JustCare

Tag: Overtreatment

  • HCA hospital system is charged with overtreating patients to maximize its profits

    HCA hospital system is charged with overtreating patients to maximize its profits

    Last week, I wrote about a hospital that incorrectly charged a patient for a costly service it did not render and only corrected the charge a year later, as a result of intensive efforts on the part of the patient’s wife. Now, Kaiser Health News reports on HCA, a for-profit hospital system that is charged with overtreating and overcharging patients and insurers. The government needs to hold hospitals accountable for inappropriate bills and other bad acts.

    Kaiser Health News reports on a patient with Covid-19 who went to a hospital emergency room to get checked out at her PCP’s direction. Instead of sending her home after seeing her, the hospital admitted her as an inpatient for three days and charged her $40,000. Of that amount, her insurer charged her $6,000. In this case, the hospital was HCA, the largest hospital system in the country.

    In this case, the patient’s PCP did not believe his patient should have been admitted to the hospital. But, hospitals control these decisions. To maximize their profits, some hospitals might provide incentives for their doctors to refer ER patients for an inpatient stay, even when not medically necessary, according to some experts.

    Congressman Bill Pascrell of New Jersey is hoping for the government to investigate HCA to determine whether it is engaged in Medicare fraud. The claim is that HCA requires its doctors to meet hospital admission targets and admit patients even when patients don’t need to be admitted. The result is both financial harm and potential health risks for patients.

    The Service Employees International Union (SEIU) released a report earlier this year documenting the issues particular to HCA. SEIU argues that overcharges to Medicare over the last ten years amount to nearly $2 billion. But, HCA is not the only culpable hospital according to SEIU. SEIU has made similar claims against Community Health Systems and Health Management Associations. Both hospitals systems settled, for $98 million and $262 million respectively.

    It’s not easy to prove that a patient was overtreated and did not receive appropriate care. You need the doctor to speak out, as one doctor did against an HCA hospital in Miami. This doctor claims that HCA told him that he would lose his job if he did not move more ER patients into the inpatient unit of the hospital. The government refused to investigate and to speak to a reporter about why it refused.

    HCA profits were nearly $7 billion in 2021.

    Here’s more from Just Care:

  • Medicare Disadvantage: How corporate insurers destroy Medicare

    Medicare Disadvantage: How corporate insurers destroy Medicare

    Merrill Goozner writes for Gooznews about the disadvantage of Medicare Advantage, which is administered through corporate insurers. MedPAC, the agency that oversees Medicare, has warned that, if the government continues to overpay Medicare Advantage plans, Medicare’s financing is in serious jeopardy. MedPAC wants the Medicare Advantage payment system overhauled so health plans can’t simply take the government’s money and run.

    Enrollment in Medicare Advantage is growing. People with lower incomes are more likely to enroll in Medicare Advantage to avoid having to buy Medicare supplemental insurance. Unlike traditional Medicare, Medicare Advantage has an annual out-of-pocket cap, albeit one that forces people to pay as much as $7,550 for their care.

    And, though people who join Medicare Advantage are giving up choice of doctors, coverage anywhere in the country, and the freedom to access care without referrals and prior authorizations, they often get partial coverage for dental or hearing care and an out-of-pocket cap; the government pays Medicare Advantage plans about four percent more per person than it spends on traditional Medicare.

    Medicare Advantage companies bid to offer their plans at about 15 percent less per person than traditional Medicare. They can afford to and still make a big profit since they tend to spend around 25 percent less on medical care than traditional Medicare by restricting access. Moreover, the government pays Medicare Advantage plans a higher rate if they can show more diagnoses for their enrollees–upcoding–even if the Medicare Advantage plans don’t provide enrollees with additional services. In 2020, these overpayments cost between $12 billion and $20 billion.

    The government pays Medicare Advantage plans even more money in the form of “quality bonuses,” stemming from self-reported data. MedPAC says this data is of such low quality that it is of no good value.

    The government is hard-pressed to collect back overpayments to Medicare Advantage. It must go to court to do so at substantial expense. Notwithstanding, 346 members of Congress, including progressives such as Ilhan Omar and Barbara Lee, seem to be ok with these overpayments, recently sending CMS a letter praising Medicare Advantage.

    Medicare Advantage is incredibly profitable because of the high fixed capitated payments per member they receive regardless of whether they cover any care for the member. Private equity and venture-backed physician practices have entered that market, as well as the new direct contracting market in traditional Medicare, which also pays companies to cover people’s care on a capitated basis.

    Goozner says that capitated payments “are the best way to incentivize providers to coordinate care, promote prevention, reduce hospitalizations, improve outcomes and prolong lives.” He cites no evidence that capitated payments do indeed lead to coordinated care, improved outcomes or longer lives. In fact, he concedes that the insurers’ “profits depend not on delivering better care but, for the majority of their enrollees, on narrowing networks and using traditional tools like prior authorization to discourage utilization regardless of its impact on outcomes.”

    In fact, while capitated payments do lead insurers to deny coverage for hospitalization and a whole range of costly services, data from the Office of the Inspector General show that often they do so inappropriately, to maximize profits.

    Goozner argues that fee-for-service payments can lead to overtreatment, which cannot be denied. But, fee-for-service payments can also help ensure that people get all the care that they need. In capitated health plans, undertreatment can be a big issue, particularly for people with complex conditions.

    And, Goozner acknowledges that Medicare Advantage has not reduced the cost of care, just transferred money from physicians and hospitals to insurers. Goozner concludes that Medicare Advantage cannot continue in its current form, gouging taxpayers, with little oversight or accountability. Goozner does not say how Medicare Advantage should be overhauled. Meanwhile, Congress has no plan to overhaul it.

    Congress needs to ensure that Medicare Advantage plans are not overpaid, cover all appropriate care and don’t spend their resources designing and implementing ways to avoid paying for costly care. One way to do so might be for it to dictate not only the benefits Medicare Advantage plans cover, but their coverage policies (so they don’t deny care inappropriately) and pay them based on the cost of services they cover. The Connecticut Medicaid managed fee-for-service model is worth exploring.

    Here’s more from Just Care:

  • Roundup: Your doctors and your health

    Roundup: Your doctors and your health

    Some doctors are a lot better than other doctors. As you get older, it’s especially important that you and your loved ones have doctors who listen to you, who do not undertreat or overtreat you, and who work with you to think through your health care wishes and your treatment options. These days, many doctors are looking at their computers and their watches during the patient’s visit, and those doctors should be avoided at all costs. Here’s a bunch of things to think about as a caregiver and as a patient:

    Take care of your health:

    Choose your doctors carefully:

    Make the most of your doctor’s visit:

    Speeding your recovery:

  • Is medication an appropriate treatment for loneliness?

    Is medication an appropriate treatment for loneliness?

    Judith Garber writes for the Lown Institute about the overmedication of isolated older adults. Loneliness can have severe health consequences. But, treating loneliness with too many medicines has adverse effects and unclear benefits.

    Isolated older adults are more likely to suffer physical impairments. They are more likely to die prematurely. They are also more prone to overtreatment.

    Some isolated older adults experience depression. Others experience pain. Both of these conditions can lead doctors to prescribe them medicines even though evidence is scarce that the medicines treat their loneliness. And, these medicines can have harmful side effects.

    One recent study in JAMA Internal Medicine found that doctors tend to prescribe benzodiazepines to older adults who feel lonely twice as often as they do to older adults who do not report being lonely, 11 percent v. 5 percent.

    Doctors also prescribe sedatives twice as often to people who report being lonely than to people who are not lonely, 20 percent v. 9 percent. And, doctors prescribe antidepressants nearly twice as often to people who are lonely than people who are not lonely, 27 percent v. 14 percent.

    Doctors are more likely to prescribe older adults who are moderately or highly lonely pain relievers, sedatives and antidepressants. They are also more likely to prescribe them multiple prescription drugs. The dangerous side effects of these prescription drugs can actually make it harder for older adults to be socially engaged.

    Older adults on benzodiazepines and antidepressants are more likely to experience cognitive impairments. They also face a greater likelihood of falling. If they take too much aspirin or ibuprofen, they face a greater likelihood of kidney and heart failure, ulcers and bleeding.

    The best way to improve your health is to have a buddy or buddies. Doctors should be arranging for patients who are lonely to be more socially active. “Social prescribing” would take a bit more time than writing a prescription. It could involve difficult discussions between patients and doctors. But, isn’t that the doctor’s role?

    Here’s more from Just Care:

  • How to ensure you get the care you want and need

    How to ensure you get the care you want and need

    Judith Garber reports for the Lown Institute on why you should not believe every new medical study you learn about. There’s a lot of medical misinformation. Be prepared to question your doctor about a recommended treatment and share in the decision-making to avoid getting care that you do not want or need.

    As a result of poorly conducted medical research, a large swath of study findings that you and your doctors might hear about are problematic at best. They are unreliable and do not help patients. In many cases, for example, researchers are paid by industry to generate findings of benefit to industry.

    Of course, you know that you shouldn’t believe everything you read. Just because a reputable journal publishes study findings does not mean that they are to be believed. Yet, like all of us, health care professionals at times believe them. Even they don’t always have the ability to independently evaluate the reliability of new research findings. The best source for independent analysis of studies on the benefits of a particular medical treatment is Cochrane.org.

    It goes without saying that people don’t have the tools to independently assess the reliability of evidence. And, most of us do not have the desire to do so. Rather, we tend to appreciate the benefits that a study might highlight and minimize risks.

    Shared decison-making between you and your doctors helps to ensure you do appreciate the risks of a treatment, along with its benefits. It engages you in conversation with your doctors about your health preferences, priorities and goals. And, you get a good idea of your treatment options. And, it likely will bring you greater satisfaction.

    Because not all physicians will engage you in a conversation about your priorities, be prepared to ask them about the treatment they are proposing. Find out how well they understand the treatment, How frequently have they recommended it to their patients. Have them tell you about the harms patients might face from a particular treatment, as well as the likelihood of benefit. Ask them whether other physicians typically recommend the treatment and, if not, what treatment is typically recommended for someone like you.

    Here’s more from Just Care:

  • Five questions to ask your doctor to avoid overtreatment

    Five questions to ask your doctor to avoid overtreatment

    When your doctor suggests a particular test or treatment, it’s OK to have questions. (Overtreatment can be a problem.) These five questions, adapted from the book Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer, are intended to help you start a conversation and get the right care. If your doctor feels like there isn’t time to answer all of these questions in one appointment, it’s OK to ask for another.

    1. What are my options? For many conditions and illnesses, there can be more than one treatment. Sometimes changing your lifestyle, such as your eating or exercise habits, can reduce your symptoms or risk of a bad outcome enough to make additional treatment unnecessary. Sometimes, not getting treated at all is a reasonable choice. Ask your doctor what your options are, and to explain each one carefully.
    2. How exactly might the treatment help me? Sometimes patients have one idea about what a treatment can do, and the doctor has another idea.You need to know exactly what you stand to gain. A hip replacement, for example, might allow you to walk again with greater ease, but it won’t cure your arthritis, and you might need another replacement in 10 to 20 years. A drug might be able to relieve some symptoms and not others. Ask your doctor how the proposed drug or procedure is supposed to help you.
    3. What side effects can I expect, and what bad outcomes might happen? Every test, drug, surgery, and medical procedure has side effects, and some can be very serious. Simply being in the hospital exposes you to the possibility of bad reactions, medical errors, and hospital-acquired infections. You need to know the risks so you can decide if the danger or discomfort of your condition is more worrisome to you than the risks of the proposed treatment.
    4. How good is the evidence that I’ll benefit from the treatment? Many of the treatments and tests that doctors prescribe have never been adequately tested to find out if they work, or if they work in patients like you. You need to know if the treatment your doctor is recommending is a proven therapy. If not, your doctor should explain why he or she thinks it’s a good idea.
    5. If it’s a test, what do you expect to learn from it, and how might it change my treatment? If the test won’t change the treatment, ask your doctor if you really need the test.

    When you or someone you care about is in the hospital for a serious condition, such as heart failure, cancer, kidney failure, emphysema or any other advanced chronic condition, all of these questions are relevant. In addition, there is one more question and request you should make.

    • Do you have a palliative specialist in this hospital? If so, ask for a “palliative care consult.” Palliative care specialists are nurses, doctors ad other health professionals who are expert in controlling pain. They also help patients and their families with important decisions, such as whether or not to have surgery. For patients who are in the terminal stage of their disease, palliative care can explain various options patients have around end-of-life care, and help them and their families decide what kind of care they want and need. You should not have to pay out of pocket for a palliative care consult.

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    This post was originally published on December 2, 2015

    Here’s more from Just Care:

  • Skip the urine test, unless you have symptoms

    Skip the urine test, unless you have symptoms

    Step into a doctor’s office for a checkup and more often than not, you’ll be weighed, your blood pressure will be checked and you will be asked to pee in a cup so that your urine can be tested. For older adults, a urine test is generally of little if any benefit and can be harmful, writes Paula Span for The New York Times. Unless you have symptoms, ask your doctor if you can skip it.

    What’s particularly odd about urine testing is that it’s done on people who have no symptoms of infection—no pain or blood when they urinate, no fever. If the lab finds bacteria in the urine, as is typical for older adults—positive lab results—it is not a sign of infection or a need for treatment. Still, older adults with bacteria in their urine, without symptoms, are often prescribed antibiotics.

    Indeed, the older you are, the more likely it is for doctors to prescribe you antibiotics even though you don’t need them, according to findings in one study. JAMA Internal Medicine recently published an editorial about this problem. The latest recommendation is for doctors to stop giving urine tests to older adults who are asymptomatic for infection.

    The US Preventive Services Task Force, an independent expert group, has asserted repeatedly since 1996 that no one without symptoms benefits from a urine test, except pregnant women. And, particularly for older adults, there are risks of harm from antibiotics, which they may be prescribed but don’t need. Side effects include nausea, harm to kidneys and harmful drug interactions, as well as C-difficile, which can be extremely difficult to treat.

    It had been thought that urinary tract infections could cause delirium in older adults, but today many people think that view is baseless. It’s more likely that patients with delirium are dehydrated and need liquid or experienced a disorienting change of medicines or place.

    Doctors need to stop prescribing antibiotics when they are not necessary. And patients need to ask more questions when tests are recommended. Do I really need this test? Why? If it’s simply routine, ask to skip it. If a urine test is intended to determine the cause of symptoms, such as pain when you’re peeing, you need it. Here are more questions to ask to avoid overtreatment.

    Here’s more from Just Care: