Patients, administrators, and family members of victims aired their reflections about medical errors in a video on the on-line New York Times this week (November 25, 2008). They all lamented that if only doctors and hospitals could own up to their mistakes, there just may be fewer lawsuits.
Two stories I listened to more than ten years ago underline that theme. A friend, a lawyer representing a medical provider, shared with me his concern about his client that he would be defending at trial that week. He had advised his client to settle because the evidence against his client was strong and he was not optimistic.
The patient had acquired an infection while in the hospital. The evidence was incontrovertible and the patient had died. But the patient was old and infirm and had little time left and even less quality time. The infection may have hastened the inevitable but it also made the end needlessly painful for both the patient and the patient’s family.
The family asked only that the hospital not bill them for the extended six month hospital stay caused by the infection. If the hospital agreed they would not sue. The hospital could not admit to a mistake and, as a result, appeared headed for a judgment that would cost the hospital several times the hospital stay.
The second story was from woman I met while waiting for jury duty. It seems that during stomach surgery her doctor had perforated her stomach and he did not discover it before she was stitched back up. The stomach acids caused havoc on her intestines. I asked her if she had sued her doctor. Oh no, she was quick to reply. The doctor was so distraught about the mistake. She could not do that to him. He had paid for all her medical expenses since the incident several years earlier. In addition, he only operated on one patient after that accident, resigning from his surgical practice, but not from his medical practice.
Every health care reform proposal attempts to offer some relief for small businesses. According to the National Federation of Independent Businesses (NFIB), small businesses create 2/3 of American jobs, yet half of the uninsured are in small businesses.
Look at President-elect Obama’s health care proposal on his campaign’s web site. The first two items:
- Require health insurance companies to cover pre-existing conditions so all Americans regardless of the health status or history can get comprehensive benefits at fair and stable premiums.
- Create a new Small Business Health Tax Credit to help small businesses provide affordable health insurance to their employees.
What’s remarkable about these proposals is that we are still discussing them.
Let’s look at the second item – a tax credit for small businesses. In my opinion, it is a mistake to separate the small business market from the individual market. Almost every small business starts out as a solo enterprise. How many creative ideas never come to market because the would be entrepreneur is afraid to go without health insurance?
Yet we don’t make it easy. Anyone who has ever itemized deductions has experienced the limits on the deductibility of health insurance costs. There is also something called a section 105 deduction that you can learn about elsewhere. Yet business owners can deduct the full cost of their medical insurance. I would welcome an explanation that justifies this disparity, or at least explains the politics to me.
The real nut is the first item. That we allow insurance companies to only insure healthy people is the greatest tragedy of American health care. This is called medical underwriting. Jonathan Cohn in his book, Sick, has a wonderful chapter on this stain on American health care.
WAIALUA (KHNL) – It’s easy to find sunshine just about anywhere in Hawaii. If you’ve ever taken a drive to Waialua on the north shore, a field of bright yellow flowers will surely put a smile on your face. Unfortunately, these beauties are not for sale.
Sunflowers set off a glow of sunshine across this forty acre parcel of land. The flowers stand tall, with their full round faces pointing toward the bright sun in the eastern sky.
“Perfect year round growing conditions, no extreme highs, no extreme lows relatively stable weather conditions throughout the year,” said Alika Napier of Pioneer Seed.
Pioneer Plant Seed Hawaii grows these sunflowers, for research. It’s a form of quality control. Researchers visually monitor the plants for uniformity. As the plants grow they also look to see if there are any genetic changes due to the environment.
“From there it’s just monitoring for insects, pests, diseases, fertilizing the crop, irrigation and it basically grows itself,” said Napier.
Data collected is forwarded to a main office in California. Because of Hawaii’s perfect growing conditions, the islands play a vital role in growing and gathering research.
“We send the product here to grow up and what it is we’ll have people come by and look at the flower and see if it meets the desired traits,” said Napier.
Eight to ten different varieties of sunflowers are grown here.
The ideal weather also allows the company to monitor other types of vegetables grown here during the year. Continue reading
I support a simpler health care system. That is my number one priority. Thus I am unimpressed with the health care reform platform of our newly elected president. I do share the hope and optimism of many that meaningful change can and will happen.
But getting a simpler health care system means that some of the stakeholders need to be cut lose from the system. That is a politically daunting task. It is why most health care reform proposals try to add more patches to what is already a shabby patchwork quilt of private and public programs.
One effort does try to simplify a small part of our current system. At least 30 states have mandated that insured health care plans cover all children until they reach a certain age. Yet as simple as this concept is, it comes with more variations than states that have adopted it.
What are we trying to simplify?
Most health plans offer parents with dependent children in college the opportunity to continue coverage for their child if they provide evidence that the child is enrolled in a qualified post secondary education program.
This is a holdover from the days when children entered the job market after high school and those jobs provided health insurance. Today, it is more likely that neither half of that statement is true. It is an obvious adaption to changing times. It is a relatively easy way to expand coverage to a vulnerable population. Young adults are healthier than the general population and therefore not an expensive expansion. Of course, that doesn’t prevent this trend’s detractors from referring to it as the “slacker mandate”.
Sometimes people are magically teleported outside of their health care silo.
This happened to a group of our participants every month for several consecutive months.
At the beginning of each month one of the members of this group would call our office – “The doctor won’t treat me because he/she was told I have no health insurance.”
Our Plan had recently approved coverage for domestic partners. Somehow, the computer system of one of our carriers could not properly interpret the code for a domestic partner. The computer saw this adult as a child. Sound like Alice in Wonderland? One computer makes you larger and one computer makes you small.
The carrier told the doctor’s office that this member had no other adults on their plan, only a dependent child or dependent children. In at least one case, the domestic partner was 52 years old and the couple had no dependent children.
Now this should not present an insurmountable challenge. The Health Insurance Portability and Accountability Act (HIPAA), Public Law 104-191, includes provisions for what is referred to as Administrative Simplification. This rabbit hole of regulations details in excruciating detail the requirements for transmitting electronic files (Electronic Data Interchange or EDI), including enrollment files, first appeared in 2000.
The implementation guide for the enrollment file, ANSI ASC X12N 834, lists the acceptable individual relationship codes. They appear in the INS02 Segment in the 2000 Loop. The primary card holder is represented by the number 18, a dependent child is a 19, a spouse is a 2. You may argue that the codes don’t make sense. But they don’t need to. After all, they are being read by a computer. The code for a domestic partner is 53.
Notice that it does not include any of the digits used in any of the other codes. So how does a 53 get confused with a 19? Is our group the first to cover domestic partners? How is a fifty two year old interpreted as a dependent child?
But as confounding as computer systems may be, they are at least constrained by laws of logic, laws that most of us find baffling, but laws nevertheless. How logical is it that every month, in some cases, every week or day, countless thousands of group health plans must send their updated enrollment and eligibility information to their respective health insurance carriers - m ost of the time electronically, but far too often, on paper.
Seven dollars and forty cents hardly seems like an amount that should erect a barrier to health care.
In fact, when Mr. Koch (all names are fictitious) called to complain about this bill for seven dollars and forty cents, my first reaction was, “You should appreciate how lucky you are that you have a health care plan that pays most of your bills. Why are you quibbling over $7.40?”
Of course, that is not an appropriate customer service response.
But listen to Mr. Koch. “This bill is for two pain pills that were given to me when I was admitted to the hospital for an emergency surgery. Medicare won’t pay for the pills because they were “self-administered.”
Our insurance plan won’t pay, because Medicare won’t allow payment. (a common Medicare complementary policy). The hospital wants its $7.40. I must have been semi conscious when they gave me the pills, because I do not remember it at all. Why should I pay for pills that some nurse made me swallow when I was semi-conscious?”
Mr. Koch’s total pharmacy bill for this hospital stay was over $8,000 Who is the one who is quibbling over $7.40? And the issue has little to do with whether the two pills cost $7.40.
In fact, it is more likely that the hospital knows full well that the two pills only cost $0.20 But they calculate that it will take at least an additional $7.20 of bureaucratic labor to collect that $0.20. The bureaucracy needs to be fed.
Think about the effort to maintain these bureaucracies. Somewhere in the bowels of the CMS (Center for Medicare and Medicaid Services) someone has crafted regulations that stipulate that Medicare will not pay for certain medications that are self administered.
The logic is apparent Before Medicare Part D, CMS did not pay for prescriptions outside the hospital or physician office. “Self administered” appears to fairly delineate the boundary between those drugs that can only be administered in a hospital or physician office setting, from those dispensed by a pharmacist.