Monday, November 28, 2011

This is not about tiered health plans

A Boston Globe story raises a number of questions, but not the ones suggested by the title, "Tiered health plans cutting costs, restricting options."  You read the lede and see if you catch my drift:

Told he had an aggressive form of prostate cancer, Glenn McCarthy faced a decision this year. He could make a $1,000 copayment and have surgery at Brigham and Women’s Hospital in about two weeks. Or he could wait more than a month for an opening at Faulkner Hospital, paying just $150 for the same procedure by the same surgeon. His doctor advised against a delay. “It was life or death,’’ said McCarthy’s wife, Tracy. “We really didn’t have a choice.’’

The issue here is that Faulkner Hospital is owned by the Brigham.  See this logo from its website:

Indeed, we even find stories on that site about prostate surgery.

Many questions arise from the Globe story, since we know that the technical capacity (i.e., equipment, supplies, support services) to do the surgery exists in both hospitals:

Why couldn't the surgeon do the surgery in timely fashion at the lower-cost affiliated hospital?  Was this his choice?  Did he know a failure to do so would cost his patient extra money?  Was his choice limited by the OR times made available to him by the hospital administration?  Did the surgeon ask the administration to make room on the schedule to avoid the extra cost to the patient?  Is there anyone at either hospital who acts as an ombudsman or facilitator to help patients receive their care in the lower cost hospital?  Is there pressure on surgeons to fill up the operating schedule at the Brigham to help offset the operating costs of the more expensive institution?

In short, this case does not seem to be about the features of tiered health plans so much as the features of an integrated provider network that either acted inadvertently or affirmatively to cause a patient to spend more money than necessary for an important procedure.  If the former, it is a shame.  If it is the latter, it is an outrage.  Or maybe there is a more innocent explanation.  Who will ask the questions?


Anonymous said...

You are absolutely correct, Paul; this would be an entirely different story were Faulkner and BW not in the same hospital system. It raises troubling questions about loopholes in tiered systems and whether a clever provider has found, once again, a way to manipulate the system.

I also find it strange that the surgical schedule in the academic center is more open than that in a community hospital - unless the latter's administrators are engaging in the time-honored practice of filling the surgical schedule with the most lucrative procedures and excluding others - a practice which I heard about ad nauseum during my many years on a hospital executive committee......

This situation deserves some further examination. As you say, a tiered plan is not the issue here.

nonlocal MD

wrinkledman said...

Frankly, as a consumer, I find it pretty troubling even if it were in two separate hospitals. There's no way for a consumer to be adequately informed and when getting the higher price he would have no idea he was being ripped off. A person in a life or death situation has no time to shop! Especially in our secret system. Hospital prices, physician prices and almost all medical things for that matter are shrouded in mystery. Physicians are witch doctors, lovely people, but culturally cloaked. And hospitals are boardrooms with cash flow and imperatives that also include healthcare. If the system isn't forced to change by physicians who rebel against the system it won't change. People will always pay for life over death when the decision is so stark and all the subtleties are just background noise. I hope you keep harping Paul, it's important. Maybe the Globe will follow up with you.

Anonymous said...

I have always maintained that the provider and payor oligopoly is understated. This is a case of provider oligopoly and the pricing which results from it.

DRGA said...

I am more often than not frustrated by the caliber of the Globe's coverage of important health-policy issues. Frequently a writer quotes an "expert" consultant whom those in the field know has an axe to grind in the issue being presented. Or, as in this case, as Paul has explained, important information that would illuminate the issue has either not been sought or included in the article.


Medical Quack said...

This says a lot about contracts today for sure and a disruption that I think is going to grow.

As of the 1st of the year Anthem Blue Cross folks can't get prescriptions at Walgreens either unless they come to terms between now and then. It's a mess.

Hospitals also building surgical centers to supplement income too in some areas where the money is a bit better from insurers too. This will all have to shake out soon I hope as analytics on steroids for profits with business intelligence are driving this, sign of the times.

Barry Carol said...

When I first read this story, I had a very negative reaction. I also wonder if the surgeon’s fee is the same at both hospitals or not. That said, it’s likely that there is significantly more OR capacity at B&W than at Faulkner. It’s possible that other patients with the same insurer had already booked the Faulkner OR slots weeks in advance to get the benefit of the lower co-pay and, hopefully, comparable quality of care. When I had my CABG at an AMC in New York City in 1999, I learned that there were 18 operating rooms in that hospital. I doubt that most community hospitals have anywhere near that many. While it’s possible that the system was manipulated to force this procedure to be done at B&W, it would be informative if we could know the facts, not just in this case but how OR time scheduling works throughout the Partners and other hospitals systems.

Anonymous said...

There are serious ethical issues, including selective (complicit?) reporting demonstrated by this case. I may be troubled less by disparity in pricing between two hospitals in the same system, which is troubling enough, than by the surgeon's participation in what may well be an unnecessary double-bind.

Physicians claim higher ground from including pricing in the cost/benefit of intervention. There is good reason for the trump of science. But at the same time, the care people receive is increasingly determined by insurer privileges, predictive models, and best guesses that are never disclosed - even when known.

If medicine is a science, then give the patient the data. Let him shop it to another surgeon, who (I can bet) will be just as capable to intervene. Scare me into action. But don't scare me into thinking that you are the only who can save my life.

Anonymous said...


As usual your comment was data driven and thought provoking. Since I had some data available from the Md. Cost Review Commission, I compared Faulkner, at 150 beds and 16 operating rooms, with several hospitals in Md. concerning # OR rooms. Here they are, beds/OR's:
126/5; 154/7; 190/11; 180/10; 170/6.

So you see Faulkner is unusually blessed with OR's for its size at least compared to Maryland. But the other question is, what is their obligation as a lower cost tier hospital to hold open some OR's for patients with the corresponding insurance? Or, should their OR's always be 'conveniently' full, should BW be forced to provide the surgery at the lower co-pay if they have open rooms? You see the conundrum.
The other piece of data we lack is how long one can safely wait to operate on prostate cancer of this particular patient's grade and stage. Perhaps he was scared into rushing. There is a great deal we do not know in this case.
As people point out, why are we asking and not the Globe?


Barry Carol said...

To add insult to injury here, even though the patient went to the high cost sophisticated AMC, he still suffered complications and was then sent to another high cost hospital to treat the complications. It seems that there is a need here for an accredited unbiased infomediary that can offer patients expert guidance regarding cost-effective medical choices. In our litigation environment, however, patients would probably have to sign a waiver agreeing not to sue the infomediary in the event of an adverse outcome. Like nonlocal, I also wondered how much risk was really inherent in waiting an extra two weeks or so to have the surgery at the less expensive hospital.

e-Patient Dave said...

I'm starting to wonder if I should cancel my subscription to the print Globe, as a public form of protest for what seems to be quite biased reporting.

Pam said...

I know of one other instance in which the same situation is going to occur: Rather than have surgery at the Brigham, my friend on MASSHealth has been directed to Faulkner with the same surgeon. Causing not only delay, but in her case extreme pain and dysfunction in the interim. It is an OUTRAGE!

e-Patient Dave said...

> an outrage

Sounds like the kind of anti-customer, pro-money manipulation at the source of #Occupy.

Sometimes things like this start to unravel by asking, face to face, "Can I talk to the person responsible for this policy?" Because somewhere, right now, sitting somewhere (or walking to a meeting or whatever) is the person who made this decision.

Sometimes, in my experience, they realize full well that they're causing pain and suffering; they don't care or they just figure it's collateral damage. Sometimes they don't realize it. But an important first step is for some individual to connect the decision maker with the consequences of the decision.

If that initiative meets a stone wall, then the gun points squarely at the executive suite, and a different level of exercise begins.

But it all starts with someone standing up and saying "NOT ACCEPTABLE!" and sounding the siren. Step 1 has happened here; how do we meet the individuals who told these people this?

e-Patient Dave said...

Interesting line today in Regina Holliday's latest epic-smart post, Top 10 Surgeries This Christmas:

"The other day I tweeted: 'The problem with medicine is not that is run like a business, but that it's run like a bad business.'"

The irony in all this is that as more and more people fall out of the system economically, because prices keep going up without commensurate satisfaction, more and more of us will start saying, "Wait a minute?? Do I really want this??" and start shopping around.

Abby said...

Uwe Reinhardt wrote an article in this month's Health Affairs asking whether an all-payer system like Maryland's all-payer hospital system (where all hospitals are paid the same for specific procedures) might be appropriate.

It seems to me that this could be combined with incentive payments for higher quality care in order to promote innovation at each hospital.

Academic hospitals always say that they incur higher costs because of their educational mission. Perhaps that ought to come from separate budgets devoted to education costed out rather than trying to recoup the costs from payers.

I know that Medicare does this already, but I am not familiar enough with the structure of that system to comment intelligently on it.