Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Health care costs. Show all posts
Showing posts with label Health care costs. Show all posts

Wednesday, June 21, 2017

The Specialists’ Stranglehold on Medicine

Jamie Koufman
The New York Times - Opinion
Originally posted June 3, 2017

Here is an excerpt:

Neither the Affordable Care Act nor the Republicans’ American Health Care Act addresses the way specialists are corrupting our health care system. What we really need is what I’d call a Health Care Accountability Act.

This law would return primary care to the primary care physician. Every patient should have one trusted doctor who is responsible for his or her overall health. Resources must be allocated to expand those doctors’ education and training. And then we have to pay them more.

There are approximately 860,000 practicing physicians in the United States today, and too few — about a third — deliver primary care. In general, they make less than half as much money as specialists. I advocate a 10 percent to 20 percent reduction in specialist reimbursement, with that money being allocated to primary care doctors.

Those doctors should have to approve specialist referrals — they would be the general contractor in the building metaphor. There is strong evidence that long-term oversight by primary care doctors increases the quality of care and decreases costs.

The bill would mandate the disclosure of procedures’ costs up front. The way it usually works now is that right before a medical procedure, patients are asked to sign multiple documents, including a guarantee that they will pay whatever is not covered by insurance.  But they will have no way of knowing what the procedure actually costs. Their insurance may cover 90 percent, but are they liable for 10 percent of $10,000 or $100,000?

We also need more oversight of those costs. Instead of letting specialists’ lobbyists set costs, payment algorithms should be determined by doctors with no financial stake in the field, or even by non-physicians like economists. An Independent Payment Advisory Board was created by Obamacare; it should be expanded and adequately funded.

The article is here.

Tuesday, February 21, 2017

Pre-existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA

Gary Claxton, Cynthia Cox,  Anthony Damico, Larry Levitt, and Karen Pollitz
Kaiser Family Foundation
Originally posted December 16, 2016

Here is an excerpt:

Estimates of the Share of Adults with Pre-Existing Conditions

We estimate that 27% of adult Americans under the age of 65 have health conditions that would likely leave them uninsurable if they applied for individual market coverage under pre-ACA underwriting practices that existed in nearly all states. While a large share of this group has coverage through an employer or public coverage where they do not face medical underwriting, these estimates quantify how many people could be ineligible for individual market insurance under pre-ACA practices if they were to ever lose this coverage. This is a conservative estimate as these surveys do not include sufficient detail on several conditions that would have been declinable before the ACA (such as HIV/AIDS, or hepatitis C).  Additionally, millions more have other conditions that could be either declinable by some insurers based on their pre-ACA underwriting guidelines or grounds for higher premiums, exclusions, or limitations under pre-ACA underwriting practices. In a separate Kaiser Family Foundation poll, most people (53%) report that they or someone in their household has a pre-existing condition.

The article is here.

Thursday, December 8, 2016

Crowdfunding FOR MEDICAL CARE: Ethical Issues in an Emerging Health Care Funding Practice

Jeremy Snyder
The Hastings Center Report
November 22, 2016


Crowdfunding websites allow users to post a public appeal for funding for a range of activities, including adoption, travel, research, participation in sports, and many others. One common form of crowdfunding is for expenses related to medical care. Medical crowdfunding appeals serve as a means of addressing gaps in medical and employment insurance, both in countries without universal health insurance, like the United States, and countries with universal coverage limited to essential medical needs, like Canada. For example, as of 2012, the website Gofundme had been used to raise a total of 8.8 million dollars (U.S.) for seventy-six hundred campaigns, the majority of which were health related. This money can make an important difference in the lives of crowdfunding users, as the costs of unexpected or uninsured medical needs can be staggering. In this article, I offer an overview of the benefits of medical crowdfunding websites and the ethical concerns they raise. I argue that medical crowdfunding is a symptom and cause of, rather than a solution to, health system injustices and that policy-makers should work to address the injustices motivating the use of crowdfunding sites for essential medical services. Despite the sites’ ethical problems, individual users and donors need not refrain from using them, but they bear a political responsibility to address the inequities encouraged by these sites. I conclude by suggesting some responses to these concerns and future directions for research.

The article is here.

Saturday, April 30, 2016

In medical market, shoppers lack savvy

By Peter Ubel
The News and Observer
Originally posted April 6, 2016

Even before Obamacare became the law of the land, the U.S. health care system was undergoing a dramatic transformation. Millions of people were shifting from generous health insurance plans to consumer-directed ones that pair low monthly premiums with high out-of-pocket costs.

This shift has been encouraged by employers, eager to reduce the cost of employee benefits. It has also been encouraged by market enthusiasts who contend that the U.S. health care system needs to be more like the traditional consumer economy.

In theory, a family with a high deductible plan – on the hook for, say, the first $5,000 of health care expenses each year – will scrutinize the cost and quality of health care alternatives before deciding whether to receive them. In practice, health care consumerism doesn’t always play out at the bedside in ways that promote savvy medical decisions.

The article is here.


  • A shift from generous health insurance plans to consumer-directed plans has not helped people
  • Most patients, or doctors, do not know how to discuss out-of-pocket health care costs
  • Frustration with our system often distracts physicians from dealing with patients’ financial concerns

Thursday, February 11, 2016

An American Psychiatric Horror Story

By Todd Essig
Originally posted January 24, 2016

Here is an excerpt:

In order to say denying care is a good thing Bennett has to denigrate the value of the care provided. He wants readers to believe weekly psychotherapy, or whatever frequency and duration a patient and therapist determine is in the patient’s best interests, has “limited potential to heal and protect.” He concludes this because, as he writes, “Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be…”

That is such an absurd pretzel I have to resist the urge to turn on my caps lock. Of course treatment is NEVER as amazing as people wish it would be. That’s what makes them wishes and not plans. His is a meaningless statement because not gratifying wishes for transcendent change is not an outcome measure. It is an inevitability. But that’s the reason he says therapy has limited potential.

And I should point out, every (EVERY!) medical intervention has limits. Remember the old joke about the patient who gets an unequivocal yes after asking his surgeon if he’ll be able to play the piano after the life-saving operation only to say “that’s great, I can’t play now!” Well, according to Bennett that would be reason enough for an insurance company to deny coverage for the life-saving operation.

The article is here.

Monday, January 26, 2015

Kaiser's 2,600 mental health workers strike in California

By Olga R. Rodriguez
AP via Yahoo News
Originally published January 13, 2014

Kaiser Permanente mental health professionals throughout California went on a strike Monday to protest what they say is a lack of staffing that affects care.

The health care provider's 2,600 psychologists, therapists and social workers began the weeklong walkout to demand that Kaiser Permanente offer timely, quality mental health care at its psychiatry departments and clinics, said Jim Clifford, a union member and San Diego psychiatric therapist.

Clifford said some patients have to wait up to two months for follow-up appointments, which prolongs the recovery process.

The entire article is here.

Tuesday, January 20, 2015

Dilemma over deductibles: Costs crippling middle class

By Laura Ungarand Jayne O'Donnell
The Battle Creek Enquirer
Originally published January 2, 2015

Here are two excerpts:

A recent Commonwealth Fund survey found that four in 10 working-age adults skipped some kind of care because of cost. The portion of workers with annual deductibles — what consumers must pay before insurance kicks in — rose from 55% eight years ago to 80% today, according to research by the Kaiser Family Foundation.

A Mercer study showed that 2014 saw the largest one-year increase in enrollment in “high-deductible plans” — from 18% to 23% of all covered employees.


Doctors and doctor groups say such individual coping strategies can be helpful, but action is needed on a national level. The American Academy of Pediatrics recently came out with a policy statement saying high-deductible plans “may be a less desirable way to lower health care costs than other means … even if ‘other means’ require more work by government, insurance companies and other health policy participants.”

The entire story is here.

Monday, November 10, 2014

More Insurers Put Spending Limits On Medical Treatments

By Michelle Andrews
Originally published October 21, 2014

To clamp down on health care costs, a growing number of employers and insurers are putting limits on how much they'll pay for certain medical services such as knee replacements, lab tests and complex imaging.

A recent study found that savings from such moves may be modest, however, and some analysts question whether "reference pricing," as it's called, is good for consumers.

The California Public Employees' Retirement System (CalPERS), which administers the health insurance benefits for 1.4 million state workers, retirees and their families, has one of the more established reference pricing systems.

The entire article is here.

Monday, August 4, 2014

Bottlenecks in Training Doctors

By The Editorial Board
The New York Times
Originally published July 19, 2014

The new head of the Department of Veterans Affairs, Sloan Gibson, told a Senate committee last week that he needed $17.6 billion over the next three years to hire some 1,500 doctors, 8,500 nurses and other clinicians to reduce the unconscionably long waiting times that many veterans now endure before they are able to see a doctor.

That news was bad enough, but the department’s problems are emblematic of an even deeper problem: a nationwide shortage of doctors, especially primary care doctors, and other health care professionals, that will only get worse in coming years. No less alarming, the current medical education system is ill-equipped to train the number of professionals needed.

Experts disagree over how bad the current shortages are. But virtually all agree that the problem is acute in rural areas and in poor urban neighborhoods. As of June 19, according to one estimate cited by analysts in the Department of Health and Human Services, there was a shortage of 16,000 primary care physicians in such underserved areas.

The entire story is here.

Sunday, August 3, 2014

Prisons are Unable to Afford New Effective Hep C Medication

Prisoners Unlikely to Benefit from New, Highly Effective Hepatitis C Treatment
Prison Legal News
Originally posted July 9, 2014

by Greg Dober

Hepatitis C (HCV) is a blood-borne virus that is typically spread through intravenous drug use (i.e., sharing needles), tattooing with non-sterile needles, and sharing razors, toothbrushes, nail clippers or other hygiene items that may be exposed to blood. It is often a chronic disease and, if left untreated, can lead to severe liver damage.

Recent good news in the battle against HCV, in the form of two new drugs that are highly effective in eliminating the virus, is tempered by the fact that the companies that produce the drugs have priced them at $60,000 to $80,000 per 12-week course of treatment. This high cost prices the medications beyond the reach of most prison and jail systems – which is especially troubling considering that a substantial number of prisoners are infected with HCV.

The entire article is here.

Friday, July 11, 2014

Why haven't more states expanded Medicaid yet?

By California Healthline
Originally posted June 26, 2014

Two years after Roberts issued the majority opinion upholding the Affordable Care Act, the decision to expand Medicaid is far from settled. Despite predictions that all states will eventually embrace Medicaid expansion, a significant number continue to hold out.

At last count, 26 states and the District of Columbia intend to expand Medicaid, while four are actively considering it and 20 have no plans to expand the program at this time.

The Medicaid expansion was considered the sleeper issue in the legal case against the ACA that ultimately made its way up to the Supreme Court. Stakeholders were closely watching issues like the constitutionality of the individual mandate, not thinking Medicaid would be significant. And yet, in a surprise decision, the Supreme Court effectively took the teeth out of one of the law's major efforts to expand health insurance, by making it illegal to penalize states for not participating in the Medicaid expansion.

The entire article is here.

Friday, May 23, 2014

Architect Of Health Law Says Reform Is 'Never Finished'

The University of New Orleans
Originally published May 7, 2014

Two polls released this week reveal challenges ahead for the Affordable Care Act.

Gallup found the nation’s uninsured rate dropped to 13.4 percent last month, the lowest monthly uninsured rate since the company began tracking it in 2008. But that means 32 million people remain without coverage.

And a Pew Research Center poll shows that 55 percent of Americans disapprove of the 2010 health care reform law, which mandates that everyone have health insurance and that it be made available to even those with pre-existing medical conditions.

The entire story is here.

Monday, May 5, 2014

Cost of Treatment May Influence Doctors

By Andrew Pollack
The New York Times
Originally published April 17, 2014

Saying they can no longer ignore the rising prices of health care, some of the most influential medical groups in the nation are recommending that doctors weigh the costs, not just the effectiveness of treatments, as they make decisions about patient care.

The shift, little noticed outside the medical establishment but already controversial inside it, suggests that doctors are starting to redefine their roles, from being concerned exclusively about individual patients to exerting influence on how health care dollars are spent.

The entire article is here.

Monday, March 24, 2014

In Health Care, Choice Is Overrated

By Ezekiel J. Emanuel
The New York Times
Originally posted March 5, 2014

Here is an excerpt:

Second, we need more transparency. Insurance companies should have to publish the measures they use to select their “high performing” or “efficient” networks. This will discourage them from looking at price alone. And consumers should be able to easily find which doctors and hospitals are included in a network. The size of a plan’s network should be as transparent as its premium.

Third, we need more reliable ways of measuring the quality of networks and the doctors and hospitals within them. The N.C.Q.A. or Consumer Reports could develop a grading system, from A to F. When comparing different plans, no one should have to rely on U.S. News and World Report’s flawed rankings or hearsay from acquaintances.

The entire story is here.

Sunday, January 12, 2014

E.R. Costs for Mentally Ill Soar, and Hospitals Seek Better Way

By Julie Creswell
The New York Times
Originally published December 25, 2013

Here is an excerpt:

Today, North Carolina has only eight beds in state psychiatric hospitals per 100,000 people, the lowest ratio in the country.(North Carolina, like other states, has added beds in local community facilities but, even then, its total beds are down a quarter since 2001.)

Uninsured patients rarely receive individual therapy, only group sessions. And it can take up to three months to see a psychiatrist.

“Now, we are seeing some of the most acute, the most aggressive and the most chronic mental health patients, and we’re holding them longer,” said Janice Frohman, the director of WakeMed’s emergency department.

The effects of the upheaval in care of the mentally ill is playing out vividly at WakeMed. A private, nonprofit organization with 884 beds, WakeMed is struggling to find a way to meet the needs of increasing numbers of mentally ill patients while also controlling costs.

The entire article is here.

Wednesday, January 8, 2014

The cheapest form of health care is to let sick people die

By John F. Hunt
KevinMD Blog
Originally posted December 21, 2013

If you learn nothing else today, I would ask you to learn that moral hazard is the cause of medical price hyperinflation.

Moral hazard is not just two words that don’t seem to go together. Moral hazard is when the person who bears the economic burden of a decision is not the decision maker. In the health care setting, moral hazard is when the third party payer (insurance/government) bears the economic consequences of a patient’s decision.


The cheapest form of health care is to let sick people die. And the government will always need to save money on health care so they can afford to send soldiers to foreign lands that have oil, subsidize big agribusiness to grow corn to make ethanol to destroy our engines, give huge grants to bankrupt companies whose executives support Obama, double the size of the NSA’s Utah data center, or bail out a few more Wall Street looters.

Remember that health insurance  – because of its inherent moral hazard — is the problem, not the solution.

The entire article is here.

Thanks to Ed Zuckerman for this blog post.

Tuesday, August 27, 2013

Introducing deprescribing into culture of medication

By Catherine Cross
Canadian Medical Association
Originally published August 12, 2013

An Ontario pharmacist has received a government grant to develop clinical guidelines to help doctors determine whether patients are on medications they no longer need or that should be reduced.

"We don't normally test drugs in the elderly, but they are taking many drugs. As they get older and get more chronic conditions, the number of medications increases," says Barbara Farrell, a clinical scientist with the Bruyère Research Institute in Ottawa, Ontario.

Sometimes when medications are deprescribed or reduced, "confusion will clear, or they'll stop falling, and a lot of literature supports that," says Farrell, who received the $430 000 grant from the Ontario Ministry of Health and Long-Term Care.

The entire story is here.

Friday, July 12, 2013

Diagnosis: Insufficient Outrage

The New York Times - Op Ed
Published: July 4, 2013

RECENT revelations should lead those of us involved in America’s health care system to ask a hard question about our business: At what point does it become a crime?

I’m not talking about a violation of federal or state statutes, like Medicare or Medicaid fraud, although crime in that sense definitely exists. I’m talking instead about the violation of an ethical standard, of the very “calling” of medicine.

Medical care is intended to help people, not enrich providers. But the way prices are rising, it’s beginning to look less like help than like highway robbery. And the providers — hospitals, doctors, universities, pharmaceutical companies and device manufactures — are the ones benefiting.

A number of publications — including this one — have recently published big reports on the exorbitant cost of American health care. In March, Time magazine ran a cover story exposing outrageous hospital prices, from $108 for a tube of bacitracin — the ointment my mother put on the scrapes I got as a kid and that costs $5 at CVS — to $21,000 for a three-hour emergency room evaluation for chest pain caused by indigestion.

The entire story is here.

Wednesday, June 26, 2013

End-of-Life Care Improves But Costs Increase, Study Finds

by E.J. Mitchell
The Medicare News Group
Originally published July 12, 2013

Improvements in end-of-life care have occurred rapidly for Medicare patients but costs have increased, according to a new Dartmouth Institute brief that was released today. The study revealed that beneficiaries in their last six months of life spent fewer days in the hospital and that more patients received hospice services in 2010 compared to 2007.

However, Medicare spending for chronically ill patients at the end of life increased more than 15 percent during that time period, while the consumer price index rose only 5.3 percent.

The data from the brief, which is through the Dartmouth Atlas Project, also found that in 2010 compared to 2007:
  • patients were less likely to die in the hospital;
  • patients were as likely to spend time in intensive care units (ICUs) during the last six months of life;
  • the variations in end-of-life care at some academic medical centers quickly changed;
  • patients spent more days in hospice care; and
  • patients were more likely to see more than 10 physicians during the last 6 months of life.
  • The Dartmouth Atlas brief found that across hospitals improvement was variable, with some experiencing rapid change while others showed little improvement.

Tuesday, April 30, 2013

A Health Provider Strives to Keep Hospital Beds Empty

By Annie Lowrey
The New York Times
Originally published April 23, 2013

On a stormy evening this spring, nurses at Dr. Gary Stuck’s family practice were on the phone with patients with heart ailments, asking them not to shovel snow. The idea was to keep them out of the hospital, and that effort — combined with dozens more like it — is starting to make a difference: across the city, doctors are providing less, but not worse, health care.

For most health care providers, that would be cause for alarm. But not for Advocate Health Care, based in Oak Brook, Ill., a pioneer in an approach known as “accountable care” that offers financial incentives for doctors and hospitals to cut costs rather than funnel patients through an ever-greater volume of costly medical services. Under the agreement, hospital admissions are down 6 percent. Days spent in the hospital are down nearly 9 percent. The average length of a stay has declined, and many other measures show doctors providing less care, too.

This approach is one small part of a growing effort by providers to hold down costs without restricting needed care. Nationwide, health care spending has grown over the last three years at the slowest rate since the federal government started keeping data more than 50 years ago. While the bulk of that is related to the poor economy, changes among insurers and health care providers have contributed as well. If the trend continues, even at a reduced pace, it could help alleviate Washington’s long-term deficit problems and ease the strain on family budgets.

The entire story is here.