More than we can imagine: Massachusetts healthcare payment reform

This was the testimony I delivered on June 30 to the hearings on health Care Provider and Payer Cost Trends, conducted by the Massachusetts Division of Health Care Finance and Policy:

I'm Ken Farbstein, a patient advocate with a private practice, and an author of a new book, Getting Your Best Health Care: Real-World Stories for Patient Empowerment, published by the Professional Patient Advocate Institute.

Thank you, Commissioner, for the privilege of learning at these hearings, and being able to testify.

Rev. Hamilton told us that God brings us more than we can imagine. Let's imagine what payment reform will look like in practice. On Tuesday, Amy Slemmer of Health Care for All stressed the importance of transparency, as did yesterday afternoon's panel of speakers. What does that look like? In Pennsylvania, where they've had mandatory reporting of serious reportable events, that reporting has now, they can confidently say, decreased wrong site surgery, according to Mike Cohen, the head of the Institute for Safe Medication Practice. That's pretty good for patients' quality of care. And it reduces costs, because there's no need for physical therapy, prostheses follow-up visits, and so on, to try to make up for the mistake, plus the cost of doing the operation right the second time around.

What else does transparency look like? Harold Miller emphasized yesterday, as did Ray Campbell and others today, about how critical it is to get clear information on price and quality. A one-pager handed to the patient well before any surgery, stating the likelihood that a repeat operation will be needed, the cost to them, the number of similar operations that surgeon has done before, and the alternatives to surgery, would provide vital information. When we brought my dog in for a surgical decision about a lump in one of his front elbows, the veterinarian gave us very clear information about the risks, costs, and alternatives. Her information was much better than the explanations I had received about my own two surgical decisions for my eye, and for my sinuses.

Fully informed, shared decision making will get many people to choose less costly alternatives to surgery, as I did twice. The Cochrane Collaborative documented the cost savings in its recent systematic review of 58 articles in the medical literature.

Impartial patient advocates can discuss end of life decisions that are based purely on preserving dignity and the quality of life. Family members will often prefer hospice care, which is more humane and less costly than "death by ICU." My father had a long gallant struggle with Parkinson's Disease. At the end, he, and we, chose hospice care. That was definitely the right decision for his dignity and quality of his remaining life. It also saved money for the taxpayers.

Yesterday, Harold Miller told us there are 3 ways to reduce costs: prevention, preventing hospitalization, and more efficient hospital care. What do they LOOK like?

Prevention, you know about. Harold Miller also mentioned avoiding hospitalizations. Last night I went to a medical home meeting. There were pediatricians, Nurse Practitioner and another nurse educator, the office manager, 3 parents of kids in the medical practice, and me, with pepperoni pizza, Diet Coke, and champagne - to celebrate a journal article to be published on the successes of the medical home. They showed a homemade video teaching parents about a new alternative to stitches when their kid gets a deep cut. They teased the nurse practitioner who was the star of the video. Their laughter, and their warmth, is a key ingredient of the medical home. That's what home looks like. The video is about DermaBond; imagine a glue stick the doctor will use to seal a deep cut, instead of stitches. Those cuts can be treated in the doctor's office instead of an E.R. visit. No stitches need to be removed in a later visit. These, and many other changes, have enabled this medical home to reduce the E.R. use among their kids over the last four years, by one-third. That's what a medical home looks like.

Third, Harold Miller said costs are reduced with more efficient hospital care. My mother complained of radiating neck pain, so I brought her to our small community hospital's E.R. She was given a telemedicine consult with a doctor at BIDMC in Boston - a 2-way TV hookup that impressed her greatly, and ruled out a stroke promptly. That's what efficient hospital care looks like.

A patient advocate who is fully independent and trusted can help patients and their families make the difficult decisions about how to get their best health care. These images are what payment reform should look like.

The fine print excluded nearly all the treatments: Aetna’s limited benefit insurance policy & bankruptcies

Lawrence Yurdin is a 64-year old computer security specialist. He had insurance through Aetna – a "limited benefit" plan, which, in hindsight, was not worth the paper it was printed on. Or, more precisely, as Aetna spokesperson Cynthia Michener said, "Limited benefits aren't right for everyone, and it clearly wasn't right for Mr. Yurdin." Aetna further acknowledged that his age and condition – an irregular heartbeat – made it likely that he would require more comprehensive coverage.

Lawrence learned this the hard way when he went to the hospital for two separate heart procedures last year, and two more procedures later.

While the Aetna brochure indicated he had purchased $150,000 of hospital care, the fine print excluded nearly all the treatments he received in the hospital, according to today's front-page story by Reed Abelson in the New York Times. With his unpaid medical bills approaching $200,000, he had to file for bankruptcy around Christmas time.

His case is common: three-fourths of the people who file for bankruptcy because of medical bills actually had insurance. As Harvard Law School Professor Elizabeth Warren says, "People do not realize that they are one diagnosis away from financial collapse."

A highly instructive expose by recent insurance executive Wendell Potter about these and other sneaky tactics used by large insurers appears in his testimony at U.S. Senate hearings last week.

Advice to people with a limited benefit health insurance policy: Read the fine print carefully. Maybe you should dump your insurance company before they dump you.

Advice to government legislators and regulators: Suntan lotion bottles must show their Sun Protection Factor prominently. Consumers know that a high SPF will protect them much better than lotion with a low SPF. A simple number that rates the Bankruptcy Protection Factor (BPF) of limited benefit insurance policies will keep consumers from getting badly burned by shoddy insurance products. Or maybe "B" will stand for something else…

Read about another cruel insurance practice.

They can stop this human disaster: A misdiagnosis story

Serving with the Morris County, N.J., sheriff's office, Jeffrey Endean arrived at Ground Zero on 9/11 when, he remembers, The Pile "looked like a war zone or a peek into hell." It was both. For two months, Jeffrey worked in a landscape he described yesterday as "surreal" and "terrifying," and soon breathing difficulties forced his retirement. "The coughing would be violent, with my eyes bulging," he said.

He went to the doctor. He was misdiagnosed with colds and allergies, and it was only in 2005 that he began getting proper care through the World Trade Center health program at Mount Sinai Medical Center. Now 57, he suffers from scarring and thickening of the lungs, a form of asthma called reactive airways distress syndrome, severe acid reflux, chronic headaches, post-traumatic stress disorder and more.

Jeffrey appeared before the U.S. Senate Committee on Health, Education, Labor and Pensions in an effort to persuade the government to fund first-class medical care for the forgotten victims of 9/11. "We could not stop the attacks, death and continued casualties of 11 September," Jeffrey told the senators. "You have the ability to stop the human disaster."

Mayor Bloomberg testified that 45,000 workers and volunteers from all 50 states pitched in at Ground Zero. He cited studies documenting that many are sick and added that "thousands of residents, commercial workers and others have reported experiencing acute breathing problems, worsening asthma, post-traumatic stress disorder and other mental illnesses which require sustained care."

Advice for 9/11 cleanup workers: Contact the Mount Sinai Medical Center about their World Trade Center health program.

Read another misdiagnosis story, or read the New York Daily News editorial.

He was told to find his own way, he testified: Access to care

Wearing a black eye patch, Sgt. John Daniel Shannon testified to a House committee, convened at Walter Reed Medical Center in Washington DC on March 5. He described how he’d been struck in the head by a bullet from an AK-47 in November 2004 near Ramadi, Iraq. The injury caused a traumatic brain injury and cost him his eye.

He was returned to the U.S., and was already moved out of the hospital within a week of his injury. Though he still was extremely disoriented, they handed him a map and told him to find his own way to his new residence on the hospital campus. There, he waited several weeks for someone to contact him and tell him how to get additional treatment. He eventually called people himself until he reached his case worker. Staff in the bureaucracy lost his paperwork several times, and each time the brain-injured soldier had to start over.

So do we!

Advice for patients with complex needs: If your case worker doesn’t contact you promptly, perhaps you should demand a caseworker who will.

Advice for citizens: Express your opinion to the Commander in Chief at 202-456-1414.


Read our related Patient Safety Quiz, or read Michael Luo’s article, “Soldiers Testify over Poor Care at Walter Reed,” in the NY Times.