I’ve been a critical care nurse for 12 years. I rarely find out about the costs my patients incur as they get care in my unit, though occasionally I hear figures. One gentleman, who had open heart surgery to fix one of his heart valves had to come back 3 months later for a re-do. His wife told me that they had just received the bills that added up to almost $200,000. That was about 8 years ago.

Not long ago I learned that the charge per day in intensive care units like mine was now $11,000. Not unrelated to that fact, just the other day, one of our patients who was a ’self pay’ (read ‘no insurance’) was quickly and quietly packed up and transferred to the county hospital for the remainder of her critical care stay which was going to be several days.

ludlow’s diary :: ::
Though I am not a health care economist I do believe that the true costs of care are incomprehensibly skewed as everyone in the system scrambles to make up for ’self pay’ patients who would most likely never in a million years have the astronomical amounts needed to cover care while the private insurers and Medicare and Medicaid negotiate greatly reduced prices from that ‘retail’ cost. And it is further skewed by plain old greed.

The whole system is such a many-headed hydra monster! And if you try to reform it bit by bit you end up with a 10,000-paged bill that still fails the American People. Just as with the many-headed hydra who immediately regrew one and sometimes more heads when one was lopped off, when you attempt to reform and regulate an aspect of the similarly poisonous insurance/pharmaceutical complex, one or more new problems spring up. The ‘hydra’ can’t be regulated or compromised with. It needs to be taken out in order to make the system safe for everyone. Once that is done, Problem. Solved.

Just today the Senate HELP Executive Committee discussed medical liability and ways to handle malpractice suits. Included in the discussion was an amendment from Senator Enzi (that he said he developed with Montana Max!) to have Medical Courts decide malpractice cases. These ‘courts’ would not be trial-by-jury but rather have some entity (who in my view would be in the insurance industry’s pocket, limiting the industry’s expenses) decide who was wronged and how much if anything they should be compensated. At least that crazy idea was rejected by the committee.

What would happen to medical malpractice costs under Single Payer? With no private insurance companies zealously trying to guard their bottom line? The Physicians for a National Health Program tell us this:
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By Dr. Ana Maria Lopez

On behalf of the 2,043 members of the Arizona chapter of the American College of Physicians, I would like to congratulate the Arizona Daily Star for tackling one of the most pressing challenges facing our health-care system — the growing shortage of primary-care physicians.

A survey of 1,200 fourth-year medical students published in the Sept. 10 issue of the Journal of the American Medical Association found that only 2 percent of graduating medical students plan to go into primary-care medicine. In a similar survey in 1990, the figure was 9 percent.

In Arizona, we have only 4,719 primary-care physicians (36 percent of doctors in the state) to provide care for all Arizona residents. In the United States, there are 88.1 primary-care practitioners for every 100,000 people. In Arizona, there are 76.5 primary-care physicians for every 100,000 citizens.

We are in the bottom fifth of states with numbers of primary-care physicians. In fact, some of our counties have much lower levels because most physicians live in urban centers. In addition, 43 percent of the practicing physicians in Arizona are over age 50. According to the American Medical Association, this is an age at which many physicians consider reducing patient-care activities.
With increasing numbers of physicians leaving practices at early ages, the impact of a health system that steers medical students to careers other than primary care is already being felt in Arizona.

Several factors conspire to impede access to primary care. Many of these were well-covered in the article, including the debt burden borne by graduating medical students. The American College of Physicians is supporting loan-repayment and scholarship programs for physicians going into primary care and insurance reform that is not skewed toward volume of services but towards prevention and coordination of care. These policies will help young physicians choose primary care.
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In Washington, the Obama administration is promising to spend billions to make health care more efficient, but Jennifer Brull, a family doctor in rural Kansas, is already a step or two ahead.

A year ago, she switched her 3,000 patients from paper charts to electronic health records, a core feature of most plans for healing the nation’s ailing health system. Now, working with computers and printouts, her staff of part-time nurses and shared front-office workers has more time to help her meet the needs of patients.

“I’ll never go back to the old system,” said Dr. Brull, 37, who runs a solo practice in Plainville, Kan. “I can always look at the records by Internet, whether I am seeing patients at the nursing home or a clinic or the hospital, or even when I’m as far away as Florida. The change has been tremendously beneficial for my productivity.”

Patients are appreciative, too. Kagay Wheatley brings her 97-year-old neighbor, Charlotte Hayes, to Dr. Brull for blood tests every few weeks. “We do not have to sit and wait while the nurses search for the records,” said Ms. Wheatley, a retired school board aide who is also a patient of Dr. Brull’s. “They find the information right there on the computer, and when we leave, we get a printout of what we did and what she said.”

About 42 percent of active family doctors have installed some type of electronic health records, according to surveys and estimates by the American Academy of Family Physicians, a professional and advocacy group. One in four said they did not plan to purchase an electronic system, and many said they could not afford the $30,000 to $50,000 in start-up costs. The academy has 94,600 members, including about 60,000 in active practice.

Medical centers like the new 24-bed critical-access hospital in Plainville, connected by a walkway to Dr. Brull’s office, are also rapidly adopting electronic records.

“The use of electronic health records and being able to transmit X-rays allows us to be in contact with the whole world,” said Chuck Comeau, a hospital board member who is chief executive of Dessin Fournir, a national furniture design company that moved its head office to Plainville from Los Angeles.

Even so, 8 in 10 of all American doctors still labor in a world of paper. And some doctors said they encountered upsetting setbacks when they tried to switch to electronic records.

Michael Ferris, a 33-year-old emergency medicine physician in Parsons, Kan., said he had to give up his solo practice after he had invested $38,000 in software for systems that kept crashing and thwarting his attempts to send out electronic bills. “I was spending as much time trying to fix the computer and the billing as actually seeing patients,” he said, “and neither process was generating any revenue for me.”

Now, as director of the emergency room at the Labette County hospital in Parsons, Dr. Ferris said, “I get paid by the hour and don’t have to worry if the software is down.” But he said he expected that some day he would have to help the hospital make the transition to electronic records. “I know it is coming.”
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By CATHY BUSSEWITZ

CARSON CITY, Nev.—Dozens of Nevadans, including patients affected by a hepatitis C outbreak in Las Vegas, packed hearing rooms here and in Las Vegas on Monday to support a bill that would allow for bigger lawsuit awards as a result of negligence by doctors.

The Assembly Judiciary Committee debated AB495, a response to the hepatitis C outbreak that led to the largest patient notification in U.S. history. More than 50,000 patients at two now-closed outpatient clinics were notified last year that they may have been exposed to bloodborne diseases by shoddy injection practices.

“These health care providers, under anybody’s standard, were grossly negligent, and they absolutely put profit ahead of patient safety,” said Bill Bradley, representing the Nevada Justice Association. “In the 14 months since this outbreak occurred, not a single provider’s license has been revoked. There are medical providers performing endoscopies today who were involved in this.”

Proponents of the bill said existing state law protects doctors who harm patients by limiting damage awards in medical malpractice suits to $350,000. The bill would remove that limit in cases of “gross negligence.” It also would expand the time in which an effected patient or family member could sue.

Megan Gasper, 33, a mother of two children, told legislators she contracted hepatitis C after having two colonoscopies performed at the two clinics where the outbreak occurred, the Endoscopy Center of Southern Nevada and the Desert Shadow Endoscopy Center.

“This has pretty much stolen a year of my life,” Gasper said, fighting tears. “When you have to get up out of bed every day, and know that you have to take a medicine that will seriously affect your ability to play with your children, it’s hard to give yourself a self-injection.”

Former patients and family members told frightening stories of substandard care. Kevin Murray lost his daughter when doctors failed to notice the signs of meningitis. Michael Washington, who was the first patient to test positive for hepatitis C after the outbreak, said he would never be normal again.
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The incentives in the economic recovery act to encourage the conversion from paper to electronic health records could mean hundreds of millions of dollars for the state’s health care systems and doctors.

The emergency spending bill also could spur the final push needed to make paper charts a medical artifact.

“It’s going to drastically increase adoption,” said Michael Repka, executive director of the Independent Physicians Network, which negotiates contracts and provides other services for physicians in the Milwaukee area.

The long-awaited transition from paper to electronic records is considered essential if doctors and hospitals are to improve coordination of care, manage patients with chronic disease, lessen the wide variation in how medicine is practiced and monitor quality.

Electronic health records also will be a crucial component in any effort to link what doctors and hospitals are paid to the quality of care they provide instead of how many tests they order or procedures they perform.

The transition from paper to electronic health records is well under way in Wisconsin. The $19.2&enspbillion in incentives in the recovery act also will cover only a fraction of what health care systems are spending on health information systems. Froedtert & Community Health, for example, estimates its system will cost more than $70&enspmillion.

But the Wisconsin Hospital Association estimates the state’s large and midsize hospitals could receive $250&enspmillion – roughly $3&enspmillion to $4&enspmillion each – in incentives, starting in 2011.

“That’s a good chunk of money,” said Steve Brenton, the hospital association’s president.

The roughly 60 rural hospitals with fewer than 25 beds in Wisconsin could receive as much as $500,000 each under the spending bill, based on the hospital association’s estimates.

The incentives come at a time when health care systems are cutting back on capital projects because of huge losses incurred in their investment portfolios from the stock market collapse and because of flat or declining revenue as the economy buckles.

“Overall, this is extremely positive,” Brenton said. “It’s good for Wisconsin.”

The health care systems also will benefit from the incentives aimed at physician offices.

Under the spending bill, health care systems and physician practices can receive up to $44,000 for each doctor, nurse practitioner or other clinicians.

“It should spur physicians to do what they need to do,” said Repka of the Independent Physicians Network.

Nationally, only 4% of doctors’ offices had a fully functional system for electronic health records, while 13% had a basic system, with a minimum set of functions, according to a study published in June in the New England Journal of Medicine. An additional 16% of physician practices had bought a system but had yet to install it, and 26% said their practice was planning to buy a system in the next two years.
Money to speed change

The incentives in the American Recovery and Reinvestment Act are expected to quicken the pace.

“There finally is money on the table that is real money,” said Steven Waldren, a physician and director of the American Academy of Family Physicians’ Center for Health Information Technology.

Up to now, hospitals and doctors have borne the cost of converting to electronic health records while any savings from improving the quality of care, such as fewer medication errors, have gone to health insurers.

The incentives starting in 2011 will come through higher payments based on a complicated formula tied to Medicare or Medicaid.
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