10 Surprising Things In Healthcare Reform (Senate version) Part 1

I promised in an earlier blog to list 10 things in the Senate version of the healthcare reform bill that you might not be aware of. Since it's New Year's Eve, technically a holiday, I'm only working at partial speed so you only get a partial list today. More to come over the next few days. 

1. Support comparative effectiveness research by establishing a non-profit Patient-Centered Outcomes Research Institute to identify research priorities and conduct research that compares the clinical effectiveness of medical treatments.   

In English: The government will fund research to directly compare treatment A to treatment B to determine which works best and is most cost effective.  

Major weakness: the Senate bill specifically notes that the results of such research "may not be construed" as mandates, guidelines, or recommendations for payment, coverage, or treatment or used to deny coverage.

Huh? What is the point of finding out that treatment A works better than treatment B if you don't use it to make coverage decisions???

Prediction: Most insurers will use this information to make coverage decisions, much to the chagrin of many pharmaceutical and medical device companies. In the not-too-distant-future, Medicare will join the party. After all, the eventual goal of all this is to improve quality and reduce costs, isn't it?

2. Award five-year demonstration grants to states to develop, implement, and evaluate alternatives to current tort litigation. Preference will be given to states that have developed alternatives in consultation with relevant stakeholders and that have proposals that are likely to enhance patient safety by reducing medical errors and adverse events and are likely to improve access to liability insurance.

In English: The feds will give money to states to explore ways to get doctors to stop practicing defensive medicine so we can bring down malpractice insurance premiums and reduce litigation. You get more money if your proposal also focuses on ways to reduce medical errors (think: cutting off the wrong leg) and make it easier for docs to get malpractice insurance.

This is really important, because despite improved attention to the problem of medical errors over the past decade, we haven't made all that much progress. And, as noted in an earlier blog, a huge number of ordered tests are unnecessary.

Prediction: We may finally be on our way to the tort reform we need in the healthcare system.

3. Develop a national quality improvement strategy that includes priorities to improve the delivery of health care services, patient health outcomes, and population health. Create processes for the development of quality measures involving input from multiple stakeholders and for selecting quality measures to be used in reporting to and payment under federal health programs.

In English. We're going to tackle the quality issues within the healthcare system that Josh referred to in his comment. It is shameful that despite spending more per capita than any other country on healthcare, we are less than average in several key indicators.

4. Establish a grant program to support the delivery of evidence-based and community-based prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates and addressing health disparities, especially in rural and frontier areas.

In English. This and other components of the bill, including grants to small businesses that implement wellness programs and a requirement that all chain and fast food restaurants post nutritional information about their menu items, begins to get at another major problem in our country and healthcare system: Lifestyle-related illnesses like diabetes and heart disease, and the lack of incentive for physicians to push prevention.

Prediction: The pendulum is swinging away from self indulgence towards restraint on fiscal terms in this country; maybe we'll start seeing the same when it comes to our personal health.

Tomorrow: Six More Surprising Components of Healthcare Reform

They Did It!!

So President Obama, the Democrats, and, yes, the American people got their much-awaited Christmas gift--healthcare insurance reform. Oh, sure, the Senate bill has to be reconciled with the House bill, but I'll bet you my weekly copy of JAMA that's a no brainer.

So now (or next Monday when the world returns to work) we can expect a slew of criticism and predictions of doom from people unhappy with the bill as passed. I want to head off some of this at the pass by saying this: No, the bill is not perfect. No, the bill will not reform the healthcare system. No, the bill will not save billions of dollars and reduce the amount of GDP (currently at 17 percent) that our country spends on healthcare.

But, as a wise friend once told me, perfect is the enemy of good.

The reality is that the Senate bill is a first step on a very long journey to contain our out-of-control health system. There will be many more such steps before we even get close to stuffing this evil genie back into the bottle. Why? Because we have allowed our system to become the kudzu of our culture. For those who aren't of Southern roots, kudzu is an evil vine that grows about a mile a day and, left unchecked, can smother a small town within a month. Health care in the United States is pretty much the same. I've often compared it to a closed toothpaste tube: you squeeze out some savings at one end and they just pop up somewhere else.

Plus, as with any huge system, once you start messing with it there will be unexpected results. For instance, when Massachusetts required that all its residents have health insurance, it didn't expect the significant shortage in primary care physicians that resulted as millions of newly insured people rushed to the doctor's office. Expect similar unintended consequences as we begin manipulating our current healthcare system.

In the meantime, though, we have the first, all important step.

On the plus side, the Senate bill (and, likely, any reconciled bill):

• Mandates healthcare coverage for most Americans and provides subsidies/low-cost options for such coverage to people who can't afford to purchase health insurance at full cost
  
• Prohibits health insurance companies from discriminating on the basis of preexisting conditions (see my blog about this)
• Prevents health insurance companies from cancelling your coverage when you get sick

These are just the headlines. I've been reading the excellent summary of the bill that the Kaiser Family Foundation provides and, in upcoming blog posts, will be addressing several of the less publicized components of the plan.

For now, though, I'm opening my bottle of champagne early.

Why You Should Ration Your Healthcare

A few months ago my 72-year-old mother told me she was having a CT scan because she had a lot of back pain. Her doctor thought it was a bulging disc. Given her age, it was most likely related to degenerative disc disease, i.e., old age. He had already prescribed physical therapy and some anti-inflammatories.

So why, I asked her, are you having a CT scan? How would your doctor's treatment plan change based on what the CT shows? Are you going to have surgery? Take stronger drugs?

She couldn't answer. She couldn't answer because she never asked the questions. Just as she never asks her doctors why they prescribe one medication over another, or why they recommend knee arthroscopy for her aching joint (which studies find no more effective than conservative medical treatment) instead of knee replacement (which studies find extremely effective both from a medical and a cost perspective because it keeps keep older people active, reducing the risk of additional medical problems and improving their quality of life).

Now, this is not to pick on my mother (who, since she reads this blog, is probably preparing to cancel her upcoming trip to see me). It's to point out a major problem with too many people in this country, particularly those, ahem, of a certain age (read: Medicare beneficiaries).

Like my mother, they were raised during a time in which you never questioned your doctor. When he (and most doctors of the time were men) said swallow these pills, you said "how many?" When he said you need surgery, you said "when?" When he sent you for x-rays, CT scan, MRI -- you went. Why worry about it when you had good health insurance and your out of pocket expenses were just a few dollars. After all, these are just tests, they're not going to hurt you, are they?

Well, yes.

In fact, the release of two major studies this week showed just how much they can hurt you. Both were published in the Archives of Internal Medicine and both looked the contribution of CT scans--those seemingly benign fancy x-rays that provide your doctors with three-dimensional images of parts of your body--to cancer. We like these scans; last year, Americans received 70 million of them!

The result? 

• CT scans performed in 2007 will be responsible for an additional 29,000 cancers and 15,000 cancer-related deaths.
  
• The younger you are when you get a scan, the greater your risk of developing cancer from it. For instance, a 40-year-old woman has a one-in-270 risk of developing cancer from a coronary angiogram (a test to evaluate coronary artery blockages that exposes you to as much radiation as 309 chest x-rays), while 20-year-old woman has a one-in-150 chance.
  
• Radiation dosages from CTs vary widely among hospitals, even for the same type of scan.
• Patients are exposed to radiation dosages that are, on average, four times higher than necessary.

What does this mean for you? It means that, unlike my mother, you should not blindly head to the radiology department whenever your doctor hands you a prescription for a CT (or MRI or any other test). Nor should you take yourself to those freestanding centers that offer full-body CTs.

Even if the test itself doesn't carry any risk, it still costs money. Or could lead to unnecessary biopsies and worries. Or could identify something that, if you hadn't known was there, wouldn't have killed you but will now subject you to treatments that could.

This is not to say that imaging tests aren't necessary. They are a very important part of good medical care. However, researchers estimate that at least a third of all CTs are unnecessary. Plus, as an editorial in the same issue of the Archives pointed out, a GAO report on  medical imaging found significant differences in expenditures on medical imaging between states, with no evidence that people getting more scans fared better medically than those getting fewer. Another study found that nearly four out of 10 scans ordered for heart conditions were inappropriate or, most likely, not needed.

So the next time you think about asking for a CT, or your doctor wants you to get one, ask the question: "Why?" Will it change the treatment plan? Are there other diagnostic options? What are you looking for?

If you and your doctor decide that yes, you do need the scan, when you get to the radiology department ask those same questions. Turns out that doctors often order one test when another would work much better at delivering the information they need--possibly with less risk.

This is the kind of thing that managed care used to do back in the heyday of HMOs. Doctor ordered an MRI or CT scan? They usually had to get authorization from a nurse or other medical professional first. Back then, of course, everyone screamed about rationing. So the practice, like most that managed care instituted to reign in runaway costs, went the way of the horse and buggy. 

Rationing? Maybe. But wouldn't you rather be refused a CT scan today than get a scan-related cancer tomorrow?

Making a List and Checking it Twice. . .

No, I'm not Santa but I'm still making a list. Unlike Santa's list, this one only includes those who have been naughty. Specifically, companies that use freelance medical writers but do not pay within a timely manner (i.e., 45 days from invoicing); do not pay at all; or significantly change the scope of the project but balk (or walk away) when the writer tries to change the scope of the fee.

This list was triggered by a Tweet from someone about Time Inc., and NBC charging freelancers a percentage of their fee if they want to be paid in a timely manner. Imagine that. If you want to be paid within a month or so, you have to agree to give up 4% or so of the money owed you.

There is just so much wrong with that thinking I don't even know where to start. My outrage might be the result, in part, of my own payment woes. As I wrote in an earlier post, I have a client who just informed me they are paying at 90 days or later and there is nothing I can do about it. The reason they are paying me so late? Because their client has not paid them!

Well, now I have something I can do. I'm putting them on the List.

So the next time they call a freelancer (as they called me last week) and ask the writer to take on a rush job, the freelancer will know that this is a client that takes forever to pay--and will ask for 50% of the project up front, overnight or wired into their checking account--before writing a single word.

I posted word of the "list" on the American Medical Writers' Association listserve and immediately several writers emailed me their own stories of woe. I also invited writers to email me directly to find out the name of my own late-paying client -- about 15 did (15 of some of the best writers out there).

Now, let me say that I've been freelancing for 10 years and I've rarely had trouble getting paid. In fact, this is the first year I've  ever faced this problem in any significant way. I know the economy is a mess, I know times are tough. What I don't understand is why a company would alienate a vendor they need. After all, if they can't find a good writer to turn out quality work (including those rush jobs), how will they meet the needs of their own clients? Is it worth the extra percent or two in interest to alienate a writer who has learned your system, worked well with your staff, and turned in good work that pleased your client? How much more will it cost you to start all over again with another writer?

I'm trying to understand, I really am, but I just don't get it.

So I'm making a list; a list I will make available to other medical freelancers.

Have a late-paying client story to share (from within the past 2 years only)? Email me directly at debra.gordon9@gmail.com. Your name will be kept confidential; only your late-paying client will be added to the list.

The TRUE Cost of Health Care

Three years ago, my husband left his perfectly secure job (read: with benefits) and became a full-time consultant for his old company (read: without benefits) so we could have a much nicer lifestyle in Williamsburg, Va than we did in the small Pennsylvania town in which we'd lived for nine years (no offense to Pennsylvanians, but I'm a Virginia born-and-bred gal and I needed to get back to the Commonwealth, where the daffodils bloom in February and we can wear flip flops before June).

Needless to say, we lost the benefits (read: employer-provided health insurance) that had allowed me to go out on my own as a freelance medical writer seven years before.

No problem, I thought. I'm a healthcare expert. Heck, I once managed the provider relations department for a mid-sized managed care company, contracting with doctors and convincing them that they hated our HMO less than the other HMOs in the area (I was pretty darn good at it, too). I'll just go out and find us some health insurance.

I started on the individual market. For my sons and husband, who had never had a serious health problem, the premiums weren't too bad: about $350 a month for all three. But for me--who had been diagnosed with clinical depression many years back and still took medication to control (note the word 'control") it--my premium for catastrophic coverage ONLY would be more than $900 a month.

Ahem.

I. Don't. Think. So.

Luckily (and I say that with my tongue planted firmly in my cheek) I formed a corporation when we moved here. So we were able to find health insurance as a small business since we had two (i.e., my husband and I) employees. Oh joy! For a monthly premium of $675 we purchased two high-deductible policies, one for me and one kid; one for him and one kid.

Note the words "high deductible." With the exception of preventive care like regular checkups, immunizations, mammograms, etc., each of the two people on either plan had to meet individual deductibles  of $2400 before either of us got first dollar coverage. Oh, and every January the deductible clock reset.

In real terms it meant that barring some serious accident or illness that landed us in the hospital, we'd be paying out of pocket for all our medical expenses. That could be as much as $5800 for each policy, in addition to the $8100 a year we were paying in premiums. Oh, and don't forget the 20 percent we'd owe even after meeting our deductibles.

The benefit of this high-deductible plan? Our premiums were actually lower than if we'd chosen a plan with a lower deductible. And, of course, we could sock away several thousand dollars tax free to cover those out-of-pocket medical expenses--assuming, of course, that we had extra thousands of dollars just lying around collecting dust (doesn't everyone?).

There was one other "advantage" to this plan, however. After nearly 25 years of employer-paid health insurance, I'd actually get to see what things cost, something that few people with health insurance ever do. I mean, think about it. When you go to the doctor you pay a copay or, maybe, a small deductible. particularly when you pay for drugs.

Like Alice, I was about to go through the rabbit hole. Only instead of the White Rabbit, Mad Hatter and Cheshire Cat, I was about to encounter--gasp!--the real cost of healthcare.


I'll never forget the first time I had my migraine medication refilled under the new plan.

At the time, there were no generic medications and a single prescription came 8 pills to the pack. When the clerk at the pharmacy asked me, with real concern in her voice, if I knew how much the refill would cost, I thought she'd tell me $50 or so.

Nope.

$280. $35 a pill.

I nearly fell to the ground. From then on, my husband and I had a pact; whoever went to the doctor always asked for samples of the medication. And every time I got a migraine, I actually considered whether the pain was bad enough to warrant the $35.

I was actually lucky; my health insurer had negotiated the $280 cost with whatever middleman supplied the drugs to the pharmacy. Otherwise, my cost would have been higher. Same thing with doctor visits and tests. I saw this on every bill in which the provider posted the charges and then the "negotiated" rate. Sure I was out of pocket hundreds of dollars; but without that negotiated rate, courtesy of my health insurance, I would have been out of pocket thousands of dollars.

The result? I thought  about whether the healthcare service I was about to consumer was something I wanted (sure it would be nice to have the doctor confirm that my cough was the result of nasal drip but did I really want to spend the $45 for the office visit?) or need (I think I have strep and need antibiotics).  

All of which is a long-winded way of pointing out one extremely dsyfunctional part of our healthcare system: We, the consumers, don't know what anything costs! Can you imagine driving up to a gas station for a gallon of gas and not knowing the price until after you pumped the gas? Even then, your cost would depend on what kind of car you drove. And, if it were a really nice car, you'd only have to pay a percentage of that cost. 

Everyone talks about the cost of healthcare; but most of those consuming it have no idea what anything costs, rarely have to pay the actual costs, and get most of the costs--including those of our health insurance--covered by others. 

Ergo, we demand every service we can get--cost be damned. 

Until the system can provide some transparency (and I'm thinking bar codes and price stickers on everything from a Pap smear to an emergency room visit) not to mention transitioning more of those costs to us, the patients, there is NO WAY we will be able to make even the tiniest dent in skyrocketing costs. 

Your thoughts?

Working on the Weekend

How was your weekend? Get a lot of Christmas shopping done? Clean your house? Spend some quality time with the kids?

I spent my weekend working, trying to get a jump on a book I'm writing for two doctors.

And that's ok.

In fact, that's one thing I always tell "newbies" (people who are thinking about or who have just decided to go into freelance medical writing who ask me for my trade secrets). Looking for a 9 to 5 work schedule? Fuggedaboudit!

When you're a freelancer you are also a business owner. And your business doesn't stop at 5 p.m., especially in these days of 24/7 access. That means being available to your clients, current and potential, around the clock at least to the point of responding to emails in a timely manner, even emails that come in on a Saturday.

I've been freelancing for 10 years now and I can count on two hands the number of full weekends I've taken off (defined as not sitting in front of my computer for anything other than e-mail checks). I work during vacations, I work while traveling, I work at night.

This might sound like I'm working 60 or 70 hours a week. But no, when I run reports from my time-tracking software the results always average out over a year to about 30 hours a week.

Why then, you might be asking, do I work beyond "normal" work hours?

First, consider those 30 hours. They are not spent eating lunch, talking at the water cooler (i.e., email listserves, Facebook, Twitter), going to the bathroom, playing spider solitaire (a major weakness) or kibitzing online. When I do any of those things, I punch out, something people in an office don't do.

Second, one of the advantages of freelancing is setting your own schedule. So while I'm typically at my desk by 7:30 a.m., I also take a break in the late morning to work out at the gym and I take a nap--yes, you hear right, a nap-- nearly every day around 1 or 2 (to all clients who have tried to schedule meetings with me during the early afternoon, now you understand! :-) I promise more on the restorative nature of naps in a future post.

I often have to drive a kid to soccer or piano in the late afternoon, hit the store for dinner, or, and this pains me to admit it, head to my massage therapy for my biweekly deep tissue therapy on the mouse arm/shoulder/back (a hazard of long-term freelancing).

So I don't mind the evenings I head back to the office after dinner to draft an article or research a project. Or the Saturday or Sundays I spend uninterrupted hours digging deep into some complicated assignment. It always amazes me how much "quieter" the office seems on weekend without a constant flow of emails and how much more efficient I am!

I'm often asked how I separate home life from work life given that I work at home. My answer is always the same: I don't. Personally, I like the merging of boundaries. I like that my kids (when they were younger) came into my office to do homework. That they always know where to find me. That if there is a snow day or a sick day or an after-school event that they need a ride home from I can manage it. I particularly like it now that I have two teenagers at home (17- and 13-year-old boys) and know that they never come home to an empty house (my mother worked out of the house and I know what I did in those dangerous after-school hours). Want to have a bunch of friends over on a school holiday? No problem. I'm always here.

My kids (including the 22-year-old) have grown up watching me work, understanding the value of hard work, and seeing what it takes--literally--to be successful.

So yes, I worked this weekend. And, to be honest, I wouldn't have traded it for the world.

So, what are your thoughts of weekend work and work/life boundaries?

(image courtesy of Flickr photos)

Ode to a Copy Editor

The heavens must be aligned today because I've been reminded twice in the past few hours of the importance of copy editors.

For those who don't know what a copy editor is let me just say this: A good copy editor is to a piece of writing what the Secret Service is to the President: protection of the most profound type. She (and most are women) stands between excellent writing and disaster. She is the one who asks if you really meant to say that direct medical costs for asthma in the United States are $11 million a year, or $11 billion a year (the latter). She is the one who realizes you skipped a reference and now none of your endnotes are in the right place. She is the one who knows that you really mean to write multiple sclerosis, not muscular dystrophy.

Bottom line, she is the one who can see the trees in the forest when the writer can barely even see the forest anymore.

For no matter how many times a writer edits a piece, even, as I do, printing it out and doing a final edit on hard copy or, as my friend Alisa does, reading it out loud, a copy editor will improve our work every time.

It took me many years to come to that realization. When I was a young know-it-all newspaper reporter at my first job and the copy desk called at night with questions, I took it personally, certain that I must be terrible at my job if they found even a single mistake. Sometimes I even hid from their phone calls (this was in the days before cell phones) but since the all reporters hung out at the same bar, they always found me.

Today I just wish I had enough money and time to send everything I write for every client (and this blog) through a copy editor before hitting “send.” These incredibly anal, unbelievably organized, astoundingly exacting professionals who carry four or five style guides in their heads and can debate endlessly about the appropriate use of conjunctives and adverbs have saved my butt countless times over the past 25 years. They are my heroes.

But copy editors, like good writing, are becoming a somewhat endangered species. They're often the first to go during layoffs at newspapers and magazines (as you probably know if you count the errors in the headlines and copy these days). Book publishers often pay so little that the only editors they can find are newbies who wouldn't know an editing mark if it bit them on the red pen. And web sites. . . don't even get me started.

Angela Hoy, who owns a print-on-demand publishing company and whose weekly newsletter on freelancing/writing I've been reading for nearly 10 years, covered the topic beautifully this week. She specifically took aim at the so-called "content" aggregators that pay pennies to writers to produce content they can sell to other sites. A couple of her examples from the headlines alone: Loosing Weight the Way Nature Intended and My Daughters Severe Nut Allergy.

My favorite example of the need for copy editors, however, was the marked-up memo from the Toronto Star about, of course, how the newspaper no longer needs its own copy editors!

I always know the client I'm working with is a true professional when she has a copy editor standing by for my copy. The ones that scare me are the ones who expect me to copyedit my own writing. I’m a writer, I tell them, not a copy editor. The two are about as similar as a five-star restaurant and a fast-food drive through window. I can edit the copy for hours. . . but that’s not copyediting.

I worry that in our quest for quantity at the lowest possible cost we're forgetting about one tiny thing: quality. And in my mind, you can’t have quality without the sometimes annoying, extremely nitpicky, always welcome questions of a good copy editor.