A Direct Primary Care Medical Home: The Qliance Experience

The Evidence Gap – British Balance Benefit vs. Cost of Latest Drugs – NYTimes.com

“RUISLIP, England — When Bruce Hardy’s kidney cancer spread to his lung, his doctor recommended an expensive new pill from Pfizer. But Mr. Hardy is British, and the British health authorities refused to buy the medicine. His wife has been distraught.

“Everybody should be allowed to have as much life as they can,” Joy Hardy said in the couple’s modest home outside London.

“If the Hardys lived in the United States or just about any European country other than Britain, Mr. Hardy would most likely get the drug, although he might have to pay part of the cost. A clinical trial showed that the pill, called Sutent, delays cancer progression for six months at an estimated treatment cost of $54,000.

“But at that price, Mr. Hardy’s life is not worth prolonging, according to a British government agency, the National Institute for Health and Clinical Excellence. The institute, known as NICE, has decided that Britain, except in rare cases, can afford only £15,000, or about $22,750, to save six months of a citizen’s life.

“British authorities, after a storm of protest, are reconsidering their decision on the cancer drug and others.

“For years, Britain was almost alone in using evidence of cost-effectiveness to decide what to pay for. But skyrocketing prices for drugs and medical devices have led a growing number of countries to ask the hardest of questions: How much is life worth? For many, NICE has the answer. “

What a great piece. I’ve been hearing more and more about NICE lately, with this being the most visible publication on it.

As I’ve said elsewhere under the “Rationing” label, I would much rather have a fair, national or regional, system of objective analysis by scientists deciding on what care we offer to patients than the current method. The current method being everything for everyone all the time until we can peel the oncologists (sorry, guys! Others of us are guilty, too!) off the patient. Our current method also includes allowing Lilly to lobby for new reimbursement codes to pay for Xigris, or Zimmer to get Medicare to pay twice as much for a “women’s” TKR and assorted other pieces of free market capitalism.

But the US’ favorite method of rationing care, of course, is by income. Don’t have it, don’t get it.

Thomson Reuters Survey Finds Cancer Patients Forgoing Treatment

Thomson Reuters Survey Finds Cancer Patients Forgoing Treatment: “cancer treatment decisions of individuals.

Entitled “The Cost of Cancer,” the report aggregates survey responses from 1,767 adults currently being treated for cancer. It finds a clear link between patients’ annual income and their decisions to curb cancer treatments due to cost — even among patients with late-stage cancers.

The report notes that among the 569 survey respondents with late-stage cancer, 12.3 percent said they have passed up recommended treatment because it was too expensive. This figure varies dramatically by patient income level. Twenty-five percent of late-stage cancer patients who earn less than $40,000 a year said they have chosen not to undergo a recommended treatment due to cost — compared with 11.2 percent of those earning between $40,000 and $80,000 per year and 4.8 percent of those earning more than $80,000 annually.

Similarly, 65 percent of all respondents with late-stage cancer said the out-of-pocket cost of treating their cancer has caused them distress. Among all cancer patients earning under $40,000 per year, that number jumps to 77 percent.

“The physical and emotional burden of illness is not the only challenge cancer patients face,” said Bill Marder, PhD, senior vice president and general manager for the Healthcare business of Thomson Reuters. “Many also struggle to cope with medical costs. This survey shows that the cost of cancer treatment is affecting patients’ ability to get the care they need.””

I think this research speaks volumes about the American healthcare system. This is why I have it categorized under so many topics (see links below and to right). It speaks to the de facto rationing by income in the US, it speaks to how consumers “drive” healthcare (i.e., decision making is not rational), how our waiting times are trimmed by not including those who don’t seek care due to financial concerns, and how those who love to try to compare anecdote horror stories just don’t geet how bad our system is for so many people.

Letter – Health Care Fiction – Letter – NYTimes.com

Letter – Health Care Fiction – Letter – NYTimes.com:

Too well said not to cite in its entirety…

“Re “Feeling No Pain,” by Paul Krugman (column, Aug. 29):

Mr. Krugman rightly notes that emergency room care cannot substitute for health insurance since the cost will be billed directly to the patient.

There is another reason emergency rooms cannot provide adequate health care. Emergency rooms are for emergencies. They can treat a patient in a diabetic coma, but they cannot provide continuing help in managing diabetes. They can treat a full-blown asthma attack, but they cannot provide the medications needed to manage asthma daily.

They can treat a woman who has gone into early labor, but they cannot provide prenatal care.
Emergency rooms cannot offer any help for managing Parkinson’s, Alzheimer’s or cancer. On a more basic level, they cannot provide eyeglasses, hearing aids or dentures.

Republican claims that no American is without access to health care because “you can just go to an emergency room” are openly false as well as appallingly callous.

Elizabeth Vandiver
Walla Walla, Wash., Aug. 29, 2008″

International Comparison: Access & Timeliness

From the Commonwealth Fund:
International Comparison: Access & Timeliness:

“U.S. patients reported relatively longer waiting times for doctor appointments when they were sick, but relatively shorter waiting times to be seen at the ER, see a specialist, and have elective surgery. Specifically:

The percentage of U.S. patients who waited six days or more for a doctor appointment when sick was not significantly different from the rate in Canada (23% v. 36%), the worst-performing country.

Only 47 percent of U.S. patients were able to see a doctor on the same or next day when sick, versus 61 percent to 81 percent of patients in the four better-performing nations.

U.S. patients were less likely than patients in Canada (12% v. 24%) but more likely than patients in Germany (4%) to wait four hours or more to be seen in the emergency department.

U.S. patients were less likely than patients in four countries (except Germany) to wait four weeks or longer to see a specialist (23% v. 40%–60%) or to wait four months or longer for elective surgery (8% v. 19%–41%) (Schoen et al. 2005).”

Additionally, Americans are less likey to have a regular doctor, less likely to get prescriptions filled, less likely to get follow-up care, less likely to keep a doctor long-term, and have a harder time getting taken care of nights and weekends.

It speaks for itself.

Health Blog : Safety Net Frays as Hospitals Shift Resources From Poor

Health Blog : Safety Net Frays as Hospitals Shift Resources From Poor:

“An increase in the number of uninsured patients and competition from well-heeled hospitals is putting pressure on safety net hospitals to reduce services for the poor, according to a report by the Center for Studying Health System Change published online today in the journal Health Affairs. [cmhmd:requires subscription]

The analysis, taken from the Center’s ongoing survey of 12 metropolitan areas, comes as nonprofit hospitals are under increasing scrutiny for the amount of free care they provide for the poor. Some critics charge nonprofit hospitals enjoy billions of dollars in tax exemptions without providing offsetting amounts of charity care.”

And yet, if you ask the typical advocate for the status quo, we have no access problems, no rationing of healthcare here in the US.

Go to the WSJ blog for the rest, it covers things nicely.

They Know What’s in Your Medicine Cabinet

They Know What’s in Your Medicine Cabinet:
“That prescription you just picked up at the drugstore could hurt your chances of getting health insurance.

An untold number of people have been rejected for medical coverage for a reason they never could have guessed: Insurance companies are using huge, commercially available prescription databases to screen out applicants based on their drug purchases.

Privacy and consumer advocates warn that the information can easily be misinterpreted or knowingly misused. At a minimum, the practice is adding another layer of anxiety to a marketplace that many consumers already find baffling. ‘It’s making it harder to find insurance for people,’ says Jay Horowitz, an independent insurance agent in Overland Park, Kan.”

This would be funny if it weren’t so disturbing.

We’ve been having a running joke at our house that our pharmacist is going to think I’m the most diseased man on the planet because I keep getting medications from my local grocer’s $4 drug list for my dog!

I’ve been getting him antibiotics, oral and ophthalmic and topical, in a wide variety, steroids, and other stuff in my name because paying for these is far cheaper than at the vet’s! Now none of these have been charged to my insurer, I strictly pay cash, but clearly my name will be in the databases with all these drugs. So next time I have to switch plans….

Falling Behind: Americans’ Access to Medical Care Deteriorates, 2003-2007 – RWJF

Falling Behind: Americans’ Access to Medical Care Deteriorates, 2003-2007 – RWJF:
(From the Robert Wood Johnson Foundation. Follow the link for the full report.)

“The number and proportion of Americans reporting going without or delaying needed medical care increased sharply between 2003 and 2007, according to findings from the Center for Studying Health System Change’s (HSC) nationally representative 2007 Health Tracking Household Survey. One in five Americans—59 million people—reported not getting or delaying needed medical care in 2007, up from one in seven—36 million people—in 2003. While access deteriorated for both insured and uninsured people, insured people experienced a larger relative increase in access problems compared with uninsured people. Moreover, access declined more for people in fair or poor health than for healthier people. In addition, unmet medical needs increased for low-income children, reversing earlier trends and widening the access gap with higher-income children. People reporting access problems increasingly cited cost as an obstacle to needed care, along with rising rates of health plan and health system barriers.”

Essay – Fed Up With the Frustrations, More Doctors Change Course – NYTimes.com

Essay – Fed Up With the Frustrations, More Doctors Change Course – NYTimes.com:
“Not long ago, fed up with what he perceived as a loss of professional autonomy, Dr. Bhupinder Singh, 42, a general internist in New York, sold his practice and went to work part time at a hospital in Queens.

“I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.”

When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty.

“But managed care is like a magnet attached to you,” he said.

He continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ””

But if they were Government Bureaucrats, now that would be intolerable…

BTW, I included this post with the category of Rationing Healthcare because it does become rationing by attrition. Physicians often are so frustrated by the battles they fight hourly with Private Insurers, they cave in and provide less than optimal care.

CITY HEALTH CLINICS NEED A BOOSTER SHOT | Philadelphia Daily News | 04/04/2008

CITY HEALTH CLINICS NEED A BOOSTER SHOT Philadelphia Daily News 04/04/2008:

“How they don’t work: The system is far from perfect. According to a report released by the Philadelphia Unemployment Project last year, it can take up to five months to schedule an appointment with a doctor at a health center. Advocates say the centers need to extend evening hours and add staff to shorten waiting times. The mayor’s proposed funding increase is supposed to deal with some of these issues.
One of the biggest challenges that health centers face is offering competitive salaries to attract qualified staff.

The salaries offered by the city for three critical positions – pharmacists, dentists and physicians – are relatively low when compared to industry averages.

The highest-paid pharmacist working for the city makes $77,013 – well below the national median of $103,000. The same is true for dentists who work for the city. A typical dentist makes $130,000 a year. That’s significantly more than the $95,630 made by the highest-paid dentists at city health centers.

The largest discrepancy can found in the salary paid to doctors. The average physician working in a family practice makes $204,000. The highest-paid physician working for the city makes $109,820 – a difference of more that $94,000.”

Just had to post this for all of those who insist we don’t have to wait for healthcare in America and that “everyoine in America has access to health care.”

Drawing Lots for Health Care -[Oregon] New York Times

Drawing Lots for Health Care – New York Times:

“Last month, right after he had the heart attack and then the heart surgery and then started receiving the medical bills that so far have topped $200,000, Melvin Tsosies joined the 91,000 other residents of Oregon who had signed up for a lottery that provides health insurance to people who lack it.

Melvin Tsosies is among Oregonians who signed up for a health insurance lottery. “They said they’re going to draw names, and if I’m on that list, then I’ll get health care,” said Mr. Tsosies, 58, a handyman here in booming Deschutes County. “So I’m just waiting right now.”

Despite the great hopes of people like Mr. Tsosies, only a few thousand of Oregon’s 600,000 uninsured residents are likely to benefit from the lottery anytime soon. The program has only enough money to pay for about 24,000 people, and at least 17,000 slots are already filled.”

further down…

“Oregon once sought to serve a far larger population of those in need.
It has been more than a decade since the innovative Oregon Health Plan became a forerunner of state health care reform as it pursued universal health coverage. Conceived on a restaurant napkin in the late 1980s, the program had by 1996 reduced the number of the uninsured to about 11 percent of all residents, down from more than 18 percent in 1992. But then, early in this decade, the state endured a wrenching recession.
“Oregon was way ahead of everyone else,” said Charla DeHate, the interim executive director of Ochoco Health Systems. “And then we went broke.” “

Top o’ the world, Ma!