More Scandals in For-Profit Medicine

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Universal Health Services is a holding company that provides behavioral health services. Its Oklahoma subsidiary, Shadow Mountain Behavioral Health System, is now being penalized by loss of Medicaid and Medicare contracts. The current accusations against the parent and subsidiary include:

  • Accounting irregularities at the parent company
  • At the subsidiary, inflating reimbursements by
    • Holding patients longer than necessary and
    • Holding patients against their will.

The accounting investigation has been expanded to include the FBI and Department of Defense. The coverage notes that Shadow Mountain has the opportunity to correct the defects to satisfy Medicare, but that the withdrawal of Medicaid contracts cannot be appealed or reversed.

As I noted in an earlier post, both my own prior research for commercial clients and some third party studies suggest that private non-profit medical facilities provide superior care. They tend to be leaders in investment in new technology and research, while public facilities have budgets that are constrained by politics, and for-profit facilities are constrained by the need to maximize profits.

Where you go for care effects the quality of care you get.

Unfortunately, as should be well known by now, medical misdeeds aren’t limited to for profit hospitals. Five NJ doctors have been charged this week related to an illegal kickback scheme. They were receiving payments for steering patients to one specific medical imaging center. (2)

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Sources:

  1. Ayla Ellison, “UHS hospital in Oklahoma faces Medicare termination on heels of Buzzfeed News investigation,” Becker’s Hospital CFO Report, 12 June 2017. http://www.beckershospitalreview.com/finance/uhs-hospital-in-oklahoma-faces-medicare-termination-on-heels-of-buzzfeed-news-investigation.html
  2. Tom Davis, “NJ Doctors Busted In Statewide Bribery Kickback Scheme,” The Patch, 13 June 2017. https://patch.com/new-jersey/princeton/s/g5g99/n-j-doctors-busted-in-statewide-bribery-kickback-scheme?utm_source=alert-breakingnews&utm_medium=email&utm_term=weather&utm_campaign=alert

Your Health: The Right to Life?

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The US was founded on the promise of “the Right to Life, Liberty and the Pursuit of ben_franklinHappiness” in Jefferson’s Declaration of Independence.

From the start, the relationship between the country and this promise has been at best inconsistent and sometimes ironic. After all, the principal writer of the Declaration, Jefferson, was a slave-owner.  So for whom was this promise made? Everyone? Or the wealthy, the planters, the slave-owners and the merchants? (Remember, there were no factories — that was before the industrial revolution.)

The inconsistency continues to this day.

We have groups concerned with whether babies or born, but not with what happens to them after they are born. How long do they live? What’s their quality of life? As Ed Cara notes, in some areas of the US, children will now have shorter lives than their parents. (2)

A new study in the Journal of the American Medical Association talks about discrepancies in life expectancy. I’ve blogged about this before, but it’s nice to see authoritative sources recognizing the issue.

The new statistical analysis shows that there is a difference in life expectancy of up to 20 years based on the county in which you live. In this analysis, the issues affecting life expectancy are

  • Income and poverty
    • The wealthy live longer
  • Race/ethnicity
    • Both Native Americans and African Americans have a shorter life expectancy
  • Regular exercise
    • Those who do live longer
  • Obesity, Diabetes and Hypertension
    • Shorten life expectancy
  • Education
    • Each level completed adds to life expectancy
  • Quality of health care
    • Higher quality is associated with living longer
  • Having health insurance
    • Having health insurance promotes longer life
  • Access to physicians
    • Having more physicians in an area helps

These factors translate into differences in life expectancy in the US based on where one lives:

  • Residents of central Colorado, coastal California and the New York Metro area live longer
  • Residents of eastern Kentucky and much of the Old South, especially along the lower Mississippi River, have a shorter life expectancy
    • The Old South in this case includes Alabama, Arkansas, Georgia (outside of Atlanta), Louisiana, Mississippi, Oklahoma and Tennessee (outside of Nashville)
    • The two metro areas, Nashville and Atlanta, offer much better life expectancy than the rest of their states

The states with the lowest life expectancy are those with the lowest spending on public health and health education.

One limitation of this study is that the analysis is at a county level, and there is only selected data available at that level regarding health. In particular, suicide is now one of the top 10 causes of death in the US. Suicide isn’t reported accurately or consistently, and there is limited data available on the causes of suicide.

A second limitation is the inter-relationships between some of the factors measured. For example, wealth is associated with having health insurance, with less use of cigarettes, and with living in an area with better access to medical professionals. By breaking the analysis into this much detail, does the report understate the role of wealth in life expectancy?

By the way, I use the image of Ben Franklin on some of these posts for the following reasons:

  • His brilliance
  • His common sense
  • His skill at negotiation
  • And among the Founding Fathers of the US, he became a profound opponent to slavery

Sources:

  1. Laura Dywer-Lindgren, et. al., “Inequalities in Life Expectancy Among US Counties,1980 to 2014,” JAMA Intern Med. Published online May 8, 2017. doi:10.1001/jamainternmed.2017.0918. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2626194
  2. Ed Cara, “Kids Will Die Younger than Their Parents in Some Parts of the US,” Vocativ. 9 May 2017. https://www.aol.com/article/news/2017/05/09/kids-will-die-younger-than-their-parents-in-some-parts-of-us/22077174/

 

 

Life Expectancy in the US: Falling Behind

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The current (2016) life expectancy from birth for the US as a whole is 79.8 years.(1) How does that compare with other countries? Countries where people live longer than in the US include

  • Andorra 82.8
  • Anquilla 81.4
  • Australia 82.2
  • Austria 81.5
  • Belgium 81.0
  • Bermuda 81.3
  • Canada 81.9
  • Cayman Islands 81.2
  • Faroe Islands 80.4
  • Finland 80.9
  • France 81.8
  • Greece 80.5
  • Guernsey 82.5
  • Hong Kong (China) 82.9
  • Iceland 83.0
  • Ireland 80.8
  • Isle of Man 81.2
  • Israel 82.4
  • Italy 82.2
  • Japan 85.0
  • Jersey 81.9
  • Korea, South 82.4
  • Liechtenstein 81.9
  • Luxembourg 82.3
  • Macau (China) 84.5
  • Malta 80.4
  • Monaco 89.5
  • Netherlands 81.3
  • New Zealand 81.2
  • Norway 81.8
  • Saint Pierre and Miquelon 80.5
  • San Marino 83.3
  • Singapore 85.0
  • Spain 81.7
  • Sweden 82.1
  • Taiwan 80.1
  • United Kingdom 80.7
  • Virgin Islands 80.0

Of course, the issue is that the US spends more per capita on healthcare than any of these other countries.  In many cases, far more.

What’s a year of life worth to you?

On top of that, the US is falling behind in growth in life expectancy.(2) Kontis et. al. forcast growth in life expectancy in industrialized countries, and the US ranks near the bottom of the list, with minimal improvement.  South Korea, which is already ahead of the US, ranks near the top in growth in longevity.

lifeexpectancychangeYou spend a lot on healthcare and health insurance.  What exactly are you getting for your money?

 


SourcesI

  1. CIA World Factbook. https://www.cia.gov/library/publications/the-world-factbook/fields/2102.html
  2. Vasilis Kontis, PhD, James E Bennett, PhD, Colin D Mathers, PhD, Guangquan Li, PhD, Kyle Foreman, PhD, Prof Majid Ezzati, FMedSc, “Future life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble,” The Lancet, 21 February 2017. http://thelancet.com/journals/lancet/article/PIIS0140-6736(16)32381-9/fulltext

 

States with Best Healthcare in US

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US News published a ranking of states on quality of healthcare.  The top 10 don’t necessarily mirror population migration patterns, but who wouldn’t want to live where the best healthcare is found?

Conversely, why are residents of states with inferior care apparently so complacent about it?  I grew up in Kentucky, which is a hotbed of cancer from smoking, and offers sub par healthcare.  Why?

1. Hawaii

2. Massachusetts

3. Minnesota

4. New Hampshire

5. Iowa

6. Vermont

7. Rhode Island

8. New Jersey

9. Washington

10. California

The 10 worst states are the usual suspects:

50. Arkansas

49. Mississippi

48. Oklahoma

47. Alabama

46. West Virginia

45. Louisiana

44. Kentucky

43. Wyoming

42. Tennessee

41. Indiana


Sources:

Hospital Costs by State

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Kaiser Health Facts has published the average per diem cost of a hospital stay.  Costs will vary between hospitals, but it is clear that some states are just more expensive than others.

Obvious question:  Why would anyone use a hospital in New Jersey when quality facilities in New York and Pennsylvania are so close?

The most recent year for which data are available is 2015.  Cost may have risen slightly over the last year in most or all states.

United States

  • State/local government hospitals — $2,013
  • Nonprofit hospitals — $2,413
  • For-profit hospitals — $1,831

Alabama

  • State/local government hospitals — $1,458
  • Nonprofit hospitals — $1,664
  • For-profit hospitals — $1,410

Alaska

  • State/local government hospitals — $1,274
  • Nonprofit hospitals — $2,332
  • For-profit hospitals — $2,724

Arizona

  • State/local government hospitals — $2,012
  • Nonprofit hospitals — $2,636
  • For-profit hospitals — $1,996

Arkansas

  • State/local government hospitals — $1,637
  • Nonprofit hospitals — $1,649
  • For-profit hospitals — $1,521

California

  • State/local government hospitals — $2,985
  • Nonprofit hospitals — $3,752
  • For-profit hospitals — $2,118

Colorado

  • State/local government hospitals — $2,248
  • Nonprofit hospitals — $2,922
  • For-profit hospitals — $2,746

Connecticut

  • State/local government hospitals — $3,426
  • Nonprofit hospitals — $2,581
  • For-profit hospitals — $2,547

Delaware

  • State/local government hospitals — N/A
  • Nonprofit hospitals — $2,828
  • For-profit hospitals — $1,468

District of Columbia

  • State/local government hospitals — N/A
  • Nonprofit hospitals — $2,717
  • For-profit hospitals — $1,976

Florida

  • State/local government hospitals — $2,095
  • Nonprofit hospitals — $2,347
  • For-profit hospitals — $1,667

Georgia

  • State/local government hospitals — $966
  • Nonprofit hospitals — $1,887
  • For-profit hospitals — $1,789

Hawaii

  • State/local government hospitals — $1,661
  • Nonprofit hospitals — $2,618
  • For-profit hospitals — N/A

Idaho

  • State/local government hospitals — $1,677
  • Nonprofit hospitals — $3,241
  • For-profit hospitals — $2,194

Illinois

  • State/local government hospitals — $2,956
  • Nonprofit hospitals — $2,422
  • For-profit hospitals — $1,546

Indiana

  • State/local government hospitals — $1,709
  • Nonprofit hospitals — $2,477
  • For-profit hospitals — $2,202

Iowa

  • State/local government hospitals — $1,454
  • Nonprofit hospitals — $1,481
  • For-profit hospitals — $1,547

Kansas

  • State/local government hospitals — $1,184
  • Nonprofit hospitals — $1,789
  • For-profit hospitals — $1,920

Kentucky

  • State/local government hospitals — $1,748
  • Nonprofit hospitals — $1,686
  • For-profit hospitals — $1,384

Louisiana

  • State/local government hospitals — $1,659
  • Nonprofit hospitals — $1,839
  • For-profit hospitals — $1,790

Maine

  • State/local government hospitals — $1,260
  • Nonprofit hospitals — $2,396
  • For-profit hospitals — $870

Maryland

  • State/local government hospitals — N/A
  • Nonprofit hospitals — $2,521
  • For-profit hospitals — $1,108

Massachusetts

  • State/local government hospitals — $1,916
  • Nonprofit hospitals — $2,965
  • For-profit hospitals — $1,773

Michigan

  • State/local government hospitals — $1,389
  • Nonprofit hospitals — $2,204
  • For-profit hospitals — $2,196

Minnesota

  • State/local government hospitals — $1,340
  • Nonprofit hospitals — $2,277
  • For-profit hospitals — N/A

Mississippi

  • State/local government hospitals — $1,214
  • Nonprofit hospitals — $1,391
  • For-profit hospitals — $1,667

Missouri

  • State/local government hospitals — $1,599
  • Nonprofit hospitals — $2,353
  • For-profit hospitals — $1,896

Montana

  • State/local government hospitals — $522
  • Nonprofit hospitals — $1,280
  • For-profit hospitals — $2,555

Nebraska

  • State/local government hospitals — $862
  • Nonprofit hospitals — $1,980
  • For-profit hospitals — $1,838

Nevada

  • State/local government hospitals — $2,073
  • Nonprofit hospitals — $2,163
  • For-profit hospitals — $1,701

New Hampshire

  • State/local government hospitals — N/A
  • Nonprofit hospitals — $2,361
  • For-profit hospitals — $1,942

New Jersey

  • State/local government hospitals — $4,569
  • Nonprofit hospitals — $2,635
  • For-profit hospitals — $1,499

New Mexico

  • State/local government hospitals — $3,011
  • Nonprofit hospitals — $2,373
  • For-profit hospitals — $2,170

New York

  • State/local government hospitals — $2,572
  • Nonprofit hospitals — $2,456
  • For-profit hospitals — N/A

North Carolina

  • State/local government hospitals — $1,962
  • Nonprofit hospitals — $2,069
  • For-profit hospitals — $1,568

North Dakota

  • State/local government hospitals — N/A
  • Nonprofit hospitals — $1,709
  • For-profit hospitals — $4,095

Ohio

  • State/local government hospitals — $2,617
  • Nonprofit hospitals — $2,611
  • For-profit hospitals — $2,538

Oklahoma

  • State/local government hospitals — $1,360
  • Nonprofit hospitals — $1,926
  • For-profit hospitals — $1,955

Oregon

  • State/local government hospitals — $3,360
  • Nonprofit hospitals — $3,397
  • For-profit hospitals — $2,520

Pennsylvania

  • State/local government hospitals — $767
  • Nonprofit hospitals — $2,377
  • For-profit hospitals — $1,826

Rhode Island

  • State/local government hospitals — N/A
  • Nonprofit hospitals — $2,809
  • For-profit hospitals — $1,857

South Carolina

  • State/local government hospitals — $1,916
  • Nonprofit hospitals — $2,086
  • For-profit hospitals — $1,650

South Dakota

  • State/local government hospitals — $407
  • Nonprofit hospitals — $1,232
  • For-profit hospitals — $3,149

Tennessee

  • State/local government hospitals — $1,393
  • Nonprofit hospitals — $1,846
  • For-profit hospitals — $1,610

Texas

  • State/local government hospitals — $2,626
  • Nonprofit hospitals — $2,464
  • For-profit hospitals — $1,821

Utah

  • State/local government hospitals — $2,699
  • Nonprofit hospitals — $2,665
  • For-profit hospitals — $2,390

Vermont

  • State/local government hospitals — N/A
  • Nonprofit hospitals — $2,162
  • For-profit hospitals — N/A

Virginia

  • State/local government hospitals — $3,132
  • Nonprofit hospitals — $1,816
  • For-profit hospitals — $1,781

Washington

  • State/local government hospitals — $2,689
  • Nonprofit hospitals — $3,592
  • For-profit hospitals — $2,529

West Virginia

  • State/local government hospitals — $781
  • Nonprofit hospitals — $1,748
  • For-profit hospitals — $1,135

Wisconsin

  • State/local government hospitals — $2,532
  • Nonprofit hospitals — $2,271
  • For-profit hospitals — $2,687

Wyoming

  • State/local government hospitals — $1,405
  • Nonprofit hospitals — $2,036
  • For-profit hospitals — $2,146

My past research suggests that nonprofit hospitals are better at deploying new technology to support patients than are either for-profit or government facilities.  Nonprofits don’t have the limits on spending that profit margins or government budgets place on the other types of facilities.  Our choices about where to go for care are based in part on that.

What you need to know:

You need to shop around to determine where you prefer to be treated.  You can’t wait for an emergency to make that decision.  And if your local hospital is no better than a “band-aid station”, you need to know where you want to go.


Soources:

Choosing a Doctor, Revisited

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In an earlier blog, I reposted the report of a speech by a senior physician regarding how hedoctor-clip-art-doctor-clip-art-4 selected a specialist for his own treatment.  I added information in subsequent posts about issues to consider in selecting a doctor as that information became available.  It’s time to add to that knowledge again.

For some US residents, there is a stigma attached to a doctor who receives medical training outside the US.  Because offshore schools aren’t accredited by US institutions and typically cost much less to attend, there is a feeling that the training provided is not as good as that provided by US medical schools.

To test that theory, a team at Harvard conducted a statistical analysis of patient treatment and outcomes, comparing results between US-trained doctors and those trained outside the US and practice in the US.

The report on this research notes that

To practice in the US, international medical school graduates must pass two exams on medical knowledge and one assessment of clinical skills, and complete accredited residency training here. However, medical schools outside the US are not accredited by any domestic agency. In response to concerns about quality of care from internationally trained physicians, the Educational Commission for Foreign Medical Graduates will require accreditation of medical schools outside the US by 2023. [Lewis]

The study looked at hospital admissions under the care of a general internist between 2011 and 2014.  Data from 44,227 general internists were included in the research, of which 44% had graduated from medical schools in one of the following countries:  China, Egypt, India, Mexico, Nigeria, Pakistan, the Philippines, and Syria.  Graduates of schools in the Caribbean were excluded from the research, on the grounds that most of those are US citizens and the fact that they studied outside the US would not be obvious to a patient.

The only two statistically significant differences between US-educated and foreign-educated doctors were

  • The cost of care was slightly higher on average for those with offshore training ($47), and
  • There was a lower rate of death among patients of offshore-trained physicians.

(Hmm.  Which is more important to you, $47 or dying?)

The general conclusion from this research is that there is no difference in quality of care between physicians practicing in the US and who attended medical school in the US or in the listed countries.

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Sources:

 

What’s Best for the Patient?

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[Note: in all of my writing, I try to place personal opinion in blue italic font to separate it from what I am reporting from other sources.]

doctor-clip-art-doctor-clip-art-4There are a number of factors that can affect decisions that doctors make about patient care. What’s “objectively best” for the patient may be only one consideration.  Patients need to know this.  While you may not be a doctor, you bear the ultimate responsibility for your own care.  You’re the one who has to live with the results.

 

Recent articles point to some of the issues that can impact treatment:

  • Doctor revenue.  Doctors can (and a few have been accused of this) maximize revenue by ordering unnecessary tests and performing unnecessary procedures.
    • A common example in the literature is the use of CT, MRI or X-ray in the first 30 days after reporting lower back pain.  Other systems besides back pain may require these test, but for lower back pain alone, no.
      • “One study found that people who got an MRI during the first month of their back pain were eight times more likely to have surgery than those who didn’t have an MRI — but they didn’t get relief any faster.” [Agnvall]
    • 61 doctors were among 301 people criminally charged earlier in 2016 with billing Medicare for care and prescriptions that weren’t medically necessary.
    • One of the current curiosities concerns rotator cuff surgery
      • Outpatient rotator cuff surgeries have increased by 272% in the last 5 years.  (Are we really that much more active??)
      • Rates of post surgery problems vary between surgery facilities from a low of 1/2% to 20%.  (If you need the work, are you having it done by the right doc?)
  • Measurements used in the current Federal “pay for performance” initiative.  “Pay for performance” is an effort to reward doctors and hospitals that delivery high quality care and penalize those that don’t.  The metrics include patient satisfaction questions, and some doctors argue that inclusion of those questions might cause doctors to cater more to what patients want than what is medically necessary.
    • That in turn raises two questions
      1. If docs pay more attention to what patients are saying, is that a bad thing?
      2. This criticism by surgeons seems similar to the complaints some teachers have about standardized testing.  In both situations, would the absence of any metrics make the situation better?
  • What insurance will cover, of course.
    • However, a dedicated physician can encourage the insurer to do the right thing.
    • My wife was injured, and the doctor felt she required a treatment the insurer was unwilling to approve.  His reaction was to hospitalize her (for which the insurer was committed to pay) until the insurer agreed to the treatment.  It worked.

What you need to do:

  • Learn how to search for information on your medical symptoms before you consult with a medical professional.  Be an informed patient.  If you don’t know, ask someone for help.
  • Prepare intelligent questions for your conversation with the doctor.
  • If tests are recommended, ask what they will accomplish.
  • If surgery is discussed, consult another doctor from a different medical practice who is unknown to the first doctor.  Conflicts of interest can be a problem, and you don’t want to go there.

Sources:

  1. Agnvall, Elizabeth, “10 Test to Avoid,” AARP Bulletin, 3 December 2015.  http://www.aarp.org/health/conditions-treatments/info-2014/choosing-wisely-medical-tests-to-avoid.html
  2. Cohen, Jessica Kim, “Outpatient rotator cuff repairs increase 272% in a decade — 5 facts on orthopedics in ASCs,” Becker’s ACS Review, 4 January 2017.  http://www.beckersasc.com/asc-turnarounds-ideas-to-improve-performance/outpatient-rotator-cuff-repairs-increase-272-in-a-decade-5-facts-on-orthopedics-in-ascs.html
  3. Frelick, Marcia, “Current Measures Flawed, Could Cause Problems, Surgeons Say,” Medscape.com, 6 January 2016.
  4. Gawande, Atul, “Overkill”, The New Yorker, 11 May 2015.  http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
  5. Haelle, Tara “Putting Tests to the Test: Many Medical Procedures Prove Unnecessary—and Risky,” Scientific American, 5 March 2013.  https://www.scientificamerican.com/article/medical-procedures-prove-unnecessary/
  6. Sandhu, Sarina, “40 common treatments and tests that doctors say aren’t necessary,” iNews, 24 October 2016.  https://inews.co.uk/essentials/news/health/40-treatments-doctors-saying-bring-little-benefit/
  7. Sun-Times Wire, “Skokie, Buffalo Grove doctors charged in Medicare fraud sweep,” Chicago Sun-Times, 23 June 2016.  http://chicago.suntimes.com/news/2-suburban-doctors-charged-with-medicare-fraud/