Monday, February 11, 2008
Aetna, Colonoscopy, and Money
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I suspect that there is much more to Aetna's recent decision (pdf) to stop paying for Propofol for all (exceptions exist) colonoscopies than either Propofol or colonoscopies. At first glance it just look like they're trying to save themselves the additional cost the anesthetist or anesthesiologist that is needed if endoscopists want their patients to receive propofol adds. But I think there's more to it than that.
Let me state at the outset that my practice does not derive significant income from providing anesthesia for colonoscopies. The vast majority of colonoscopies done with propofol use RN's with anesthesia training (CRNA's) to provide the service. I point this out because it seems that having any financial involvement at all is cause for discounting ones opinion--it should not be, but it is.
Using propofol allows colonoscopies to be done without patient awareness of discomfort, true, but the real advantage is that patients recover from the drug fast. By way of example, if a colonoscopy is done the 'old fashioned way' using the sedative midazolam and the narcotic demerol or fentanyl, the patient will likely need to remain in the center for one to two hours before they meet discharge criteria (assuming they don't have any nausea). Propofol allows them to go home in about 30-45 minutes. Roughly twice as fast from completion of colonoscopy to discharge. That means they occupy a recovery bed for less time and that's the limiting step for many centers. Once all the recovery beds are full, you can't do any more procedures until one opens up. Being able to quickly discharge patients after their exam allows much greater throughput in terms of exams per day that can be done .
Here is where I think the policy change will have its real effect. Either endoscopy centers will continue to provide the option of propofol sedation but charge the patient for it (in which case the insurance company will pay less), will provide it as part of the facility fee as a way to compete more effectively for patients (in which case the insurance company will pay less), or centers will go back (and I do mean back) to using older drugs but sacrifice throughput (in which case the insurance company will pay less).
Is having a colonoscopy easier with propofol? Don't take my word for it. Ask any endoscopy nurse which way he or she would prefer having a colonoscopy done.
Aside from cost and cost savings there's the issue of who decides what appropriate care is. If insurance companies are allowed to dictate who can and cannot get a certain kind of anesthesia, what will they do next? Get rid of anesthesia payments for cataract surgery? How about for trigger finger releases and carpal tunnel surgery. Vasectomy? See where I'm going with this?
Tuesday, December 18, 2007
Health Care Reform Distilled
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GruntDoc has an excellent distillation of the choices to be made in health care reform:
"Price.
Quality.
Access.
Pick any two"
Sort of a permutation of C. Everett Koop when he said that Americans want the best medical care in the world, they want it for free, and they want it now.
Sunday, December 16, 2007
Patients pay only 14% of health care costs? Wow.
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Free the market; Government interference hampers healthcare reform
"In a system in which medical care seems free or is artificially inexpensive, with someone else paying for one's healthcare, medical costs spiral out of control because we are encouraged to demand medical services without having to consider their real price. For every dollar's worth of hospital care a patient consumes, that patient pays only about 3 cents out of pocket; the rest is paid by third-party coverage. And for the healthcare system as a whole, patients pay only about 14%."
This article has several nice pieces of data.
Saturday, December 15, 2007
Pennsylvania's Ed Rendell Playing Games With Mcare Abatement
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The Governor of my state, Ed Rendell, has decided he wants to spend any surplus from the catastrophic malpractice insurance fund (which pays awards and settlements over $500,000) on providing insurance for uninsured adults in Pennsylvania. He wants this so much that that he's threatened not to renew the Mcare program unless he gets what he wants. Thought he State Senate has voted to extend the abatement, the House adjourned before voting.
Here's an interesting quote from Rendell:
"We're not going to go through the pain initially of having the doctors send in their checks, and then having to return them if we continue the (subsidy)," Rendell said after speaking at a nurses' conference in Hershey."
What about the pain of the physicians who will have to figure out how to get the money to pay the full amount in January rather than April? Does the Governor think it's harder for the State to issue a refund than it is for doctors to get their hands on that kinds of money?
There should be no linkage between renewal of Mcare abatement and funding of the Cover All Pennsylvanians insurance program. Mcare funds should be used to cover the program's unfunded liability and make it easier to privatize later. The Governor's Cover All Pennsylvanians should get funding in a way that does not impact Mcare's ability to retire unfunded liability and he should stop playing political games to fund it otherwise.
Tuesday, June 19, 2007
Sicko: Socialism in a capitalist society?
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This is the best summary I've read of the barriers to implementing significant change to our current health care system:
Sicko: Socialism in a capitalist society?:
"Bang the Drum with some analysis of whether a government-run health care system is possible in America:
To accomplish any meaningful reform, Americans will have to dismantle the insurance and pharma lobbies at a minimum, and begin to tackle the question of how to deliver universal health care without tying it to employment, marital status, or other qualifiers (and figure out how to put all those unemployed pharma and insurance reps to work, too). Once those lobbies have been set aside, the questions of how to implement a healthcare system which avoids the pitfalls faced by Canada, the UK and France, embraces the positives in the Cuban system, and essentially folds a socialist system into a capitalist society will have to be addressed.
"
[Via Kevin, MD - Medical Weblog]
Friday, March 30, 2007
P4P: Are Vested Interests Pushing the Agenda?
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New Data, More Doubts About Pay-for-Performance (P4P)
"Again, as we have noted before, developing performance measures that will truly benefit patients will require detailed understanding of the clinical context, keen skeptical analysis of the available relevant research data, and careful balancing of benefits, harms and costs. All this would be very hard under the best of circumstances. But the continual attempts by those with vested ideological and financial interests to influence performance measures to advance their own interests make it unlikely that the whole P4P movement will have any good effects on patients.
The first improvement needed in the P4P movement is clear, detailed disclosure of all conflicts of interest affecting those involved in the movement at any stage.
At this point, patients and physicians should be very skeptical about who is likely to benefit from any new performance measure, particularly measures that are lavishly promoted."
This nicely sums up my suspicions about P4P beyond just the fact that it rewards task completion over the exercise of medical judgement...
[Health Care Renewal]
Wednesday, February 21, 2007
DaVinci Surgical Robots. A Hospital CEO Asks Advice.
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Running a hospital: da Vinci Uncoded -- or, Surgical Robots Unite!
"Here you have it folks -- the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the "state of the art", so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?"
I just discovered this blog today via Medgadget and am already impressed. The large health system our group works in purchased a DaVinci last year. I don't know outcomes yet but it was apparent to me before the purchase that it was largely driven by regional competition in Central Pennsylvania. I think it's telling that many of the institutions which were the early adopters no longer use the systems.
I'm hoping to pick one up cheap in a couple of years so I can do labor epidurals from home. ;-p
Monday, February 19, 2007
Is CRNA Independent Practice Coming to Pennsylvania?
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Governor Rendell's 2007 budget document includes a section titled Prescription for Pennsylvania on page A3.32. The first paragraph of that section states:
"Ensuring that all licensed health care providers – including nurses, advanced nurse practitioners, midwives, physician assistants, pharmacists and dental hygienists – can practice to the fullest extent of their training. Pennsylvania consistently lags behind other states in fully utilizing health care providers who are not physicians. Prescription for Pennsylvania will seek to eliminate the barriers in existing laws, regulations and insurance reimbursement policies that limit the ability of health care providers to practice to the fullest extent allowed by their training and education."
Sounds like independent practice to me. Rather than write a knee-jerk reaction right now, I'd like to take some time to educate myself and consider the ramifications...
Saturday, January 21, 2006
Can damage caps influence premium growth and physician supply?
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The Impact of Caps on Damages: How are Markets for Medical Liability Insurance and Medical Services Affected?
"[This report] provides a summary of research on the impact of caps including those on punitive and total damages in addition to those that apply only to non-economic damages. Our focus is on those papers that employ statistical techniques to control for potentially competing explanations of changes that are observed when simple descriptive statistics are used."
and concludes
"the body of research on the impacts of tort reform shows that caps have resulted in lower growth in medical liability losses in states that passed caps than in states that did not. The more recent literature on premium effects has found that caps result in lower premium growth. And, two very recent papers based on sufficiently many years of the AMAâs Masterfile data have found that non-economic caps and direct tort reforms more generally have a positive effect on the number of physicians per capita in a state."
Sunday, January 1, 2006
QA On New Medicare Part B Prescription Drug Plan
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Deconstructing drug plan
- Who is eligible for the new Medicare drug benefit?
- What does the basic Part D plan include?
- Do I have to enroll in a Medicare drug plan?
- Do I have to decide today?
- What if I miss the deadline?
- My drug costs are really low and I don't have any coverage. Do I really need this?
More at http://www.medicare.gov/pdphome.asp
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