Health – Page 105 – artdiamondblog.com

“My Merit Is My Caste; What Is Yours?”

NEW DELHI, May 22 — The problem of caste prejudice here is as ancient as the Hindu texts. The efforts to redress it date from the formation of modern India nearly 59 years ago. Today — as India enjoys awesome rates of economic progress and confronts the challenge of spreading the benefits to its needy majority — the nation faces a polarizing totem of public policy: a government plan to extend college admission quotas to certain "backward" castes.

Affirmative action is in some ways an even more emotional issue in India than in the United States. In recent weeks, a proposal to extend quotas for admission to some of the country’s flagship, federally financed universities has caused fresh turmoil.

Protests — particularly by medical students who say merit should be the only basis for admission to India’s intensely competitive medical schools — have spread across the country and, here in the capital, hobbled public health services. Advocates and opponents of the measure have exchanged often ugly rants.

. . .

Medical students have been particularly outraged because the plan would further restrict the limited number of seats. Medical education in India begins with a five-year undergraduate program, and the proposal could affect students’ chances of completing their training.

The central lawn of the All India Institute of Medical Sciences, the pre-eminent public hospital, was occupied Friday by medical students on the fifth day of a strike that began last week and continued on Monday. "My merit is my caste. What is yours?" read one T-shirt.

. . .

The opponents say set-asides would diminish the quality of India’s best universities and divide students along caste lines.

"Why after 55 years are we still thinking in terms of caste-based reservation?" demanded Poojan Aggarwal, a third-year student at Safdarjung Medical College here. "We should talk now of total meritocracy. We know on this issue none of the political parties will support us."

For the full story, see:

SOMINI SENGUPTA. "Quotas to Aid India’s Poor vs. Push for Meritocracy." The New York Times (Tues., May 23, 2006): A3.

(Note: ellipses added.)

Doctor Overhead Increased 15 – 20% Due to Insurance Delays in Paying Claims

Source of the graphic: the online version of the NYT article cited below.

What is noteworthy in the table above is not the differences in delays in paying. What is noteworthy is that the fastest payer still takes a month to pay.

(p. C1) Few things rankle a doctor more than an insurance company’s saying it cannot find a claim for medical services. Particularly when there is even a signed return receipt to document delivery of the bill.

"We actually had the little green card to show who signed for the dang thing," said Elizabeth Wertz, chief executive of the Pediatric Alliance, a large group of Pittsburgh doctors. "We sent it by certified mail. The insurance company said they didn’t have it."

The claim was for several thousand dollars, according to Ms. Wertz, who declined to identify the company, a large regional insurer, for fear of making it more difficult to wrangle payments. It is a problem known to many doctors as they struggle to balance the rising cost of providing patient care with what they see as a reluctance by some powerful insurers to pay promptly.

Pediatric Alliance’s 37 doctors are among the 7,000 physicians, nurse practitioners and other health care providers around the country who are clients of the claims-processing company Athenahealth, which plans today to present a rare warts-and-all look at how well — or not — the nation’s seven biggest health insurers pay their bills.

Not well enough, in many cases, according to the data and to experts who say the survey provides the most comprehensive look yet at the state of accounts payable vs. accounts receivable in the nation’s health care system.

Tardiness or refusal to pay what doctors consider legitimate medical claims may add as much as 15 to 20 percent in overhead costs for physicians, forcing them to pursue those claims or pass along the costs to other patients, according to Jack Lewin, a family doctor who is chief executive of the California Medical Association, a professional group of 35,000 physicians.

. . .

(p. C10) Athenahealth, which says it collected $1.8 billion on behalf of its physician clients last year, is among the biggest of several thousand companies that help doctors and hospitals get paid by editing their claims and helping them to deal with difficult cases. Health care providers who can afford such services say they have become a necessary part of doing business.

In the case of Pediatric Alliance, with 37 pediatricians in a dozen offices in and around Pittsburgh, the doctors’ group spends at least $250,000 a year on salaries for eight billing clerks who handle claims and pursue money owed by insurers and patients. That is on top of salaries in Pediatric Alliance’s offices for staff members to verify the patient’s coverage and collect co-payments, plus paying an outside company to check for errors before the bills go out.

Ms. Wertz, the alliance’s chief executive, says some insurers’ telephone call centers limit claims-related issues to 10 per call. "That’s incredibly inefficient," she said. "We see thousands of patients. Our people have to sit on phone 30 minutes to get a live person."

. . .

"I would much rather have my staff talking to patients than talking to insurance companies," Dr. Katz said.

For the full story, see:

MILT FREUDENHEIM. "The Check Is Not in the Mail." The New York Times (Thurs., May 25, 2006): C1 & C6.

(Note: The "Dr. Katz" mentioned is "Dr. Molly Katz, a Cincinnati gynecologist and former president of the Ohio Medical Association.")

Paperwork is 31% of U.S. Health Care Costs

. . . , a large part of America’s health care spending goes into paperwork. A 2003 study in The New England Journal of Medicine estimated that administrative costs took 31 cents out of every dollar the United States spent on health care, compared with only 17 cents in Canada.

For the full commentary, see:

PAUL KRUGMAN. "The Medical Money Pit." The New York Times (Friday, April 15, 2005): A19.

Canada may beat the U.S. in this dimension of health care, but they lose in many other important dimensions–for example the wait time to receive ‘elective’ surgeries. And anyway, isn’t 17 percent still too high?

British Pull Own Teeth Under Public Dental Care

"William Kelly, 43, extracted part of his own tooth, leaving a black stump. He plans to pull one more." Source of caption and image: online version of NYT article cited below.

ROCHDALE, England, May 2 — "I snapped it out myself," said William Kelly, 43, describing his most recent dental procedure, the autoextraction of one of his upper teeth.

Now it is a jagged black stump, and the pain gnawing at Mr. Kelly’s mouth has transferred itself to a different tooth, mottled and rickety, on the other side of his mouth. "I’m in the middle of pulling that one out, too," he said.

. . .

But the problem is serious. Mr. Kelly’s predicament is not just a result of cigarettes and possibly indifferent oral hygiene; he is careful to brush once a day, he said. Instead, it is due in large part to the deficiencies in Britain’s state-financed dental service, which, stretched beyond its limit, no longer serves everyone and no longer even pretends to try.

Every time he has tried to sign up, lining up with hundreds of others from the ranks of the desperate and the hurting — "I’ve seen people with bleeding gums where they’ve ripped their teeth out," he said grimly — he has arrived too late and missed the cutoff.

"You could argue that Britain has not seen lines like this since World War II," said Mark Pritchard, a member of Parliament who represents part of Shropshire, where the situation is just as grim. "Churchill once said that the British are great queuers, but I don’t think he meant that in connection to dental care."

Britain has too few public dentists for too many people. At the beginning of the year, just 49 percent of the adults and 63 percent of the children in England and Wales were registered with public dentists.

And now, discouraged by what they say is the assembly-line nature of the job and by a new contract that pays them to perform a set number of "units of dental activity" per year, even more dentists are abandoning the health service and going into private practice — some 2,000 in April alone, the British Dental Association says.

. . .

The system, critics say, encourages state dentists to see too many patients in too short a time and to cut corners by, for instance, extracting teeth rather than performing root canals.

Claire Dacey, a nurse for a private dentist, said that when she worked in the National Health Service one dentist in the practice performed cleanings in five minutes flat.

Moreover, she said, by the time patients got in to see a dentist, many were in terrible shape.

"I had a lady who was in so much pain and had to wait so long that she got herself drunk and had her friend take out her tooth with a pair of pliers," Ms. Dacey said.

Some people simply seek treatment abroad.

For the full story, see:

SARAH LYALL. "In a Dentist Shortage, British (Ouch) Do It Themselves." The New York Times, Section 1 (Sun., May 7, 2006): 3.

(Note: ellipsis added.)

Disruptive Innovation in Medicine

Source of image: http://online.wsj.com/article/SB114540135592529301.html?mod=home_personal_journal_middle

(p. D1) The dysfunctional doctor’s office is getting a makeover.

A growing number of programs around the country are helping doctors redesign their offices to wring more profit out of their practices and fix problems that have long frustrated patients: weeks-long delays to get appointments, hours in the waiting room, too-brief visits with the doctor, and the near impossibility of getting the physician on the phone. While the goal is to improve care, the programs also aim to avert a looming shortage of primary-care doctors who are frustrated with low pay, long hours and rising overhead costs.

The new programs borrow lessons from other industries to help doctors work more efficiently, especially those in solo and small group practices who account for the majority of outpatient office visits. One approach employs calculations used by airlines, hotels and restaurants to predict demand: The idea is that doctors can cut patient waits much the way restaurant chains seat diners and turn over tables efficiently. Others involve relatively simple changes, such as leaving afternoon appointments open for urgent visits, or having patients fill out paperwork ahead of time online.

Managed-care giant Kaiser Permanente is launching a program to help 12,000 doctors that contract with its health plan increase their efficiency with a new electronic-medical-records system. Portland, Ore., physician Chuck Kilo, whose GreenField Health Systems helps restructure medical practices, and is assisting with the program, says that too many doctors’ appointments take up valuable office time with follow-up that could be accomplished with phone calls and email.

Other models involve more-radical change, such as one called "Ideal Micro Practice" that sharply reduces or even eliminates support staff. With this blueprint, doctors rely on electronic health records and practice-management software to quickly dispense with administrative tasks. And they may run their offices solo, greeting patients personally as they come in the door.

"The office practice hasn’t changed much in 50 years," says John Wasson, a Dartmouth Medical School professor and practice redesign expert who is helping to launch a national program to expand the Micro Practice concept. "This is a disruptive innovation that can lead to increased quality and reduced costs."

For the full story, see:

LAURA LANDRO. "Cutting Waits at the Doctor’s Office; New Programs Reorganize Practices to Be More Efficient; Applying ‘Queuing Theory’." The Wall Street Journal (Weds., April 19, 2006): D1 & D3.

Source of graphic: http://online.wsj.com/article/SB114540135592529301.html?mod=home_personal_journal_middle

Radiologist Outsourcing Is Mainly a Myth

David Leonhardt. Source of image: http://www.nytimes.com/2006/04/19/business/19leonhardt.html?_r=1&oref=slogin

A few years ago, stories about a scary new kind of outsourcing began making the rounds. Apparently, hospitals were starting to send their radiology work to India, where doctors who make far less than American radiologists do were reading X-rays, M.R.I.’s and CT scans.

It quickly became a signature example of how globalization was moving up the food chain, threatening not just factory and call center workers but the so-called knowledge workers who were supposed to be immune. If radiologists and their $350,000 average salaries weren’t safe from the jobs exodus, who was?

On ABC, George Will said the outsourcing of radiology could make health care affordable again, to which Senator Charles E. Schumer of New York retorted that thousands of American radiologists would lose their jobs. On NPR, an economist said the pay of radiologists was already suffering. At the White House, an adviser to President Bush suggested that fewer medical students would enter the field in the future.

"We’re losing radiologists," Representative Sherrod Brown, an Ohio Democrat, said on CNN while Lou Dobbs listened approvingly. "We’re losing all kinds of white-collar jobs, all kinds of jobs in addition to manufacturing jobs, which we’re losing by the droves in my state."

But up in Boston, Frank Levy, an economist at the Massachusetts Institute of Technology, realized that he still had not heard or read much about actual Indian radiologists. Like the once elusive Snuffleupagus of Sesame Street, they were much discussed but rarely seen. So Mr. Levy began looking. He teamed up with two other M.I.T. researchers, Ari Goelman and Kyoung-Hee Yu, and they dug into the global radiology business.

In the end, they were able to find exactly one company in India that was reading images from American patients. It employs three radiologists. There may be other such radiologists scattered around India, but Mr. Levy says, "I think 20 is an overestimate."

Some exodus.

For the full story, see:

Leonhardt, David. "Political Clout in the Age of Outsourcing." The New York Times (Weds., April 19, 2006): C1 & C4.

An Osama-Sudafed Link?

The drug cops want everyone to share their mission. They think that doctors and pharmacists should catch patients who abuse painkillers — and that if the doctors or pharmacists aren’t good enough detectives, they should go to jail for their naïveté.

This month, pharmacists across the country are being forced to lock up another menace to society: cold medicine. Allergy and cold remedies containing pseudoephedrine, a chemical that can illegally be used to make meth, must now be locked behind the counter under a provision in the new Patriot Act.

Don’t ask what meth has to do with the war on terror. Not even the most ardent drug warriors have been able to establish an Osama-Sudafed link.

The F.D.A. opposed these restrictions for pharmacies because they’ll drive up health care costs and effectively prevent medicine from reaching huge numbers of people (Americans suffer a billion colds per year). These costs are undeniable, but it’s unclear that there are any net benefits.

In states that previously enacted their own restrictions, the police report that meth users simply switched from making their own to buying imported drugs that were stronger — and more expensive, so meth users commit more crimes to pay for their habit.

For the full commentary, see:

JOHN TIERNEY. "Potheads and Sudafed." The New York Times (Tues., April 25, 2006): A27.

Doctors Erect Barriers to Keep Out Competition

A Bangalore radiologist. One of three radiologists in India known to be reading U.S. scans. Each of the three has a U.S. degree, as required by U.S. law. Source of image: http://www.nytimes.com/2006/04/19/business/19leonhardt.html?_r=1&oref=slogin

(p. C1) Radiologists seem like just the sort of workers who should be scared. Computer networks can now send an electronic image to India faster than a messenger can take it from one hospital floor to another. Often, those images are taken during emergencies at night, when radiologists here are sleeping and radiologists in India are not.

There also happens to be a shortage of radiologists in the United States. Sophisticated new M.R.I. and CT machines can detect tiny tumors that once would have gone unnoticed, and doctors are ordering a lot more scans as a result.

When I talked this week to E. Stephen Amis Jr., the head of the radiology department at Montefiore Medical Center in the Bronx, he had just finished looking at some of the 700 images that had been produced by a single abdominal CT exam. "We were just taking pictures of big, thick slabs of the body 20 years ago," Dr. Amis said. "Now we’re taking thinner and thinner slices."

Economically, in other words, ra-(p. C6)diology has a lot in common with industries that are outsourcing jobs. It has high labor costs, it’s growing rapidly and it’s portable.

Politically, though, radiology could not be more different. Unlike software engineers, textile workers or credit card customer service employees, doctors have enough political power to erect trade barriers, and they have built some very effective ones.

To practice medicine in this country, doctors are generally required to have done their training here. Otherwise, it is extremely difficult to be certified by a board of other doctors or be licensed by a state government. The three radiologists Mr. Levy found in Bangalore did their residencies at Baylor, Yale and the University of Massachusetts before returning home to India.

"No profession I know of has as much power to self-regulate as doctors do," Mr. Levy said.

So even if the world’s most talented radiologist happened to have trained in India, there would be no test he could take to prove his mettle here. It’s as if the law required cars sold here to have been made by the graduates of an American high school.

Much as the United Automobile Workers might love such a law, Americans would never tolerate it, because it would drive up the price of cars and keep us from enjoying innovations that happened to come from overseas. But isn’t that precisely what health care protectionism does? It keeps out competition.

For the full story, see:

Leonhardt, David. "Political Clout in the Age of Outsourcing." The New York Times (Weds., April 19, 2006): C1 & C4.

Private Enterprise “computer-chip makers have better hand-cleaning standards than most hospitals”

With rising alarm over hospital infections, which cause 90,000 deaths annually, a growing number of hospitals are adopting aggressive hand-hygiene surveillance and monitoring programs, and in some cases imposing penalties for doctors, nurses, and other health-care workers who don’t follow the rules.
. . .
Despite strict guidelines issued by the CDC to stop the spread of bacteria on contaminated hands, and wide adoption of alcohol-based hand-rub dispensers in patient rooms and hospital corridors to make it easier for harried health-care workers to disinfect between patients, compliance rates remain mired at 40% to 50% nationwide, studies show.
The IHI program recommends a far more activist approach that holds hospital administrators and staffers accountable for failure.
“It no longer is tolerable to accept noncompliance rates of more than 50% when we are dealing with critically ill patients,” says Don Goldmann, a senior vice president of IHI and a professor of pediatrics at Harvard Medical School, who notes that computer-chip makers have better hand-cleaning standards than most hospitals. While the IHI program emphasizes education and positive feedback, “repeated violations in health-care, or any industry, need to have consequences,” Dr. Goldmann says.

For the full story, see:
LAURA LANDRO. “THE INFORMED PATIENT; Hospitals Get Aggressive About Hand Washing; Staff Surveillance Programs, New Penalties Aim to Boost Sagging Compliance Rates.” The Wall Street Journal (Weds., April 5, 2006): D3.

Solution to Problems in Health Care and Higher Education: Change the Incentive Structures

Vernon Smith, one of the 2002 recipients of the Nobel Prize in economics, advocates fundamental institutional reform:

Physicians and medical organizations face escalating administrative costs of complying with ever more detailed regulations. The system is overwhelmed by the administrative cost of attempting to control the cost of medical service delivery. In education, university budget requests are denied by the states who also limit the freedom of universities to raise tuition.
If there is a solution to this problem, it will take the form of changing the incentive structure: empowering the consumer by channeling third-party payment allowances through the patients or students who are choosing and consuming the service. Each pays the difference between the price of the service and the insurance or subsidy allowance. Since he who pays the physician or college calls the tune, we have a better chance of disciplining cost and tailoring services to the customer’s willingness to pay.
Many will say that neither the patients nor the students are competent to make choices. If that is true today, it is mostly due to the fact that they cannot choose and have no reason to become competent! Service providers are oriented to whoever pays: physicians to the insurance companies and the government; universities to their legislatures. Both should pay more heed to their customers — which they will if that is where they collect their fees.

For the full commentary, see:
VERNON L. SMITH. “Trust the Customer!” The Wall Street Journal (Weds., March 8, 2006): A20.

Private Health Care Taking Root in Canada

TORONTO, Feb. 19 – The cracks are still small in Canada’s vaunted public health insurance system, but several of its largest provinces are beginning to open the way for private health care eventually to take root around the country.
Last week Quebec proposed to lift a ban on private health insurance for several elective surgical procedures, and announced that it would pay for such surgeries at private clinics when waiting times at public facilities were unreasonable.
The proposal, by Premier Jean Charest, who called for ”a new era for health care in Quebec,” came in response to a Supreme Court decision last June that struck down a provincial law that banned private medical insurance and ordered the province to initiate a reform program within a year.
The Supreme Court decision ruled that long waits for various medical procedures in the province had violated patients’ ”life and personal security, inviolability and freedom,” and that prohibition of private health insurance was unconstitutional when the public health system did not deliver ”reasonable services.”

For the full story, see:
CLIFFORD KRAUSS. “Ruling Has Canada Planting Seeds of Private Health Care.” The New York Times (Mon., February 20, 2006): A4.