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Limit the malpractice

Currently there is a bill being considered in Congress that would change medical malpractice standards across the country. This bill would lower the amount of non-economic damages available in any malpractice case to $250,000. An article found on the Hill’s website shows that many state legislatures are against putting a one-size-fits-all malpractice standard in place. Many think that such a bill would undermine the authority of the state to initiate reform related to health care. However, one Republican Representative from Texas, who is also one of the major proponents of the bill and a doctor, reports that he has sent a letter to Obama about this subject, and has received no reply. He feels that the country could institute a medical malpractice reform similar to the one instituted in Texas.

While searching for information on this topic, I found a few sites that I show good arguments for and against such a reform. One site discusses the pros and cons of malpractice reform. There is a large list of for and against arguments so I won’t really go into all of them, but I found it interesting that many of the arguments for malpractice reform point out the fact that malpractice causes doctors to focus on other things besides healthcare. According to the list, doctors, worried about lawsuits, spend more time practicing defensive medicine rather than curing the patient. Also some doctors are retiring because medical malpractice premiums are too high. I didn’t know exactly how much the premiums might be so I looked it up and found the answer. For an OB/GYN the cost of malpractice for one year can be anywhere from $37,122 (Houston, TX) to $127,083 (Chicago, IL). According to CNN’s salary calculator, the average salary for a gynecologist in these areas is$248,341 and $265,614, respectively.  So why is there such a big difference between the malpractice insurance premiums if the salaries are almost the same? The difference is the fact that in Texas there has already been a serious malpractice reform, but in Illinois there hasn’t been one. By lowering the possible malpractice damages, insurance premiums will go down, doctors will want to work longer. So what can we do? Is a country-wide reform of malpractice laws necessary to change this growing problem? Or will states do what should be done?

Mistakes are made

This week I found an article discussing the prevalence of errors in America’s health care system. According to the article, a new tool for measuring hospital errors has found that 1 in 3 people will experience a medical error during their hospital stay. The new tool was compared with the two current, advocated methods of error tracking systems. In 795 patient record reviews, one of the current methods found 35 mistakes, while the new tool found 354 mistakes. This is an extremely large gap between the two methods. When looking at either of the methods we can clearly see that there is a problem with mistakes being made, but the magnitude is dependent on the method of tracking. The article also states that the top 10 mistakes accounted for more that two-thirds of the costs related to medical errors, with the top three being pressure ulcers (bedsores), postoperative infections, and persistent back pain following back surgery. For most medical errors, there is room for improvement. But what can be done?

I do not know the answers to these questions, because I am not a doctor, but I found another article that not only discusses this problem, but also shows a program that as an extremely low number of errors.  The program is the Veterans Administration Hospital system. The article mentions the 3 biggest reasons that the VA has so few errors compared with other hospitals. First is the existence of a fully-functioning medical records system in every hospital. This allows doctors, nurses and any other people administering care to the patient to see the patient’s complete medical record. Second is existence of safety officers in each hospital. If something is not run correctly, the doctors and nurses receive feedback immediately. The last reason mentioned in the article is the way inter-shift transfer of patients is run. In regular hospitals, sometimes the nurse coming in to his/her shift may not receive a verbal update on the patient from the previous nurse, but in the VA hospitals, the article states that the inter-shift coordination is more streamlined.

What can be done to make hospitals more error-free? Should they follow the lead of the VA hospitals? Clearly the implementation of electronic medical records would help immensely with coordination among doctors and nurses. But are there other things that we can learn from the VA? Or should new, possibly better methods be found?

The “In”-network

Last week I found an article talking about accountable-care organizations (ACO) and the stress put on creating them by the new health care law. For those of us who don’t know what an ACO is I will explain. In theory it is a group of clinics, hospitals, doctors (primary care and specialists) and other health care providers who join forces to create a system in which they can lower spending, create a unified system for patient records and increase the quality of care. With the money saved the ACO would be able to repeat the process.

An management model of what an ACO should look like, in theory.

The only problem is that there are no true ACOs in existence. In the article one chief executive is quoted as comparing an ACO to a unicorn because “everyone thinks they know what one is, but no one has ever seen one.” However, even though there is not a single ACO in existence, a question and answer page states that the health care law has seven pages dedicated to ACOs and their implementation. Why is there such an emphasis on something that doesn’t even exist in reality?

Because of the weight placed on creating ACOs in the law, hospitals, clinics, and doctors across the country are trying to create the fabled “unicorn.” While reading the questions on the FAQ mentioned above I was under the impression that the ACO is very similar to the HMO concept. In an HMO patients were only referred to providers in the HMO. HMOs kept costs low, but did not allow for going outside the HMO network, limiting options for the patient. The FAQ states that although the ACO idea is similar to the HMO concept, the difference is that an ACO patient would not have to stay in the network. Currently most insurance plans have “in-network” and “out-of-network” providers. If you go to an “out-of-network” provider you have to pay more, and sometimes all, of your hospital bill. Theoretically an ACO could lower the costs for health care in the area, by allowing the patient to go to any of the doctors in the ACO for cheaper than going out of the ACO.

One of the biggest problems with the concept of an ACO, and one that most health care economist fear, is the fact that hospitals and clinics who merge will have a greater market share of the area they serve, and thus will be able to have more control of the price of health care for that area. This idea is similar to the concept of insurance monopolies that I mentioned in an earlier post. So what will happen with all of these hospitals and clinics merging to create an ACO? Will it lower costs for the short term only or for the long term? No one is sure because currently ACOs are just a mythical creature that only exists in theory, similar to unicorns.

Medical March Madness

With the NCAA tourney ending last night the focus on the true March Madness is done. But what most people in america don’t understand is that there is another March Madness that is hidden. This is the March Madness that occurs in medical schools across the country. Each year 4th year medical students apply for the residency specialty of their choice.  And on March 17th in medical schools across the country these students find out where they will spend the next few years. Regardless of the school this day is always very important. According to an article I read most students open their envelope around 12 pm EST. However, some schools have different traditions. Some schools have the students read them aloud in an auditorium. One school mentioned in the article, but not named, has every student put a dollar in a big class jar when they’ve opened their envelope with their “match” and the last person to open it gets all of the money in the jar. Another article talked about the trend of medical schools to stream this experience on Facebook and other live streaming websites, or with regular updates on twitter. What an exciting way to find out how you will spend the next few years!

Match day is an exciting day for all medical graduates. But for some it be very disappointing.

However, many people are also worried about the future of residencies. Besides the high debt that most medical school graduates have, there is still not enough residencies for all of the graduates. Medical schools are allowing in more students, but residencies are not. This increase in medical school grads makes sense because increasing class size by 5, 10 or even 20 is not that difficult, but increasing the number of people working on a limited number of patients is impossible. One article states that for almost 38,000 medical school grads there are only about 26,000 residency openings each year. So what happens to those who don’t make it? What can they do? This lack of openings is becoming a growing problem for medical graduates. If they don’t get into a residency they can’t take the medical boards for that specialty. If they can’t pass the boards, then they can’t legally practice in that specialty. If they don’t get “matched” their career is over before it even starts.

Medical students gets both theoretical and practical education

As I mentioned in the beginning of the blog, American medical schools are viewed around the world as some of the best. According to a recent article I read even other professional schools in the US are beginning to see the benefit of the medical school teaching style. This article talks specifically about Massachusetts School of Law (MSLAW) which, although founded in 1988, has dominated law school competitions in the past few years. This has been surprising because this school has completely rejected the teaching methods recommended by the American Bar Association. Instead, as the article mentions, the school has followed the teaching methods of medical schools, which the associate dean of MSLAW calls “see one, do one, teach one.” Because of this stress on medical competency before graduation, American medical school graduates are better prepared for their residency than those in other countries. In fact some are so prepared that some medical schools offer their students the opportunity to study medicine abroad for a semester during their last 2 years of school or even for the entire 4 years, such as Duke and its counterpart in Singapore.

Clearly our medical schools are extremely good at preparing our medical graduates for a stressful future as medical practitioners. However one complaint that many people have, especially with the possibility of medical reform lowering physicians’ salaries, is the cost of medical school. Depending on the quality of the school and whether or not it is private or public, medical school tuition can range from about $30,000 to about $80,000 a year. And the costs are steadily increasing. According to AAMC medical school tuition and fees rose by 11.1 percent from 2001 to 2006. Many schools use a large portion of the tuition for research funding.

According to the AAMC, in 2006 the average amount of debt for a medical graduate from a public school was $120,000 and for a medical graduate from a private school it was $160,000. This amount is projected to increase steadily because there has been a steady increase in medical school tuition and fees. This increase in tuition and fees will likely cause an increase in medical graduate debt. A lower potential salary with an increasing amount of debt would mean that fewer people would want to become doctors. Especially because upon graduation doctors aren’t even earning close to their potential salary. They have to spend somewhere between 3 and 6 years working 80 hours a week and get paid between $40,000 and $50,000, depending on the specialty. The amount of hours, years, and salaries during residencies has not changed much in the recent past. All of this change or lack of change could be potentially dangerous for America’s health care system. But what needs to be done? Do residency salaries need to be increased or should medical school tuition be lowered? Or should the current trend of increasing tuition and debt continue? Do doctors really need all of the money they make? These are questions that need to be addressed with any health care reform laws that are made in the near future.

I’m sure you have probably had enough discussion of the problems related to health insurance so I’d like to talk about another aspect of the health care system in the United States: medical records. I recently found an article printed in the Washington Post. This article discussed the recent trend of American health care professionals to switch from paper files to electronic records. In discussing this topic, the article discusses a few pros and cons of the electronic records. One extreme benefit of electronic records that is discussed is the ease of viewing the patient’s entire chart in a few clicks. The author mentions a couple of examples. In one example he talks of a doctor who clicked an “FYI” button and was reminded of to ask the patient how he was feeling after his wife’s recent death. Another example discussed the experience of another doctor was reminded of a recent kidney CT scan when he went to order another one. Because of this second example, the patient was able to save time and money. Another example of the effectiveness of electronic records mentions how a doctor was able to see any drug allergies, prescribe a drug and send that prescription to the patient’s preferred pharmacy with a few clicks. Not only are electronic medical records easier for doctors access, but they are also easier for patients to gain access to. In fact, according to the article, some of the systems allow patients to fill out forms and ask doctors question via an online portal. Maybe we should look to France for ideas about medical records. According to T.R. Reid, in France, all patients have a card, appropriately named the Carte Vitale which means the vital card. These cards have a chip that allows any doctor who has the proper reader to scan the card and view the patient’s complete record, even any things that were done by a doctor on the other side of the country while the patient was on vacation. By scanning it on the reader, the doctor also allows for you to be reimbursed more easily (in France the patient pays up front and is then reimbursed by the insurance company.)

An example of the possibilities of electronic records

However, even with all of these benefits there are some weaknesses in the available systems of electronic records. One big weakness for many doctors is the cost of setting up the system and transferring paper records into the new system. For each doctor, the cost can be up to $50,000. Many of the older doctors, especially those not associated to a hospital system, feel that these high costs make transferring to electronic records too expensive.  Although there is some grant money available from the government to transfer records, many clinics and physicians don’t qualify. Another big problem is related to patient privacy. The federal Health Insurance Portability and Accountability Act (HIPAA), a law created in 1996, focuses on protecting patient privacy. Most of these new electronic systems allow doctors to turn the encryption ability on or off at will. Because of this possibility, some systems are considered not completely safe, but there needs to be more studies done to ensure that the all patients have the privacy necessary under HIPAA.

When I found this article I was very interested. As a recent high school graduate I was hired as a records specialist in a medical clinic near my house. My job was to scan all of the forms the patients filled out, the records we received from other doctors, and any non-digital medical record into our system and organize them in the database under the appropriate patient’s file. This job was very tedious. Although the clinic was technically “paperless” I would usually scan and organize between 600 and 1000 papers every day.  Based on the papers I would guess that I scanned in about 2 to 3 papers for every patient that had an appointment that day. Because of all the time I spent on doing this job, I have often wondered if a medical system could truly be “paperless.” And if it could be paperless, would it be completely safe? What would happen if the servers holding all of the data crashed? What if the United States instituted a card system similar to France’s could that be a violation of HIPAA? I don’t know the answers to these questions but I think medical records is a very important topic that needs to be discussed as our medical system is reorganized.

A graphical expression of the medical loss ratio. It does not show actual percentages.

On the New York Times website there was recently a post about health insurance commissions that the brokers receive. It talked about how one Senator is trying to persuade lawmakers to change the health care law so that brokers’ commissions would be included in calculating the administrative costs. Under the new health care law, insurers have to spend 85 percent of their income from health care premiums on actual health care costs for their insured. All administrative costs for insurance companies currently entail all the money spent on claims, rescissions of coverage, employee salaries. By forcing the insurers to include brokers’ commissions in the calculation, the money spent on other administrative costs will decrease, which could be very beneficial to insured people in America.

To put this 85 percent into perspective, according to Wendell Potter, most insurers keep their “medical loss ratio,” or the industry term for the amount of money spent on health care of those insured, at about 78 or 79 percent. Any increase in this number is viewed by those on Wall Street as a loss for the company and causes a serious decrease in the price of that company’s stock.  However, on the other hand, if a company is able to keep this number low, the board of directors often compensate the executives well, making it worth their while to worry about it. For example, in Potter’s book, he talks a recent insurance executive whose retirement package was over 100 million dollars. But where did all this money come from? From the insurance premiums of people who trust that the money they pay will eventually be spent on their health care and the health care of others insured by that same company. Why is spending the money on what it’s actually meant for viewed so badly? In other countries the administrative costs for insurance are a lot less than they would be in America even after implementation of the health care law. In America it will be 15 percent for administrative costs, and according to T.R. Reid in his book, in France it is 5 percent, Germany’s costs are about a third as much as ours, and in Canada, where it is universal coverage for all, it is still only 11 percent. Maybe we should outsource our health insurance administration to India or China. Isn’t that how people decrease costs now?