Monday, May 21, 2012

Skipping the Daily Blood Draw

The following anecdote is from Ioana Baiu, a joint degree candidate in medicine and public health at Harvard University

One of the most memorable discussions regarding the cost of care was at 4:45AM during surgical morning rounds.  As usual, the interns would present the overnight events of their patients to the chief resident and a plan for the day would be agreed upon.  These morning rounds were particularly intense: in addition to the 30 patients that an intern had to manage solo over night, the brutal hours that the surgical oncology service demanded, our chief resident, Dr. W., was a former army officer and his team was therefore ran in the most organized fashion that one could hope for.  On the first morning, as the interns were plowing through test results from laboratory data, Dr. W. asked them to justify some of the lab tests.  “Why did we order a Calcium on Mr. Z.? “, “Why do are we getting daily coagulation studies on Ms. S.?”.  Everyone seemed puzzled, as this was the first time when they were confronted with this issue.  Doing daily blood draws is considered as much of a routine as feeding patients and it seemed inconceivable that a blood test would be skipped. Indeed, this practice has become such a habit that nobody questioning anymore.

Dr. W., with the firmness of a longtime army veteran and the boldness of a surgeon, looked his interns in the eye, slowly, one by one.  And as everybody’s heart was racing, he referenced a study done at the Harvard School of Public Health a few years prior, illustrating the lack of utility of most blood tests for hospitalized patients.  Indeed, not only was drawing five tubes of blood on a daily basis a physiologically unnecessary stress on a post-surgical patient, but the costs associated with these tests or their results were not justifiable.  Quite the contrary, many of these results would lead to unwarranted attempts to correct an imbalance that did not affect the patient’s outcome. One famous phrase in Intensive Care Units is that patients die with perfectly normal levels of electrolytes; in other words, our fervent desire to measure everything and balance every electrolyte is often futile.

The following morning, Dr. W. was surprised to see that once again, every patient had a complete panel of blood test.  To their despair, the interns impatiently searched their orders just to realize that the blood tests had been performed in the absence of physician’s orders.  So deep was the custom of collecting blood and doing daily tests, that everyone assumed it to be a routine.  As we continued to round, Dr. W. would occasionally point to the cost of a blood test, painfully emphasizing the excessive and worthless money spending of our team.  Perhaps it was the fear of missing a small detail, or the need to be perfectionists and thorough to unreasonable limits; or perhaps it was just our naïveté as medical students and interns to the culture of medicine and the assumptions that we automatically accept as part of the “usual practice.”

It took more than a week for the interns to talk to each nurse, phlebotomist or lab assistant about not performing the blood draws without explicit orders  It was not an easy battle, and the interns had to take over the responsibility of convincing the staff one by one that while the harm of a simple blood draw is fairly minimal, the impact that extra 30 blood draws have each day on each team’s patients in the entire hospital is immense.  Empowered by the knowledge and the passion that Dr. W. inspired into all of them, the interns began a slow but effective fight against unnecessary blood draws.  And as a domino effect, only a few days later, other residents had engaged in the argument and convinced their fellow surgeons of their cause.

While Dr. W.’s fight was against a simple blood draw, his emotional determination to make a change in the cost of health care, and more importantly in the education of brand new residents, made him a champion.  He proved that big changes can be made on a small scale and that it is not always the $5,000 MRI test that will crush our budget, but the trivial daily tests that add up to hundreds of MRI costs.  He showed us how one person can change a team, a mentality, a culture.  And that it is through small acts that great deeds can indeed be accomplished.

Monday, May 14, 2012

Waiting for Discharge...

The following anecdote was written by Kelly Donovan, a third year medical student at Chicago College of Osteopathic Medicine

On a late afternoon in mid-July I was finishing up my first Sunday on call as a third year medical student. I glanced over the patient list for 4 East, the internal medicine floor I had been assigned to cover. Familiar with patients in their eighties and nineties, I was surprised to see a 22-year-old patient admitted with acute kidney injury.  

He was a nice-looking young man in good spirits. Spanish was his first language, but he could converse pleasantly in English, stating that he felt “good.” I palpated his abdomen and listened to his heart and lungs. He reminded me of my own 21-year-old brother, and I could easily imagine him throwing back some beers with friends or tossing around a football.  He worked for a roofing company and had been subject to the sweltering Chicago heat for the last six days. The emergency department had surmised that his acute kidney injury was caused by severe dehydration. My internal medicine residents agreed and we began loading him with fluids. This was day two of Garcia’s hospital stay.

On Monday morning, Garcia continued to deny any complaints. His blood pressure was  high at 150/80, despite treatment with medications. Creatinine, a marker of kidney function, continued to be abnormally elevated at 4.1. Ultrasound imaging showed evidence of a complex cystic mass in the kidney, along with areas indicative of chronic kidney disease. Multiple test results were pending to figure out the cause, including a comprehensive immunology panel. The nephrologists consulting on his case recommended a kidney biopsy, and a follow-up ultrasound and CT scan, finding Garcia’s previous imaging results inconclusive.
On hospital day four, Garcia’s blood pressure remained elevated with kidney function stable but poor. On day five, the nephrologists ordered vein mapping in case the need arose for hemodialysis. The team suspected chronic kidney disease secondary to nephrotic syndrome; a biopsy would confirm this diagnosis. Day six was a lot like day five, except someone checked the urine for protein. At 6.5 grams per 24 hours, Garcia had nephrotic range proteinuria. This is when I found out that Garcia was a self-pay patient and thus unable to afford a biopsy.

The case manager suggested we discharge home and recommend he follow up at the county hospital. Unfortunately, County doesn’t take transfers. So, Garcia would have to start at the beginning by seeing a primary care doctor during clinic, and be referred to a nephrologist on staff. While this would save Garcia significant money, the case manager worried about losing track of him. Despite his worrisome blood pressure and lab values, he felt great. Daily, he denied any complaints and smiled pleasantly throughout physical exams.

Days 7, 8 and 9 followed. Garcia’s blood pressure gradually normalized, but his kidney function remained very poor. The medicine we originally used to treat his proteinuria caused elevated potassium and uric acid, so we had to discontinue it. His hemoglobin dropped, either due to the kidney disease, or because we were loading him with IV fluids. It wasn't clear if our interventions were helping or hurting. So, we just watched him for three days while waiting for Nephro to sign off on the case so he could be discharged.

On day 10, Garcia’s bed was empty. The case manager shared that he had finally been discharged. The immunology workup still pending, they promised to alert him to the results when available. He was instructed to look into programs that would help pay the cost of dialysis.

During Garcia’s hospital stay, he received competent medical treatment. However, patient care was lacking. The failure of communication lead to an excessive hospital stay and thousands of dollars the patient clearly could not afford. There did not appear to be an open line of communication between the primary doctor, the nephrologists, the case manager and the patient’s family. By day three, the patient was stable. Why did he stay an additional six nights in a hospital bed he could not afford? There was no need to observe the patient while waiting for the immunology panel that typically takes 2-3 weeks to process. Did the physicians not know he was a self-pay patient? If aware, would it have changed their treatment plan? Perhaps the nephrologists wanted to “solve” this unusual case. Why did it take them so many days to sign off on the patient? And, given the language barrier, did Garcia’s family understand the suspected diagnosis and prognosis? With better communication, these obstacles to cost-awareness could have been avoided and improved Garcia’s outcome.

Monday, May 7, 2012

Side Effects May Include Financial Ruin

Christopher Moriates, MD is a senior resident in Internal Medicine at the University of California San Francisco (UCSF). He is a co-creator of a cost awareness curriculum for residents at UCSF and is currently working with the American College of Physicians (ACP) on their national “High Value, Cost Conscious Care” curriculum. 

He winced in a way that made me feel his discomfort. It wasn’t overly dramatic; it was a response of a man trying to put on a brave face and hide his pain, but - as I gently laid my hands on his belly - failing against his best efforts. This man had real abdominal pain, the kind that is impossible not to immediately empathize with. I got concerned.

“How long has this been going on?” I asked, while my mind began to immediately tick through a differential diagnosis.

“Well it probably started a year ago, but got really bad about four months ago,” this otherwise healthy-appearing, thirty-something-year-old man said.

We were in a small curtained-off area in the hectic Emergency Department at San Francisco General Hospital (SFGH). I started to wonder what in the world would possibly cause somebody to wait many months with severe abdominal pain and rectal bleeding before coming to see a doctor.

I asked a few more questions, verifying that he was indeed having bright red blood with his bowel movements, had lost at least 10-pounds over the last few months and has dealt with nausea and debilitating abdominal pain ever since the end of last year.

So, I pulled out one of my most tried-and-true questions that I have picked up during residency:
“What made you come to the hospital today as opposed to yesterday or last week?”

The answer should have surprised me.

“Well, I didn’t want to see a doctor because I couldn’t pay for it. I had to wait until my benefits kicked in so that I had insurance.”

The Emergency Department had already put him through the CT scanner prior to calling me to admit him to the hospital, in order to ensure that he “didn’t have something really bad going on,” which I have to admit that if you had put your hands on his abdomen you would probably think was a more reasonable (if not very eloquently phrased) concern. 

The CT scan showed inflammation of his colon in a pattern that the radiologist said was very likely Crohn’s Disease.

His lab tests returned with severe anemia (hemoglobin of less than seven) and an undetectable iron level, revealing that the bleeding had been going on for a long time. I told him that I thought he needed a blood transfusion and a colonoscopy procedure in the morning by one of our gastroenterologists.

Then he asked me one of my most feared questions that I have picked up during residency:
“But how much will that all cost and will my insurance pay for it?”
“I wish that I could answer that for you, but I really don’t know.”

Now, the thing is that I actually have spent more than the past year working on cost awareness for residents and looking into issues related to costs of care, and even I couldn’t answer this question in a straightforward and truthful manner. This man needed these things done and costs be damned. Sure, but let’s be honest, his concern is very real. Medical bills are the leading cause for personal bankruptcy in the United States. And at his young age, the effects of an expensive inpatient work-up could be devastating for a long time to come. Incredibly, in 2007, 78% of filers of personal bankruptcy caused by medical problems had medical insurance at the start of their illness.

The best I was able to do was tell him that in my medical opinion he needed these procedures in order to make the diagnosis and get the right treatment for his disease. My medical training has taught me how to recognize inflammatory bowel disease, diagnose it and treat it, but it has not adequately addressed how to not inflict insurmountable financial harm on some of my patients in the process. To me, it is straightforward; this man needs medical treatment for Crohn’s Disease. To him though I may be replacing his abdominal pain with another debilitating problem.

This all seems especially unfair when just a few weeks ago we reviewed a case in our monthly UCSF Cost Awareness conference of an elderly man with a headache who was seen at our University-affiliated clinic across town from SFGH and underwent BOTH a negative head CT and a brain MRI and didn’t pay a dime – the outpatient MRI was “charged” on his bill at $3,644, of which Medicare paid the incredibly reduced “price” of $275 and Medi-cal picked up the $178 that the patient would have been responsible for.

The man’s headache, by the way, resolved with “meditation.” That’s probably a good prescription for all of us right now.

Tuesday, May 1, 2012

The case of the $517 chest x-ray

The following anecdote is from Dr. Paul Abramson, a physician based in San Francisco, and originally appeared on his blog, and is part of a series of posts on this topic

So the story goes like this.  A patient of mine needed a chest x-ray.  He doesn’t have health insurance, so rather than just give him a requisition and send him to the local hospital, I decided to do a little calling around on his behalf to find out what the damage would be… 

Vendor #1: A well-known local hospital
I called up the radiology department and asked them how much a PA and Lateral Chest X-ray would cost.  “I don’t know – we don’t have that information” I was told by the clerk.  The radiologist gave me the same answer.  They both said I should just send the patient over and he would find out the cost when he received the bill.

That seemed a little dumb.  Since when do we go into stores and buy things without knowing the price?

So after 4 additional phone calls and about 2 hours, my assistant and I finally reached Bob who is in charge of uninsured patient billing.  He was able to tell me the price: $517.

For a PA and Lateral Chest x-ray.

For cash paying patients who pay at the time of service and know to ask for the
“20-20″ discount
 by name, the price ends up being reduced to$310.20. But you have to know the secret code word.
Time to receive report in my office: 2-3 days.
Quality: Good

Vendor #2: Free-Standing Private Radiology Office (call us if you wish to know which one)
I called up and the receiptionist answered on the first ring.  I asked how much for a PA and Lateral Chest x-ray.
An immediate answer: $73.
Time to receive report in my office: 1 hour.
Quality: Just as Good

So my quesiton is this.  How can the hospital be charging 4.25 times as much as the place down the street to cash-paying patients, for the same product and actually inferior response time?   (or 7 times as much without the secret code word).  I know, “cost shifting” is a common refrain.  But that just doesn’t fly any more.

And what’s more disturbing, how can it be so difficult to find out the price when you call up and ask?

So many doctors just send their patients to the hospital x-ray department or lab without thinking that it may bankrupt them.  And many doctors have no idea that the price spread can be so great.

It’s time we developed some more price transparency in health care.  I know there are companies trying to create online price comparison databases.  That is good, but really every entity should be required to have front-line staff know the prices
for every service they offer.  That way patients and doctors can make rational decisions about how to get each patient what they need.