JustCare

Tag: Surgery

  • Want surgery? Some hospitals make you pay upfront

    Want surgery? Some hospitals make you pay upfront

    Melanie Evans reports for the Wall Street Journal on the rise of hospitals requiring patients to pay upfront  for their surgery. In one case, a hospital wanted $2,000 from a patient’s mother. It said it would postpone her daughter’s surgery if she could not come up with the money. While the patient is insured, she has a high deductible so her insurance would not cover the treatment.

    The good news: If you have Medicare, you should never have to pay upfront for your care. Upfront payment issues are greatest for insured Americans with high-deductible health plans. That said, one recent study by the Consumer Financial Protection Bureau found that older adults owe $54 billion in medical debt.

    Paying upfront is a challenge for millions of working Americans. In a Kaiser Family Foundation survey, half of adults said they could not pay an unexpected bill for $500 for their care without having to borrow money. GoFundMe is too often a solution. People do not have enough savings.

    Some hospitals have essentially flipped the way they do their billing. Rather than waiting until after a procedure to bill a patient, they are refusing to perform the procedure without a payment in advance. They don’t want to be dealing with patients who won’t or can’t pay the bill after they have been treated.

    Many people are in a bind, without the money they need to get care for themselves and their families. Sometimes they must delay critical care. Other times they find that the hospital overcharged them and need to spend their time getting the refunds they are due.

    People giving birth, needing knee replacements and CT scans are increasingly being asked to pay in advance for these services.

    Which hospitals are requiring these upfront payments? It appears that hospitals owned by UnitedHealth are among them. While hospitals cannot turn away patients who need emergency care, they can refuse to treat people needing elective care.

    Today, hospitals collect nearly a quarter (23 percent) of patient bills in advance of treatment. That’s up from one fifth (20 percent) just two years ago.

    Hospitals do not want to be forced to write off debt. And, even patients with insurance today are not able to cover their costs. Advance payments are how hospitals are getting around this issue to the detriment of many patients and their families.

    Some claim the benefit to these upfront charges is that they let the patients know their costs so that they can possibly comparison shop. That is generally an impossible task, as it can mean switching doctors or traveling too great a distance to get needed care.

    Before you pay a hospital bill upfront:

    • Ask about other options. Non-profit hospitals must offer charity care for people who can’t afford to pay. Dollar For is a non-profit that can assist you in getting charity care.
    • If the cost is high, ask whether there is a way to pay a lower price or to pay in installments with no interest.

    Here’s more from Just Care:

  • Surgery comes with life-threatening risks for older adults

    Surgery comes with life-threatening risks for older adults

    Almost 14 percent of older adults die soon after receiving major surgery. They face life-threatening risks from surgery, according to a new study. Judith Graham reports for Kaiser Health News on the cohort of older adults who are most likely to die from surgery.

    Frail and demented older adults, as well as older adults having unplanned surgeries, and those over 90 are most at risk. Older adults with multiple chronic conditions, along with those who are not fully independent going into surgery, are also at serious risk. In addition, people with cognitive issues are more likely to die post surgery.

    Inexcusably, though the Medicare population represents about 40 percent of the surgery population, there is little national data on surgery outcomes. Surgeries include cancer tumor removal, gallbladder removal, heart and hernia repairs, hip replacements and much more.

    In addition to a high risk of death from surgery, many older adults become disabled, lose their independence or experience a decline in quality of life post surgery. Why doesn’t Medicare collect this data?

    The researchers found that, six months post surgery, as many as one third of older adults are not as functional as they were when they went in for surgery. Those who rebounded most quickly were older adults who had planned ahead for their surgeries.

    We are left wondering when surgeries performed on people over 65 are appropriate and how many surgeries are undertaken without weighing the risks or engaging the patients? It’s also not clear how many surgery patients are instructed on planning ahead for surgery. People going into surgery should, to the extent possible, prepare themselves and strengthen their bodies, through physical activity and high-protein diets.

    With the population aging, Medicare costs could rise significantly as a result of more surgeries performed. However, there are projected to be 30,000 fewer surgeons over the next decade than the US will need to meet demand. In addition, hospitals are ill-prepared to meet the needs of older patients getting surgery; the overwhelming majority of hospitals are not participating in a national effort to meet standards for expertise in geriatric surgery.

    Hospitals that are prepared to treat geriatric patients generally will assess them for delirium post surgery, ensure they are engaging in physical activity, and avoid giving them narcotic pain medicines. These three things can reduce the risks of post-surgical harm.

    The researchers relied on traditional Medicare data for their study because Medicare Advantage data was unavailable.

    Here’s more from Just Care:

  • Even simple surgeries carry serious risks for frail older people

    Even simple surgeries carry serious risks for frail older people

    Gina Kolata reports for the New York Times on new findings reported in JAMA surgery showing that frail older people can be at serious risk even when receiving simple surgeries. Frail older patients are far more likely to die prematurely from procedures deemed to be “low-risk” than younger patients in better health.

    In a nutshell, surgery on a frail older patient is never low-risk. Frail patients tend to be physically and mentally weak; they are often underweight with multiple health conditions. Most of the time, they struggle to get their strength and independence back post-surgery.

    Surgical procedures for people who are frail have high risks. Surgeries increase frail older people’s likelihood of death within 30 days after surgery by one and a half percent or more. And, for the most frail people, there’s a 10 percent increase in likelihood of death. In sharp contrast, high-risk procedures for people who are not frail increase their likelihood of death by as little as one percent.

    Doctors may not be aware of the high risks of surgery for frail older patients. Even something as simple as a gall bladder removal has a five percent higher risk of death for frail older patients in the 30 days after surgery and a 19 percent higher risk if they are very frail. In the 90 days after surgery, the risk of death is still higher. And, it’s higher still in the six months after surgery.

    To be clear, when frail older patients die in the weeks and months after surgery, it is not necessarily because they underwent surgery. The researchers cannot know what precisely causes death in frail older patients. There are a multitude of possible causes. And, sometimes, surgeries can increase quality of life for frail older patients.

    Still, given the known risks of surgery for frail older adults, talk to your doctor before opting for surgery. Ask your doctor about choices for treating your condition. And, learn about the possible outcomes of these choices. You want to know the best and worst case scenarios and  what is most likely to happen from a given choice.

    If you are frail and opt for surgery, you may want to take some time pre-surgery to “pre-habilitate” or improve your strength and ability to withstand the traumas of surgery.

    Here’s more from Just Care:

  • Risks of harm from surgery towards end of life often outweigh benefits

    Risks of harm from surgery towards end of life often outweigh benefits

    Medicare data reveals that almost one in three older adults have surgery in the year before they die. And one in four have surgery in the three months before they die. But, Liz Szabo reports for Kaiser Health News that the risks of harm from surgery often outweigh the benefits in people at the end of life. There may be no miracle cure, but you do have options.

    Dr. Rita Redberg, Director of Cardiovascular Care at the University 0f California–San Francisco Division of Cardiology, believes that doctors opt to operate rather than not because they often fail to appreciate what patients value most. They do not ask their patients. Yet, many patients at the end of life place a higher priority on quality of life than on a prolonged life in a nursing home.

    Doctors tend not to focus on the fact that older people fare far worse from surgery than younger people, for whom surgery can be lifesaving. Older people tend not to benefit in terms of longer lives or better quality of life. Indeed, functional decline is too often the consequence of surgery. The recovery rate for older adults is far slower than younger people, requiring them to spend twice as long in intensive care.

    One in five older adults die within a month of getting emergency abdominal surgery. But, surgeons may not want to, or know how to, communicate this information to older adults. Some are now using a best case/worst case framework for helping older adults share in decision-making about their care.

    The issue is extremely complex. It is easy to imagine that the surgery will not deliver the desired benefits. But, it is hard to turn it down if the doctor recommends it as an option. Maybe, you think, you will be lucky and the surgery will improve your condition. It is far more difficult to weigh the potential harms in the balance.

    Just the other day my 95-year old father went to the emergency room with a health care buddy after he took a fall. After waiting five hours for the brain imaging scan the ER staff claimed he needed, he called me for advice. He wanted to leave. I urged him to go home and get sleep. He was clearly of sound mind but totally exhausted. Instead, he spent the night in the ER, exposed to dozens of people in poor health and at risk of infection. His geriatrician discharged him the next day.

    My dad had tried to leave the ER after we spoke, but a doctor, not his treating physician, blocked his way. The doctor was adamant he stay for the test and for the night. And, though my dad is a retired doctor, neither he nor his health care buddy felt they could disregard the doctor’s instructions.

    Requiring people at the end of life to pay a portion of the surgery’s cost is not the solution. That simply rations care based on ability to pay rather than on need. It does nothing to move doctors to both help patients understand they have options and respect those options.

    Decision-support tools could be helpful for older patients to understand the risks of surgery, along with the best, worst and most likely outcomes. The mounting evidence suggests that fewer medical interventions and medicines often mean a longer and better life for older adults at the end of life–people need to understand that.

    Here’s more from Just Care:

  • Prepare for surgery, heal faster

    Prepare for surgery, heal faster

    Judith Graham Reports for Kaiser Health News on new research revealing that older adults who prepare for surgery, heal faster and are discharged more quickly. They also are less likely to be rehospitalized. Some hospitals are taking the lead to help older patients best prepare for surgery.

    More than anything else, you want to be sure pre-surgery that you really want surgery. Surgery is not risk-free, and many older adults end up in need of additional medical care post-surgery. Medicare data reveals that one in three older adults who are hospitalized are rehospitalized within 30 days of discharge.

    If you do want surgery, there are ways you can minimize risks both during and after your hospital stay. Doctors at Duke, UCSF and Michigan are finding that older adults who exercise, eat a healthy diet and reduce their stress in anticipation of surgery, fare better post surgery than those who do not. Their aim is to highlight surgical centers that best help older adults to prepare for surgery.

    Data from Duke University suggests that good preparation, including a thorough geriatric assessment, in advance of abdominal surgery significantly reduced the number of days older adults spent in hospital as well as their likelihood of readmission.  The data also indicates that good preparation reduced the likelihood of patients needing home health care after discharge.

    The Duke program, “POSH” (Perioperative Optimization of Senior Health,) spends time explaining to patients the benefits and risks of surgery. Patients are helped to understand the physical and emotional toll surgery can take on them and that it can lead to complications. Patients can then decide whether having surgery is in line with the quality of life they want.

    Much of the advice given to patients who opt for surgery applies to everyone, regardless of whether they are getting surgery.  Walk at least 20 minutes a day, do core-strengthening exercises every other day. Drink a lot of liquid. Do breathing exercises and take time to relax.

    People taking medications need to beware adverse interactions with anesthesia. The POSH program advises people to stop taking benzodiazepines and antihistamines three days before surgery.

    Questions patients should ask include:

    • What choices do I have other than surgery?
    • What are the risks and benefits of surgery or of making a different choice?
    • Will surgery extend my life meaningfully?
    • What will happen after surgery barring any complications? Will I be able to care for myself after surgery? If not, what kind of care will I need and how long will I need this care?
    • Who should have a copy of my advance directive, appointing someone to speak for me if I cannot speak for myself after surgery?

    Duke’s POSH program also offers advice that cannot be repeated too often regarding the value of having a health care buddy—someone to be with you during your hospital stay and after discharge–exercise, healthy eating and a good night’s sleep.

    Here’s more from Just Care: