Equal Treatment? Not Always For the Uninsured

While many would like to pretend that this is not the case, I think we are all aware of the fact that many times work done for free tends to be of lower quality than work that one pays for. It's hardly a shocking revelation. Incentive counts for a lot, and being paid is the incentive on most American's minds when considering the work they have made their career.

This makes for disturbing contemplation when you apply that little truism to the medical field. Manoj Jain at The Washington Post takes a look at the disturbing differences in care received by uninsured patients as opposed to those with coverage:

It's not uncommon for patients with no insurance or poor insurance to receive different treatment. A 2006 study of 25 primary care private practices in the Washington area showed that in nearly one in four encounters, physicians reported adjusting their clinical management based on a patient's insurance status; nearly 90 percent of physicians admitted to making such adjustments. For patients with no insurance, alterations occurred 43 percent of the time; and for the privately insured, just 19 percent.

This brings to light an aspect of the health care equation that is oft overlooked. It is especially troubling when you consider that one out of every five patients seen by primary care physicians in a hospital setting are uninsured. From a physician's perspective, that is one fifth of their workload that goes completely uncompensated.

As physicians sometimes say, "No other professionals -- lawyers, plumbers, accountants -- provide uncompensated service to one-fifth of their clients."

There are many reasons possible for a lack of coverage, especially in times as tumultuous as these have been recently. From the workplace that does not offer insurance to sudden job loss or complications arising from pre-existing conditions the possible reasons run the gamut. It is not always a matter of husbanding one's resources or living within one's means:

My primary care friend told me about a patient who had left a boil untreated until it needed surgical drainage and intravenous antibiotics. When asked why didn't have insurance, the man said he had lost his job and was recently divorced. Stories like that helped my friend realize what injustices the uninsured face.

SOURCE: "Equal Treatment for the Uninsured? Don't Count on It. Lack of Compensation Can Tempt Doctors to Tailor Their Care to a Patient's Coverage" 10/14/08
photo courtesy of tacomabibelot, used under its Creative Commons license

More Does Not Equal Better

The Seattle Post Intelligencer's Cherie Black brings us today's reality check by sharing a recent study from Dartmouth that points to an overabundance of care being a problem in and of itself:

Too much medical care could be harmful to your health.

That's what researchers concluded after examining the nations' hospitals and the care patients receive. Some hospitals and some areas of the country give patients more aggressive care -- meaning more tests, longer hospital stays and more procedures -- than others. And the extra treatment doesn't always translate to longer or better lives.

This brings us firmly back to the issue of our medical system charging per procedure rather than charging for overall results. Billing codes abound, although as we often point out here on the blog, there is not one code for a cure.

The 2008 Dartmouth Atlas of Health Care study, released Thursday, studied more than 4 million Medicare patients at nearly 3,000 hospitals across the country from 2001 through 2005 during the last two years of life.

The patients were 65 years and older and were treated for the top nine leading causes of death, including congestive heart failure, chronic pulmonary disease, cancer, dementia, coronary artery disease, chronic kidney failure, peripheral vascular disease, diabetes with organ damage and severe chronic liver disease.

Since all of these are chronic conditions, they fall into that segment of health care that produces a vast majority of costs incurred in the United States. When you add in the number of Baby Boomers who are hitting this age bracket, the equation becomes more and more worrisome.

The study found that depending on where patients lived and what hospital they went to, there were big discrepancies in how they were treated.

Researchers reasoned all medical care carries some risk, so the longer a patient is hospitalized and the more procedures and tests performed, the greater the risks, in addition to greater costs.

Costs. It seems to always come full circle back to costs, no matter what angle of the health care discussion you approach. Costs keep people from seeing a doctor until it is unavoidable. Costs keep providers from adding more Medicare patients to their rolls. Costs directly affect who can afford insurance. On that note one tool that is immediately useful came online along with the report:

Launched in conjunction with the Dartmouth study, the online tool at ConsumerReportsHealth.org lets consumers compare treatment approaches among hospitals for the nine serious chronic conditions in the study on a scale from 0 percent to 100 percent (the higher the percentage the more aggressive the treatment).

The percentile rank is based on the total number of hospital days and inpatient physician visits over the last two years of life. Next to each of the nearly 3,000 hospitals, there also are the patient out-of-pocket costs over the last two years of life.

While aggressive treatment is not always a bad thing, in some cases, it is the only correct path. There are far too many cases where it is counterproductive and exists simply due to the perverse nature of financial incentives within the health care industry. Ms. Black's examination of the Dartmouth report provides some interesting and unfortunate new statistics to add to the ongoing discussion.

SOURCE: "More health care may not always be better: Study finds extra treatment can mean extra risks, costs" 05/30/08
photo courtesy of Jeff Kubina, used under its Creative Commons license

From Oregon to Pennsylvania: Quality of Care Data is Going Online

The third week of March 2008 may well be remembered for the debut of online access to quality of care info simultaneously on both the east and west coasts of the United States.

On the west coast, Kaiser Permanente* stepped up to plate as the first provider in the Oregon areaa to issue a public report on quality of care at its outpatient medical offices using nine different measures. The results are available online and debut roughly a year ahead of a regional effort of a similar nature.

The Portland Business Journal reports:

"This report is just the beginning of our plan to share our quality story with our members and the public," said Dr. Maureen Wright, assistant medical director for Quality Management and Systems. "Each year we will add more measures. For 2008, we will also be reporting scores on screening for colorectal cancer and controlling high blood pressure."

The Kaiser report uses nationally recognized quality standards called the Healthcare Effectiveness Data and Information Set (HEDIS). More than 90 percent of U.S. health plans use the HEDIS yardstick. You can access the report and look up Kaiser clinic scores at kp.org/medicalofficequality or kp.org/qualityscores.

Meanwhile on the east coast, the Pennsylvania Health Care Quality Alliance (PHCQA) launched a website on March 19 that contains similar data for all of the state's acute care hospitals. The Pittsburgh Business Times brings us the news:

The site contains information gathered from Medicare, the Pennsylvania Health Care Cost Containment Council, and the Joint Commission. Visitors to the Web page are able to search hospital quality measures in four major clinical areas: heart attack, heart failure, pneumonia and prevention of health care-associated infections.

Additional clinical areas will be added over time.

"While hospital quality data has become more available on the Internet, consumers are at a disadvantage when they must search out multiple sites, each with its own measurement standards," said Gerald Miller, chairman of the alliance. "PHCQA has developed, and is continuing to refine, a consistent and uniform approach that makes it easier for consumers to access, understand and use the data."

These bicoastal efforts are far from the whole picture. There are many significant initiatives around the country to shine a spotlight on the details of our health care transactions. As more and more people become agitated about the costs of their health care, I predict this much needed trend will sweep the nation.

The question before us is this: how will these systems interact when the areas they cover meet and overlap? At what point will we achieve the uniform standards of quality measurement necessary to enact true and lasting reform?

* Disclosure for new readers: This blog is a companion to Kaiser CEO George C. Halvorson's newest book: Health Care Reform Now!.

SOURCE: "Kaiser publishes quality data for clinics" 03/20/08
SOURCE: "Pennsylvania quality-of-care data available online" 03/19/08
photo courtesy of Unhindered by Talent, used under this Creative Commons license