Hospitals increase cost of health care...and pick and choose what they market to whom

The greed of pharmaceutical and insurance companies is the stuff of legend. There can be no justification for the huge costs that the American people have to bear as a result. Their administrative costs and profits alone are unconscionable and drive up the cost of health care so much that it takes a completely self-serving and willfully ignorant Democratic presidential candidate to disingenuously ask “how will we pay for” Medicare for All – and we  have a lot of them. The financial cost is, however, is not the most evil part of what they do. That would be the deaths and disability and bankruptcy that affects so many Americans because the insurance companies deny them care and the pharmaceutical companies make their drugs unaffordable. (This is a mild term for drugs that can cost $30,000-$100,000 a year and more!)

I have written about these issues many times. More recently I have also written about the role that providers (mainly hospitals and “health systems”, but also some physicians, nursing homes, etc.) play in the two-pronged scandal of the US health care system – too expensive and too unavailable to too many. There are some hospitals (I include “health systems” but will use “hospital” to avoid confusion with the “health care system”) that are actually for-profit, but most are officially “non-profit”. This means that they don’t have shareholders – and don’t pay taxes – but they otherwise behave just the same, trying to make as much money as possible. They say that they plow this back into the services that the hospitals provide, but it also includes salaries for C-suite executives that look just as outrageous as those in the “for-profit” sector.

More important, the “improvement” in services does not always – or even usually – create new services that were absent from the community previously, or make them available to more people than previously, say the poor and uninsured. They are usually efforts to attract insured, paying, profitable patients away from other hospitals by building a new, fancier cancer center, or heart center, or orthopedic center. Hardly ever pediatrics (except neonatal intensive care) or mental health – they only want to expand those services that are big profit centers. In this way, it is parallel to the behavior of drug companies; they prefer to minimally modify existing big sellers to get a piece of that market (“me-too” drugs) rather than to develop drugs to meet needs not currently being met.

It is good to see the hospitals being called out by major health system critics. Elisabeth Rosenthal, president of Kaiser Health News, wrote an important article on September 1, 2019 in the New York Times (where was once the health reporter) titled “That Beloved Hospital? It’s Driving Up Health Care Costs”, in which she makes many of the same points. She writes that

Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.

A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.

The reason, of course is the political clout that the big hospitals can buy (with, of course, our money!).The Democratic presidential candidates are beholden (with the exception of Sens. Sanders) to both hospital contributions and the role of big hospitals as major employers and economic drivers. “In 2018, PACs associated with the Greater New York Hospital Association, and individuals linked to it, gave $4.5 million to the Democrats’ Senate Majority PAC and $1 million to their House Majority PAC. Its chief lobbyist personally gave nearly a quarter of a million dollars to dozens of campaigns last year.” Could this have anything to do with why “The cost of a hospital stay in the United States averaged $5,220 a day in 2015 — and could be as high as over $17,000, compared with $765 in Australia”? Ya think? Ask you politicians what they are going to do about it…

The media, including Kaiser Health News, has been running stories on hospitals that are aggressively pursuing lawsuits against patients who have been unable to pay their bills. On September 3, 2019, the Times ran a long piece on the poster child for this practice, Carlsbad Medical Center in New Mexico, in “As Patients Struggle With Bills, Hospital Sues Thousands”, but Carlsbad is by far not the only one. The practice is most common in towns with just one hospital, and of course, patients do not know how much they owe – or for what. It doesn’t matter if you are insured: “Ms. Price, 40, a nurse and local 4-H leader, has been sued five times by Carlsbad Medical Center, for bills totaling more than $17,000….Ms. Price said she had never received an itemized bill outlining exactly what she owed money for. The collection agency wanted the balance in full, and she was not able to work out a payment plan until after she was sued.”

This article names other hospitals that sue patients as a core business practice, and mentions over 20,000 suits in Virginia. Turns out that this was in no small part driven by the state-owned University of Virginia hospital in Charlottesville, documented by the Washington Post and MSN in “‘UVA has ruined us’: Health system sues thousands of patients, seizing paychecks and putting liens on homes”. In a quick response, the Governor of Virginia and the University vow to stop suing patients, but this has apparently not affected those already sued: ‘“Fixing the problem “is complicated,” in part because “we are legally obligated as a state agency to collect debts,” he [UVA president Ryan] said. “But we have discretion within those legal constraints to make our system more generous and more humane.”’ It also has not hurt the CEO of the hospital “…Pamela Sutton-Wallace, who will leave in November to join New York-Presbyterian Hospital as a senior vice president”. Maybe she can teach them to sue their patients…

Many of us have sort of emotional attachments to our local hospitals, where we were born, or delivered our babies, or had our life-saving surgery or other treatment; for which we raised money through bake sales and car washes, or maybe volunteered in the gift shop. But these are not the warm fuzzy hospitals you remember. Rosenthal acknowledges that many rural hospitals are in financial trouble – and they are – but supporting the fantastic (“non-”) profit of these major hospitals is not going to change that. As in every other sector of society, we have two classes of service. One is to those in major metropolitan areas with money or good insurance, with conditions that are highly-profitably reimbursed, like cancer. Preferably all of the above. There is no limit to what will be invested in them. Then there are those without money, or good insurance, who live in rural areas, or have problems that are not well reimbursed, like mental health or substance use. They will not get investment. Simple as that.

Major hospitals are big businesses and act like it. You are a customer – but, compared to other industries in which you are a customer, a particularly uninformed one. Need a car? A refrigerator? Financial services? Dental care in Mexico (had to get that one in)? You can find out what it will cost and compare prices. Hospital care? In the US? You gotta be kidding.

The answer? Improved an expanded Medicare for All, a single-payer system in which, as in Canada, hospitals get global budgets, and separate capital budgets so that they cannot use the money (profit) they earn on your care to build spas to attract high-paying patients from competitors. Where everyone gets the care they need, and no one gets excessive care. Possible? Too expensive? Ask the Canadians. Or Australians, where the average hospital bill is less than $800. Or British, or French, or Swedish, or Danish, or Dutch, or German, or Taiwanese….

Medicine should not be primarily a business: choosing appropriate care for all, not excess testing for some

The American Academy of Family Physicians (AAFP) has added five new recommendations to its Choosing Wisely campaign. I have discussed “Choosing Wisely” before (‘“Eggs Benedict” and “Choosing Wisely”: Often the best thing to do is nothing’, April 14, 2012), but will briefly review it. First introduced by the American Board of Internal Medicine Foundation (ABIM-F), the program calls for each specialty society to list at least five things that are done by members of that specialty but either should not be done at all or should only be done in far more restricted circumstances that they currently are.

The five new recommendations by the AAFP bring their total to 20; this is good, because many other specialty societies have never expanded upon their original five. And for some of those groups, even those original five were kind of tentative, almost like “well, this test or procedure is not good, so you probably shouldn’t use it too much”.  One reason Family Medicine has more is because the field is so broad and its practitioners care for problems in all areas, but I fear that another reason is the reticence of some specialty societies to make negative recommendations about things that their members make a lot of money from doing, even if they are not medically indicated. As I noted in ‘Medical interventions we shouldn’t be getting: issues of cost, health, and equity’(December 12, 2015) regarding imaging for uncomplicated back pain:

…some of the tests chosen (MRI or CT for new-onset uncomplicated low back pain) were imaging studies not recommended by the American Academy of Family Physicians and American College of Physicians (Internal Medicine) as part of the “Choosing Wisely” campaign, but are not recommended against by the American Academy of Orthopaedic Surgeons in their “Choosing Wisely recommendations. Of course, orthopedists stand to benefit from doing surgery on these patients.

The radiologists, who perform the MRIs and CTs, also did not recommend against this procedure.

The radiologist societies also recommend screening for lung cancer with low-dose CT scans in smokers and former smokers, and in fact, to date, none of the specialty societies are recommending against it. There is some evidence that this (not inexpensive) test may be able to detect lung cancer early in many people, sometimes while it still can be effectively treated, but even this is not certain. Rita L. Redberg, MD, in an editorial in JAMA Network “Failing Grade for Shared Decision Making for Lung Cancer Screening”, notes that while (payment by Medicare for) the test was approved on the basis of one positive study, three subsequent studies have not shown the benefit. In addition, it is not without risk of harm. The harms come not only from radiation exposure, but from complications of the biopsies needed to follow up on positive tests. And, also noted by Redberg, 98% of positive tests are “false positives”, where the patient does not have cancer. Some of this high percentage of false positives comes from testing the wrong people (“screening creep”, where a test that has been shown to be of benefit in a limited population is incorrectly assumed to also be of benefit to a wider group). the US Preventive Services Task Force (USPSTF) recommends that the screening only be done on the patients for whom it is indicated (!!), and only after the doctors engage in “shared decision making” (SDM) with their patients by helping them understand both the potential risks as well as benefits to the test, and what their individual probability of each is.

Apparently, doctors do not do this, as demonstrated by the research article that Redberg’s editorial accompanies, “Evaluating Shared Decision Making for Lung Cancer Screening” by Brenner, Malo, Margolis, et al. Taping and analyzing recordings of doctors recommending this test to their patients, they found noevidence of the physicians presenting the important information and engaging in SDM. It was a small sample (this is difficult and time-consuming work), but as Redberg points out there is no reason to imagine that overall practice is significantly different. While this study specifically looks at low-dose CT screening for lung cancer, and finds that SDM doesn’t happen often, this is a concern for many other tests and interventions that are often done when they are not indicated, and rarely have the risk/benefit presented to people so that they can participate in SDM.

One example of such a test is the use of screening pelvic examinations (the part where the provider puts her hands in and feels around, not the Pap smear part) in non-pregnant women. One of the AAFP’s new “Choosing Wisely” recommendations (#16) appropriately comes out against it: “Don’t perform pelvic exams on asymptomatic nonpregnant women, unless necessary for guideline-appropriate screening for cervical cancer”.  This is because the most basic characteristic of a screening test (essentially, any test – whether a physical exam or lab or x-ray – done in asymptomatic people) is that there has to be a disease that the test can, with some reasonable rate of accuracy, screen for. There is no condition that can be screened for by a pelvic examination (including ovarian cancer, which has been cited, and is always too advanced to successfully treat by the time it can be felt). I have been teaching students and residents to not do “screening” pelvic examinations in asymptomatic non-pregnant women for decades.

For similar reasons, previous AAFP “Choosing Wisely” recommendations, had already recommended (#5) against doing Pap smears in women in whom it is not indicated (those who are under 21 or have had removal of their cervix for non-cancer disease), and in women over 65 who have had negative prior Paps and are not at high risk for cervical cancer (#9), and not requiring either Paps or pelvic exams for prescribing oral contraception (#15). In addition to not doing a screening test when there is no disease to screen for (pelvic exams), they should also not be done when the risk is very low and lead to excessive false positive tests. This seems like a lot of “don’t dos” in the same general area of women’s screening, but it is warranted not only because family physicians do a lot of such screening, but, more embarrassingly, because many OB/Gyn specialists both continue to do them and to teach students and residents to do so. Indeed, not doing screening pelvic examinations is distinctly not one of the 10 “Choosing Wisely” recommendations by the American College of Obstetricians and Gynecologists (ACOG).

Yes, OB/Gyns do make some of their living doing such procedures (as do family doctors), but frankly it is a small percent compared to doing surgical procedures. Sometimes tests and procedures continue to be done even when they are not indicated (or potentially harmful) because of tradition. Or because of publicity campaigns run by disease-specific advocacy groups, especially for various types of cancer, that sow fear rather than truth.

But when such tests and procedures continue to be done, even in part, because those who perform them, the doctors and hospitals and laboratories and device makers, make money doing them rather than for medical benefit, it is reprehensible. And, even more, it saps funds from other important health-related care, particularly for those people who have the least money and are least likely to be insured. We do not have a unitary national health system in which money not needed in one area can be easily transferred to spending on necessary care for other people or conditions, but we need to get there.

It is unacceptable for people to get tests and procedures that are dangerous and of no benefit regardless of funding. It is similarly wrong for even relatively benign tests and procedures that are not medically indicated to be done because those performing them make money. But it is worst that many people do not get even basic, indicated, beneficial care while money is being wasted, or worse, on these other procedures.

The terribly flawed attitude of treating healthcare as a business was illustrated by a comment from Charles Bouchard, senior director of theology and ethics at The Catholic Health Association, in a NY Times article that found fewer than 3% (all in Washington State, which legally requires it) of Catholic hospital websites “contained an easily found list of services not offered for religious reasons.” He said '“I think that any business is not going to lead off with what they don’t do. They are always going to talk about what they do do. And that goes for contractors and car salesmen. They are not going to start off by saying, ‘We don’t sell this model,’ or ‘We don’t do this kind of work.’”

That’s the problem. Selling things people do not need to them if they have money (and not offering things there is no profit in so doing) is a common way to run a business. It is no way to run healthcare.

Maternal mortality in the US and UK: Why do we tolerate paying so much more for so much worse outcomes?

Last year, ProPublica, in association with NPR, published Why Giving Birth Is Safer in Britain Than in the U.S. In typical journalistic style, it starts by grabbing your attention with a case report of a woman in England who almost died of post-partum hemorrhage, but did not. The lesson is presumably that she did not because the physicians, midwives, and others attending her followed a rigorous set of established protocols for addressing post-partum hemorrhage that are implemented nationally in the UK.

Of course, there is a possibility that this individual woman could have died, or had to undergo more invasive surgical procedures further down the protocol’s algorithm, but the real point is that, overall, the system is working. The evidence is in that the maternal mortality rate (deaths/100,000 women delivering) is 8.9 in Britain, while in the US the rate in 2015 was 25.1, three times that of the UK! What makes this more dramatic is that the disparity has developed only since 1990; until then the maternal mortality rates in the US and UK had been declining in parallel since the 1950s.

The article cites several reasons for this difference. One, a very important one, is that the UK collects data on maternal mortality nationally and develops guidelines based upon this data which are implemented nationally. In contrast, the US collects data at best by state, or even by hospital, and

There is no federal-level scrutiny of maternal deaths, and only 26 states have an established committee (of varying methodology and rigor) to review them. Nor do all U.S. hospitals routinely examine whether a death could have been avoided. Procedures for treating complications such as preeclampsia, and for responding to emergencies such as hemorrhage, vary from one doctor, hospital and state to the next.

This is true despite the fact that the methods used by the British to collect and analyze this data were developed in the US. While there has been a well-documented 30-year effort to improve quality and to reduce preventable deaths (a category into which most maternal mortality falls) in the US, led by such organizations as the Institute for Healthcare Improvement (IHI) and embraced by such other organizations as the American Hospital Association (AHA), National Center for Quality Assurance (NCQA), the Joint Commission for the Accreditation of Healthcare Organizations (TJC), the National Academy of Medicine, and on and on, no compulsory national approach to this problem has developed. This reflects a common, and often knee-jerk, opposition to centralized approaches to almost everything, even when they have been determined to have an important effect on reducing death. It is actually parallel to efforts within hospitals to standardize care, to require, for example, all surgeries to go through a series of prescribed steps (“timeouts”) before operating, or limiting the number of different devices implanted to those needed by different types of patients rather than by the preference of the individual surgeon (for an interesting discussion, see A. Gawande, “Big Med”, New Yorker, August 13, 2012). That is, it is effective where it has been done, but it is not mandated to be done everywhere and comprehensive national data is not even collected.

Another big part of the successful UK approach to the reduction of maternal mortality has been collecting detail on what happened and why; this goes beyond “there was a death”, or “there was a death from hemorrhage”, or “there was a death from sepsis”, to identifying why it happened, particularly if the reason was something that is relatively easily addressed. Marian Knight, head of MBRRACE-UK, the group that collects the data and makes the guidelines, says

It’s all very well to know a woman died of sepsis, but to know that she died of sepsis because nobody measured her temperature, as they had no thermometers on the postnatal ward, that’s where the instruction Put a thermometer on your postnatal ward might make a difference. It’s not just the what, it’s the why.

Can you believe that there might be post-partum units where there is no thermometer? Apparently it has happened. And having a rule that it must be present is a way of preventing it from happening again.

There are at least three other important dimensions. One is that, as the report states, “These U.S. deaths are not spread equally. Women who are poor, African American or live in a rural area are more likely to die during and after pregnancy.”  This is not a big surprise.  Poor women, minority women, rural women, and uninsured women do much worse, and are much more likely to die from complications of delivery. It is the familiar song in the US, as in so many areas, of health and of every aspect of society. Is it not true in Britain? The article goes on to say

In the U.K., while inequalities persist when it comes to serious complications, according to 2012-2014 data, there is no statistically significant difference in mortality rates between women in the highest and lowest socioeconomic groups. All British women have equal access to public medical services, including free care and prescriptions from pregnancy through the postpartum period.

This also has two components; the greater equity of the quality of healthcare delivered to all segments of the population, a result of having a national health care system, and less disparity in the “social determinants of health”, the actual quality of the lives of people (women, in this case) before they access care. Especially for rural women, some of the problem the lack of an adequate number of health professionals. Over 20 years ago, family medicine residencies in Texas were surveyed and only a small percent of residents were interested in providing rural obstetric care, but no OB/Gyn residents were! This has not improved; while a recent study published by Tong, et al., in Family Medicine (Characteristics of Graduating Family Medicine Residents Who Intend to Practice Maternity Care) found that 22% of FM residents planned to deliver babies, they cite his 2012 study that showed that only 9.1% of FM residency graduates were delivering babies 1-10 years out into practice despite an intention to do so of 24%, comparable to the current study.

Another dimension is that the difference in maternal mortality reflects a greater focus on the health – and life -- of the pregnant woman in Britain, while in the US the focus is more on the health of the fetus and the newborn. This goes far beyond the issue of abortion, although the focus on children rather than women is one that is also characteristic of the anti-choice movement in the US. It is so deeply ingrained in our culture that even many health professionals (including midwives, doctors, and nurses) who see themselves as “pro-choice” and would never want to see a maternal mortality, are still more focused on the fetus and baby. It results in a practice, if not a belief, that considers the woman but a vehicle for producing a child.

Finally, there is cost, ironically but again unsurprisingly much higher in the US. Much higher. The total cost for a normal vaginal delivery in the US is about $30,000, and about $50,000 for a Caesarean section. In Britain, the cost for a normal vaginal delivery or planned Caesarean is about $2500, or less than 1/10^th the cost in the US, perhaps rising to $3400 for complicated cases (such as the one that leads off the article). Thus, the US charges far more, but has much worse outcomes for maternal mortality (as for many other conditions). This is not a side note; it is not just an interesting contradiction that our care costs more but has worse outcomes. And it is not by any means limited to pregnancy care or maternal mortality, but is present in our healthcare system at almost all levels and for most conditions. What ties these two components, cost and quality, tightly and inversely together, is that our “healthcare system” is only secondarily about delivering quality healthcare, and primarily about being a profit-making business.

So, that is the bottom line. The US has three times the maternal mortality rate of the UK despite charging ten times as much for delivery. The reasons are the absence of a national strategy to identify and remedy the causes of maternal mortality and the lack of a national healthcare system to provide the access necessary for women at risk. It causes the suffering and death to disproportionately affect those women who are already at greatest risk: the poor, minority, rural, and uninsured. The root cause is that our healthcare system is composed of poorly interconnected components, most of which are run as businesses to make money.

It is inequitable, and it is irrational from a health perspective if not from a business one. It causes unnecessary death and excessive cost, and seems to not be improving. It is not acceptable. We need to change it.