Being involved on the business side of the medical device industry in recent years, I have taken a keen interest in all things healthcare related. I also have a mother who is over 65 by a good deal and has dealt with Medicare and Medicare Advantage programs (in Florida) for some years now. I have had the dubious distinction of sorting through the hundreds of Medicare Advantage programs out there to find some that are appropriate for her and then guide her to reasonable choice. (Thank heaven the government has a website to help with that. I cannot imagine most folks on Medicare coping with that project, but that’s another post entirely. You can start here if you’re researching the matter yourself: http://www.medicare.gov/Choices/Overview.asp )
Before the Surgery
My mother complained of a painful right hip for a couple years. Her primary physician finally said mom was a candidate for a hip replacement and she would recommend the operation whenever mom would like to have it done. This is a very common operation these days and a good, experienced surgeon will normally yield good results. Recovery progresses fairly quickly, you can walk again within a couple days, and the patient is back to mostly normal (pain free) in 3 to 4 months.
A separate request had to be made to my mother’s primary doctor to obtain a recommendation on a surgeon, which I thought was odd. I would have expected her primary care physician to help guide her to a surgeon, but I guess not. We were given 5 surgeon names, 3 of which, upon investigation, were participating in her insurance plan. Of the 3, we requested that the primary care physician’s office recommend one of the three. We asked around (in the over 55 community in which she lives) about hip replacement surgeons and got additional recommendations, eventually all converging on a particular nearby surgeon. Surgery was scheduled at Blake Medical Center in Bradenton.
Surgery, the Hospital, and Rehab
Surgery was scheduled and then moved to an earlier date as one became available. She was in surgery maybe 3 hours, then in the hospital for 4 days, then transferred to a physical therapy rehab facility a short distance away that was highly recommended.
I arrived in Florida the day she entered rehab and my sister flew out the next day. We were initially told she’d be in rehab for maybe 10 days. She was in rehab for 15 days. It was clear to me that it would have been longer if I hadn’t kept asking questions about her progress and their expectations.
The rehab facility did physical therapy for patients 5 days out of 7. Why it was not 7 days out of 7 I don’t know. Their website claims 7 days out of 7. I never received an answer. I was at the rehab facility several hours a day, every day, bringing what my mother considered “real” coffee, walking around with her, giving her outdoor wheelchair rides, monitoring her medications, and so on.
Her first roommate (two people in every room) was a nearly deaf lady who would turn her TV on so loud that you could hear it from the nurses station down the hall. It took several days to have my mother transferred to a different room. Moving was dependent upon somebody else leaving the facility. There were 55 beds and all were full, pretty much all the time from what I could learn. Did I mention the food was surprisingly good?!
The staff was wonderful. Everyone we met was helpful, kind, and gave 110% to every task. That was encouraging. I did ask about the medications being supplied in the morning, during the day, and in the evening. Some meds were things we had agreed with her primary care physician that she no longer needed. It was disturbing to see them pop up again. It turns out that older people are seen by several doctors (primary, surgeons, specialists) who do not talk to each other. Each prescribes meds. Sometimes without looking at what has been prescribed by someone else. (My mother-in-law had been prescribed near lethal levels of one med by several physicians before her two sons figured out what was going on with her.)
My mom is becoming a bit forgetful, not Alzheimer’s but forgetful. Doctors and therapists should not assume that telling older people something is adequate. Things need to be written down and should be transmitted to family members. Even if the older person does not appear to have dementia, it seems to be a natural issue as people age. It is very clear to me that both in hospitals and in rehab facilities, people needs advocates watching out for them when they are not completely able to manage their own care. This appears to be true for everyone, regardless of their age.
Upon entering rehab, we were told that my mother was now under the care of one of the two physicians associated with the rehab facility. She was there 15 days. She NEVER saw a doctor of any size, shape or color while she was there. Her second roommate had been there for a month and she said a woman doctor had popped her head into the room once during that time and asked her “How are you doing today?” and then left. Without being overly cynical we all assumed that both doctors were charging everyone in the facility (55 patients) on a regular basis for “visits.” Let’s see, 55 people a day times let’s call it $100 a visit would come to $5,500 a day that Medicare is paying this place for absolutely nothing. Let’s assume that these two doctors are on call. Maybe they do get called to deal with a patient once or twice a day, maybe. Still, $5,500 a day is pretty good. Times 7 days a week that’s, let’s see, $38,500 a week. Not bad for being on call and walking through the building maybe twice a week. The nurses and staff do all the work and are very good. I thought the references to patients being under the care of these doctors was pretty clearly fraudulent.
(1) Ask questions. What is being done? Why? When and where will it be done? How long will it take? What are the expectations? When does the patient transition from one stage to another and what are the criteria for transitions?
(2) Watch medications. Who prescribed what? Was the surgeon aware of the person’s previous medications? Does anything conflict with anything else? Are any of the medications to be given on an “as needed” vs. “regular” basis? What are the meds and what is each being given for? Assuming some of the meds are sent home with the patient, find out again what needs to be given and when. Then make an appointment with the person’s primary care physician to review.
(3) Watch what you are being billed for. Since most bills will be transmitted directly to Medicare or to the Medicare Advantage health insurance program, this is not always something you see. I remember when my father died, the doctors charged for several visits “to him” after he had already died. (That was also at Blake Medical Center in Bradenton, FL.) These people have no shame. They simply game the system for their own benefit. If that explanation seems harsh, the only other explanation is that they are too disorganized to bill correctly, but somehow the errors are always in their favor. You pick.
That’s what I learned. I hope it helps you.
And today (3-17- 2010) I learned something else
Martha Coakley, the Massachusetts Attorney General, published a preliminary report titled Investigation of Health Care Cost Trends and Cost Drivers dated January 29, 2010. I highly recommend you read it. All 21 pages. Don’t worry, there are some large graphs! It will either enlighten you or confirm whatever cynical views you may have about our healthcare system. The conclusion is that in our free market system, healthcare providers charge what the market will bear. And that drives up costs. Let’s put it this way: you can pay 280% more for the exact same market basket of healthcare services, depending on where you go in the state of MA. And we have some pretty fancy, well known medical institutions here. Mind you, I am not condemning them for this, because I believe those that charge more are also doing more in the community that they are not being paid for. But the overall report helps explain how broken the system currently is. I hope you can read this below. It shows the variation in price for the same services is, broadly, 100% from lowest to highest paid, with the exception of one heck of an outlier which is 280% of the lowest paid. Still, a 100% difference is a heck of a market premium for healthcare.
Pages 19 and 20 have conclusions, including the following:
Our preliminary findings show that the current system of health care payment is not value-based – that is, wide disparities in payment levels are not explained by differences in quality or complexity of the health care services provided. These findings have powerful implications for ongoing policy discussions about ways to contain health care costs, reform payment methodologies, and control health insurance premiums without sacrificing quality or access in Massachusetts. The Office of the Attorney General looks forward to completing its investigation and to presenting a fuller exposition of its findings through the DHCFP cost containment hearings.
Although our investigation continues, it is clear that prices paid for health care services reflect market leverage. As a greater portion of the commercial health care dollar shifts, for reasons other than quality or complexity, to those systems with higher payment rates and leverage, costs to the overall system will increase and hospitals with lower payment rates and leverage will continue to be disadvantaged. If left unchecked, there is a risk that these systemic disparities will, over time, create a provider marketplace dominated by very expensive “haves” as the lower and more moderately priced “have nots” are forced to close or consolidate with higher paid systems.
The present health care marketplace does not allow employers and consumers to make value-based purchasing decisions. Our findings show the system lacks transparency in both price and quality information, which is critical for employers and consumers to be prudent purchasers.
These market dynamics and distortions must be addressed in any successful cost containment strategy. Payment reform, such as the global payment methodology recommended by the Special Commission on the Health Care Payment System, may result in system benefits such as better integration of care. But, a shift to global payments may not control costs, and may result in unintended consequences if it fails to address the dynamics and distortions of the current marketplace.
We need universal healthcare. And we aren’t likely to get it in the near future, no matter what Congress does.