income I’d lost post-surgery or the days I couldn’t go to work because I was too weak or too sick to go in. It ate through my sick leave and savings quickly. I am so fortunate to have great health insurance.

Undeniably, my insurance company paid well. I’d look at the explanation of benefits every month, astonished and overwhelmed that chemotherapy could actually cost $75,000 a month or that one shot to keep my white blood cell count could cost $7,000 and I needed two every month. It’s still bizarre to think I paid them to inject poison in my veins.

When the end of chemo came in 2010, I was well over $35,000 in the red – all from stupid cancer. Costs are crippling cancer patients to the point of losing jobs, losing businesses, losing homes, having liens, going bankrupt. Sadly, due to complications from treatment, I can no longer do bedside nursing. I am currently going back to school for my master’s degree to teach nursing students. A lot of people don’t have that option. What happens to them?

The economic impact of cancer care alone in the U. S. during 2011 was astronomical; annual costs were estimated to be at $88.7 billion.  Yes, that’s billion with a “B.”  In 2012, it was estimated that over 15 percent of Americans didn’t have insurance. Those that are “lucky” enough to have insurance are burdened with the higher costs of deductibles; they’re also paying for the newer FDA-approved medications that are helping win the fight.  A drug that cost a few hundred dollars last year is being replaced with the newer drugs this year, costing consumers tens of thousands a month now. When I sat with my oncologist for the first time, we talked about side effects of chemo. The tingling in my hands and feet, the mouth sores, how my balance would be affected, how I could only eat and drink room-temperature foods, to cover up when it’s cold because it will feel like shards of glass are ripping your skin off. He never mentioned the side effect of my finances. He didn’t tell me just how expensive it would be to fight the beast.

Countless colorectal cancer friends I’ve met along this journey have similar stories. One friend lost his business and his home. He’ll never work again due to the after-effects of this treatments. Even though his insurance paid, his treatments ate up his retirement, his savings and his way of life. Another friend, after his wife died, filed for bankruptcy from the resulting medical bills. His credit is ruined, he drives a $200 car and lives with his mom.

Cancer expenses are about more than just money. Cancer has cost us peace of mind. It’s knowing you wake up in the morning and can never go back to a job you love, one that you planned on retiring from. It’s about keeping the wolf away from your back door.

We’ve worked hard and we’ve mostly dug out from the bills that cancer gave us. I’ve sat my husband down and told him however, under no terms, if this cancer returns, I’m not treating it. I refuse to leave him bankrupt. I believe I live in the richest country in the world, with the best medical care available; fighting cancer shouldn’t have to make you pick between treatment and food or medicine and rent.

holly woodcockHolly Woodcock is a nurse from Idaho.She was one of the winners in the 2015 Costs of Care Essay Contest. Her cancer has returned incurable, not terminal, and she has decided to treat it.



Duke, Colorado Explore Innovative Payment Models for Specialty Care

By Khin-Kyemon Aung

???????????????????There’s no time like now to test new ways to pay for specialty care, and the federal government has offered immense support in this endeavor. Earlier this year, the Center for Medicare and Medicaid Innovation (CMMI) sought input from stakeholders to develop payment models for diseases cared for by specialists. CMMI is also in the midst of testing bundled payments for 48 different episodes of care, launching a new accountable care organization (ACO) model for patients with end-stage renal disease, and developing an episode-based payment model for oncology care. Additionally, through Health Care Innovation Awards and State Innovation Model funding, the Centers for Medicare and Medicaid Services is aiming to further drive innovation around how specialty care is delivered and paid for to incentivize improved outcomes and higher quality at lower costs.

Continue reading Duke, Colorado Explore Innovative Payment Models for Specialty Care

Health Wonk Review: Polar Vortex Edition, July 2014

Okay, so the vaunted summer polar vortex didn’t exactly bring the expected plummeting temperatures this week, but at least the oppressive humidity is lessened. Along with that refreshing change, some fresh thoughts from our Health Wonkers:

Over at InsureBlog, Henry Stern, LUTCF, CBC, kicks things off with a post on “SexistCare.” Stern reveals that the ACA mandates a whole raft of benefits specifically for women and children, but none for men. He wonders why mammograms are covered as preventive care, for example, but there are no corresponding provisions for prostate cancer screening. “Where’s the hue and cry?” he asks.

Continue reading Health Wonk Review: Polar Vortex Edition, July 2014

WSJ Contributors Have It All Wrong About CMMI

By Coleen Kivlahan, MD

On April 23, 2014, an op-ed in the Wall Street Journal described the Center for Medicare and Medicaid Innovation (CMMI), one of the few bright spots on the health reform horizon in our country, as “a stealthy menace.” It was written by Lanhee Chen from the Hoover Institute (a scholar and attorney) and James Capretta from the American Enterprise Institute (a scholar and long term public policy government servant). The authors are not working in one of our nation’s health systems

Continue reading WSJ Contributors Have It All Wrong About CMMI

Rebooting Primary Care from the Bottom Up

Originally posted on April 16, 2014

Zubin DamaniaFor the better part of a decade, I practiced inpatient hospital medicine at a large academic center (the name isn’t important, but it rhymes with Afghanistan…ford).

I used to play a game with the med students and housestaff: let’s estimate how many of our inpatients actually didn’t need hospitalization, had they simply received effective outpatient preventative care. Over the years, our totals were almost never less than 50%.

For my fellow math-challenged Americans: that’s ONE HALF! Clearly, if there were actually were any incentives to prevent disease, they sure as heck weren’t working.

In a country whose care pyramid is upside down—more specialists than primary care docs, really?—we’re squandering our physical, emotional, and economic health while spending more per capita than anyone else. Four percent of our healthcare dollars go towards primary care, with much of the remaining 95% paying for the failure of primary care. (The missing 1%? Doritos.)

Continue reading Rebooting Primary Care from the Bottom Up

Connecting Physicians to Health Care Cost Transparency

teaching_values_projectBy François de Brantes, MS, MBA and Neel Shah, MD, MPP

We recently returned from the National Summit on Healthcare Price, Cost, and Quality Transparency, where leading thinkers convened to discuss next steps in a growing movement to hold caregivers accountable for delivering better care at lower costs. Traditionally quality, cost, and patient experiences remained locked inside black boxes of individual patient–physician encounters. However, at the cusp of 2014, the window of opportunity to shine a light on physician performance appears to be permanently jammed open by public demand, payer pressure, and a technology marketplace that is eager and capable of making it happen. Continue reading Connecting Physicians to Health Care Cost Transparency