Other Topics on this Site: List of all US doctors who offer long office visits
List of the most experienced specialist doctors
Most of the Medicare program provides needed treatment. Some aspects reduce treatment to save cost, as explained here. For example Medicare discourages hospitals from treating patients twice in 30 days. This policy hurts frail elderly patients who need more frequent care than average. Medicare also offers doctors and hospitals bonuses if they reduce treatment. (More sources about this subject)
1. Re-hospitalization, or Readmission into Hospitals
Medicare pays for hospital stays. Then they count how many Medicare patients are readmitted within 30 days after the hospital stay. If readmissions are above the national average, adjusted for patient mix, Medicare will charge the hospital an expensive penalty, even if readmissions are unrelated to the original hospital stay, and even if the readmission is at a different hospital.
84% of hospitals measured pay penalties, and some pay over a million dollars per year. Hospitals cannot give up this much revenue. They are shifting to less treatment of Medicare patients, and patients are dying. There are better ways to save Medicare money, without cutting needed hospital care.
The numbers here show penalties in 2018. There are changes in 2019, to put hospitals in five groups, by their fraction of poor patients (eligible for Medicaid as well as Medicare). These changes mean about 80% of each group get penalties. Before, more of the hospitals serving poor patients had penalties, and fewer hospitals serving non-poor patients.
Table A. Readmission Penalties in 2018, Paid by Hospitals, for Six Conditions
Hospitals with Penalties over $1 million in FY 2018
Those hospitals have large penalties because of a combination of their large size and the patients they treat, who need extra care. They do NOT deserve the penalties. They are penalized for giving thorough care.
$6,250,000 FL Florida Hospital Orlando
$3,940,000 MA Southcoast Hospital Group, Inc Fall River
$3,430,000 CT Yale-New Haven Hospital New Haven - They think the penalties are a good idea and calculate them for Medicare.
$3,010,000 FL St Lucie Medical Center Port St. Lucie
$2,630,000 FL North Florida Regional Medical Center Gainesville
$2,610,000 FL Lakeland Regional Medical Center Lakeland
$2,290,000 NJ St Joseph's Regional Medical Center Paterson
$2,270,000 MS Forrest General Hospital Hattiesburg
$2,190,000 MA Beth Israel Deaconess Medical Center Boston
$2,080,000 PA Thomas Jefferson University Hospital Philadelphia
$1,780,000 MI Beaumont Hospital, Royal Oak Royal Oak
$1,730,000 NJ Virtua West Jersey Hospitals Berlin Berlin
$1,710,000 NY Vassar Brothers Medical Center Poughkeepsie
$1,660,000 NY Montefiore Medical Center Bronx
$1,610,000 VA Reston Hospital Center Reston
$1,610,000 IL Presence Saint Joseph Medical Center Joliet
$1,600,000 MA Lahey Hospital & Medical Center, Burlington Burlington
$1,550,000 NY Orange Regional Medical Center Middletown
$1,540,000 NY Long Island Jewish Medical Center New Hyde Park
$1,540,000 NJ Robert Wood Johnson University Hospital New Brunswick
$1,530,000 MI Beaumont Hospital - Dearborn Dearborn
$1,490,000 NY North Shore University Hospital Manhasset
$1,440,000 FL Lee Memorial Hospital Fort Myers
$1,430,000 TX Memorial Hermann Hospital System Houston
$1,420,000 MO North Kansas City Hospital North Kansas City
$1,420,000 SC Grand Strand Regional Medical Center Myrtle Beach
$1,340,000 TN Baptist Memorial Hospital Memphis
$1,290,000 NY Good Samaritan Hospital Medical Center West Islip
$1,290,000 CA Oroville Hospital Oroville
$1,280,000 PA Pinnacle Health Hospitals Harrisburg
$1,250,000 FL Leesburg Regional Medical Center Leesburg
$1,240,000 NJ Kennedy University Hospital - Stratford Div Stratford
$1,190,000 NJ Jfk Medical Ctr - Anthony M. Yelencsics Community Edison
$1,190,000 MO Centerpoint Medical Center Independence
$1,180,000 VA Cjw Medical Center Richmond
$1,170,000 NY Mount Sinai Beth Israel/Petrie Campus New York
$1,170,000 VA Chesapeake General Hospital Chesapeake
$1,170,000 FL Baptist Medical Center Jacksonville Jacksonville
$1,160,000 CA Regional Medical Center Of San Jose San Jose
$1,150,000 IL Advocate Christ Hospital & Medical Center Oak Lawn
$1,140,000 AL D C H Regional Medical Center Tuscaloosa
$1,140,000 DE Bayhealth - Kent General Hospital Dover
$1,130,000 NY New York-Presbyterian Brooklyn Methodist Hospital Brooklyn
$1,130,000 MI Mclaren Flint Flint
$1,120,000 AZ Northwest Medical Center Tucson
$1,120,000 FL Lawnwood Regional Medical Center & Heart Institute Fort Pierce
$1,100,000 NJ Cooper University Hospital Camden
$1,090,000 DE Christiana Care Health Services, Inc. Newark
$1,090,000 NY Huntington Hospital Huntington
$1,070,000 MA Lowell General Hospital Lowell
$1,070,000 MA South Shore Hospital South Weymouth
$1,070,000 MO Mercy Hospital Springfield Springfield
$1,070,000 MI Edward W Sparrow Hospital Lansing
$1,050,000 NV Sunrise Hospital And Medical Center Las Vegas
$1,050,000 PA Aria Health Philadelphia
$1,040,000 TX East Texas Medical Center Tyler
$1,030,000 IL Franciscan Health Olympia & Chicago Heights Olympia Fields
$1,000,000 NY Maimonides Medical Center Brooklyn
2. Find Your Local Hospital's Penalties
Maryland and Puerto Rico are exempt.
2015 August 10 - Hospitals Treat Fewer Seniors when Medicare Charges Penalties
2014 August 6 - Hospitals Fined $529 Million or here
2014 May 30 - Readmission Penalties Put Burdens on Hospitals or here
Coverage by Bloomberg BNA
2013 August 14 - Size of Readmission Penalties, or here
Coverage by EHRIntelligence, Orthopedics This Week
If we want legitimate patients treated, how can we penalize their hospitals? Faced with the level of penalties being imposed, hospitals cannot afford to treat many seniors. There are also incentives against treatment in some of the other ratings of hospitals.
Measuring and rewarding medical providers can backfire and reduce quality by reducing motivation (see a very good, broad article on these effects). Studies find that doctors avoid treating risky patients, when there is public reporting of outcomes. 75% of interventional cardiologists decided not to treat a patient due, at least in part, to protecting the doctor's or hospital's success rate. 74% sometimes or often delay treatment to see if the patient dies first. 52% worry their superiors won't support a decision to treat risky patients.
Because of the readmission penalties, all hospitals try to be below average on readmissions, which makes the average get smaller (8% smaller in 2013; goal is 20% smaller, p.292). Faced with moving targets, hospitals cannot afford these penalties. They need to prevent as many readmissions as possible, often by emergency treatment without hospital admission, or brief admissions for observations instead of full treatment, or treating fewer patients for these conditions in the first place. If a risky patient is not admitted, s/he can't be readmitted.
The American College of Surgeons has warned Medicare about "the potential that these hospitals will decrease their care for such patients, thereby creating an access issue."
The latest data and several studies show that readmissions prevent deaths, so penalties are deadly. The American Hospital Association reported in Trendwatch September 2011, "mortality is inversely related to readmissions."
Dr. Kripalani of Vanderbilt University asks, "which would we rather have -- a hospital readmission or a death?"
Doctors Krumholz, Lin and colleagues in the Journal of the American Medical Association Feb.13, 2013 reported a 17% correlation between higher readmissions and lower deaths among heart failure patients. These are the same Yale authors who develop Medicare's readmission data, yet their own hospital cannot avoid readmissions. Yale-New Haven Hospital did 253 hip and knee replacements and will pay a quarter of that revenue as a readmission penalty.
Doctors Gorodeski, Starling and Blackstone of the Cleveland Clinic showed with a graph in the New England Journal of Medicine July 15, 2010 that hospitals with higher readmissions after heart failure treatment had significantly fewer deaths among the patients.
Hospitals are disclosing the financial risks of penalties in bond disclosures (p.25).
Evaluations have shown limited results.
Researchers at Columbia and Yale found that even an extra day of hospital treatment for pneumonia or heart attack saves thousands of lives (Table H). So reducing access to hospital treatment will be deadly.
Table H. Lives Saved by More Hospital Treatment
Other sections of this site discuss some of the ways patients and hospitals can respond to readmission penalties, not always healthily. One unhealthy approach that Medicare advocates is to limit care and promote hospice, comfort care (symptom relief or palliative care), and "do not resuscitate" (DNR) orders, so patients die at home and do not come back to the hospital.
The list of all hospitals shows the number of excess readmissions charged to each hospital, though privacy prevents showing the reasons. Many numbers are fractional, because of the adjustment for patient mix, which changes hospitals' baselines by fractions. No matter what they do, half the hospitals will be above average on each condition and will pay penalties. With 6 conditions, over 80% of hospitals will always be above average on some condition and pay penalties. Medicare does not know better than 80% of hospitals, and has no business penalizing them.
The penalty is far worse than simply refusing coverage, as Medicare does with long nursing or hospital stays. When Medicare lacks coverage, people can plan with other insurance or their own money. But hospitals cannot accept other money for these readmissions, since
These pervasive efforts, important to hospitals and life-threatening to patients, only save $1.5 billion per year (p.26), less than a third of a percent of the Medicare budget. There are better alternatives.
Congress is considering similar penalties for skilled nursing facilities (SNFs) which have above-average rehospitalizations. If adopted, SNFs will find it hard to admit and serve the frailest patients, who need them most.
5. Which Readmissions Are the Hospital's Responsibility?
Medicare approves for payment both the initial admission and the readmission. When it fines the hospital years later, it implicitly reverses those approvals, and overrules the doctors who decided hospital care was medically necessary, without even looking at the charts.
Many readmissions are random and unrelated to the original hospital care.
The law requires Medicare to exclude readmissions unrelated to the initial admission. Medicare does exclude planned readmissions, such as cancer treatment, and transfers to other hospitals for specialized care, but otherwise it does not follow the law's exclusion of unrelated readmissions. Medicare penalizes hospitals for unplanned readmissions, whether related or not.
People have commented on this discrepancy and Medicare answered in the Federal Register Aug. 19, 2013, "creating a comprehensive list of potential complications related to the index hospitalization would be arbitrary, incomplete, and, ultimately, extremely difficult to implement." So they found it hard to obey the law on excluding unrelated readmissions, and they decided not to obey the law, which seems even more arbitrary.
Four research papers confirm that low readmissions mean more deaths.
Other research papers show faster deaths for patients with palliative care or "Do Not Resuscitate" (DNR) orders.
Medicare has chosen not to release its own findings on deaths, which it said it was monitoring years ago, in the Federal Register Aug 12, 2012. Earlier deaths save billions of dollars for Medicare, Social Security, and private companies' pensions.
The general approach of penalizing readmissions derives from an old estimate that 76% are preventable. This was based on experimental software, not verified by reviewing actual cases and seeing what it would have taken to prevent readmissions. (MedPAC 6/07 pp.107-108)
Dr Ashish Jha, of Harvard's School of Public Health, told PBS, "If you look at, for instance, the U.S. News [and World Report] publishes its list of top 50 hospitals. Those hospitals tend to have very low infection rates, very low mortality rates, very low death rates. Guess what? They tend to have very high readmission rates, because they do such a good job of keeping their patients alive that many of them are readmitted."
Doctors are begining to reduce care, to save money, throughout medicine, without discussing the options with patients. For example Medicare proposes a payment for less-invasive heart surgery which makes it unaffordable for hospitals
Patients can get an outside professional advocate, often a senior nurse, to advise them about recommended and alternate treatments. Some will come to the hospital to listen to doctors and advise. Others can interact with patients and doctors on Skype or Google video chat. Cost can be $90-$200 per hour, cheaper than poor health care. As long as doctors and hospitals have hidden incentives to avoid care, patients need expert advocates. (The parallel is with courts, where most people would get a lawyer, in spite of the cost.)
National directories are at:
Free telephone help will not be as effective, but it is free for the very ill from Patient Advocate Foundation on skin, breast, cervix, ovaries, prostate, and colorectal cancer, narcolepsy, heart valves, Aetna claim problems, and dealing with other insurers.
B. How Patients Can Manage Risk
The heavy penalties which Medicare puts on hospitals for readmitting patients, mean that doctors and hospitals may advise patients not to get treatment, if there is much chance of readmission, even when the treatment would help the patient.
So patients need to worry that advice from doctors, hospitals, or Accountable Care Organizations (ACOs) can be biased away from treatment.
Patients who want treatment can avoid being a subject of hospital penalties and hospital risk by:
Regardless of exemptions, it is possible doctors who primarily see ordinary Medicare patients will have a habit of minimal treatment, even for managed care and private insurance patients exempt from the penalties.
Foreign Nurses in US
Hospitals and others hire foreign nurses through agencies. The State Department must approve visas. Some agencies train the nurses on arrival about the differences between work & life with US practices, compared to practices in their home countries. They may be paid the same as US nurses, plus a fee to the agency. Traveling nurses are more often US nurses who travel where needed, and are often paid more than local hires.
Insurance premiums for Medicare and Medigap policies are described in 9 pages on SeekingAlpha. There is also information on SeniorCare and Medicare Rights Center about differences in Medigap plans. Medigap covers a lot of copays not covered by Medicare Part A and B. You can't use Medigap if you have Medicare Part C (Medicare Advantage). If you don't get a Medigap policy when you start on Medicare, in most states you may not get it later.
Community Health Centers get federal grants and often have lower costs than average.
Cost disclosures are in flux. Checkbook has a good article.
The Wall Street Journal has a good free guide to looking for health care costs, no matter if you pay with Medicare, other insurance, or cash. Finding costs before you get treatment is hard. Dr. David Belk explains about the confusing cost of office visits, including higher pay from HMOs than from fee-for-service. The Atlantic describes 2019 laws and practices of debt collection for unpaid hospital bills.
Each patient's cost depends on his or her insurance.
Doctors' fees under Medicare are in the Specialists tab above. They show what Medicare pays, and the list price for each procedure from each provider. Medicare costs include the total paid by Medicare, supplemental insurance and patients.
Hospital fees for the most common 100 diagnoses are in hospital spreadsheets from Medicare, and are mapped nicely at ClearHealthCosts.
For example the data files show that surgeon costs for knee replacement are typically around $1,500, assistant surgeon $300, anesthesiologist $200, and hospital costs (for "major joint replacement or reattachment of lower extremity") averaged $14,000 if there were no major comorbidities and complications (MCC), or $23,000 if there were.
For a few procedures (primarily imaging, tests, counseling, dental extractions or implants, cosmetic procedures), ZendyHealth gives (free) a range of local prices within a radius you choose. They offer you a doctor based on how much you want to pay ($49 referral fee). You cannot use insurance with the doctor, but Zendy helps you submit a claim to your insurance company, so your cost counts against the deductible. For these and other procedures they offer a free consultation. You have to pay their legal bills if there's a problem ("indemnify"), and accept arbitration. You have no choice of provider, and see the name assigned to you only after you have paid the referral fee. For example different MRI centers have different strength magnets, and you are likely to get the cheapest, weakest magnets, which give less precise images. If you have time to search the Specialists tab above, you can find the lowest price providers and negotiate directly.
Costs in New York state are at pndslookup.health.ny.gov/
Costs for treatments in North Carolina are available from Blue Cross/Blue Shield of North Carolina, based on their patients and their contracts with providers: bcbsnc.com/content/providersearch/treatments. These have actual costs for a treatment episode, including hospital and doctors. Very easy to access. The free system compares all providers within any radius of a zip code, up to the whole state. You can sort by cost, name or distance. However there are only 1,200 procedures, no info on how often each doctor does the procedure, voluminous output with typically 3 providers per screen, not downloadable, only North Carolina, no procedure codes, so it is hard to be sure what each item covers, no lab costs or drug costs. Their data come from one year, but they don't say which year.
Doctors' incomes derive from the payments above and the volume each doctor does. Average incomes (after expenses) by specialty range from $240,000 per year for Public Health and Pediatrics to $580,000 for Plastic Surgery, with wide variation. Top pay is in KY, TN, AL, MO, probably because of standard payments combined with lower costs. Concierge practices have 1% of doctors. The most rewarding parts of the job are gratitude and relationships with patients, doing a very good job and making the world better. They average 15 hours per week on paperwork and administration. 27% would not choose medicine again, varying by specialties. Wealth averages $1-2 million, depending on specialty and age. A quarter of doctors have over $1 million by the time they are 35, and two thirds do by the time they are 50.
Most doctors at hospitals work for large groups (TeamHealth, Schumacher) which contract to provide hospitalists, radiologists, emergency doctors, etc. Some companies provide doctors to hundreds of hospitals (Envision + Amsurg). Hospital doctors earn $200,000 - $400,000 per year. About half feel fairly compensated. Only a quarter "regularly" discuss the cost of treatment with patients. Over three quarters would choose medicine again and the same specialty.
Insurance payments are complex, and are further discussed throughout this site. A glossary defines insurance terms.
Direct URL: drugs.globe1234.com
Patients can get independent information on drugs and medical devices from sites listed farther down on this page (many track your IP address; you can check their privacy statements).
A. This page is not about substance use disorders, but here are 2 resources
The sources in italics below cover medical devices, like pacemakers, artificial joints, lenses, etc. as well as drugs. FDA has a search box for US recalls of medical devices, and the press has an international list. Many devices have serious problems, and experts advise finding how many patients a device was tested on, how many times your doctor has installed it, and how it can be removed if necessary, before getting it implanted.
B. GENERAL SITES ON DRUGS AND MEDICAL DEVICES:
Advice from WorstPills.org, the first site below:
D. Erroneous Prescriptions
The NY Times has a good 2020 article about errors when drug stores give the wrong pills to patients, and ways to protect yourself.
There are even big problems when doctors send prescriptions to pharmacies electronically. This is more reliable than hand-written faxes, but:
Cancellation orders are crucial to correct mistakes and cancel refills. Patients can overdose when they keep getting the old medicine after the doctor orders a new one. Only a third of prescribers and 40% of pharmacies use software certified to handle cancellations, so less than a third of cancellations can go through. "Electronic health records allow prescribers to stop a prescription, but what many physicians may not realize is that in most cases that directive is not sent to any pharmacy," even though original prescriptions are reliably sent. Some doctors put cancellation orders in the notes of a new prescription, where many pharmacists will not see it.
Health systems like the Veterans Health Administration and Kaiser Permanente can cancel electronically, where prescriber and pharmacy are in the same organization. Otherwise only 5 pharmacy chains accept e-cancellations (CancelRx):
No other chain is certified for e-cancellation, such as Walgreens ($57 billion of US prescriptions) and Walmart ($19 billion). Consumer Reports unfortunately recommends Costco and Sam's Club for price (uncertified), Walgreens for its apps (uncertified), and supermarket chains for convenience (only Kroger's is certified). CR should know better.
Doctors can cancel electronically only if their software is certified under "CancelRx". Out of 954 systems, only 156 are marked as certified, and usually only the latest updates. If your doctor is part of a large group, you can ask the group to ensure its software gets certified and updated. Individual doctors have little control. CancelRx is getting more widespread, but the sponsor, Surescripts, is not willing to say how many doctors or pharmacies use it.
Automatic refills are even more dangerous. When pharmacies call patients to say, "Your prescription is ready," patients and callers do not know whether the doctor recently ordered it or it is a zombie renewal. Costco, CVS, RiteAid and Walgreens encourage patients to sign up for automatic refills, so patients at Costco and Walgreens (two which lack e-cancellations) can get undesired medicine for long periods, thinking their doctor ordered it.
Prior authorization for prescriptions is a system where an insurer tells a pharmacy that a doctor needs to send the insurer detailed information and get the insurer's approval for the prescription. Insurers tell pharmacies, not doctors or patients, when prior authorization is needed, and pharmacies say they have no obligation to tell doctors, though they have the forms and information which the doctor needs, and no one else does. A Massachusetts court says pharmacies must tell doctors, and a doctor says the entire circuitous system of prior authorization for drugs kills patients.
Several sites show interactions among all drugs and vitamins you type in, while they track you.
I tested them with 6 medicines which do interact: aspirin, atorvastatin, epinephrine, erythromycin, vitamin K, warfarin.
You can find more about drugs, including side effects, on the main drugs page.
Drug stores in half the states are not allowed to volunteer to you that the cash price is less than your co-pay, but the other half of states have laws letting them tell you. You can always ask about the cash price and ask if they have coupons or discount cards for the drugs you're buying.
Dr. David Belk has clear data on wholesale (NADAC) and retail costs of generic and branded drugs (from GoodRx) and what drives the costs.
CMS has National Average Drug Acquisition Cost (NADAC) database at data.medicaid.gov/nadac. An explanation from West Virginia dhhr.wv.gov/bms/BMS%20Pharmacy/Documents/NADAC%20Survey.pdf
Commercial services (cost) wolterskluwer.com/en/solutions/medi-span/price-rx and www.fdbhealth.com/
IQVIA reports on wholesale and retail costs and number of prescriptions.
Express Scripts has numerous articles on drug pricing and 11 billion prescription records (paid access).
Drugs are distributed to retail pharmacies primarily by three companies: AmerisourceBergen, Cardinal, and McKesson, which have paid small fines, relative to their revenue, for not reporting excessive deliveries of opioids.
Hospitals which serve many poor people get discounted drugs for some patients from the 340B program.
You can find the number of drug prescriptions from each doctor and costs for Medicare patients in at least 2 places, described below. For non-Medicare prices see above.
ProPublica has Medicare Part D cost for each drug: number of prescriptions and total spending. You can get separate totals for US and each state, so you can get average cost per prescription, and for each doctor who prescribed a drug 50 or more times in 2013.
Medicare itself has more complete Part D data. The US and state summary files (bottom of the link) show for each drug: the number of beneficiaries as well as prescriptions and spending, so you can get average per beneficiary (total during a year), as well as per prescription for each drug.
Medicare's detailed files show number of days prescribed, so you can get average cost of a daily dose, as well as each doctor who prescribed a drug 11 or more times in 2013. This info is in 23 million records, without state or US summaries. However you can get good state and national estimates by opening any of their 36 spreadsheets (divided by last name of prescriber) and getting averages there. The average costs do not vary much by last name of prescriber. (Tips for working with large spreadsheets)
Some doctors and drugs typically have 30-day or 90-day prescriptions, which may be renewed all year. Their averages include the cost for each whole long prescription (30 or 90 days). Docs & drugs with shorter prescriptions only include that lower cost. Medicare's focus seems to be on cutting total costs, not cost per dose.
ProPublica's methodology says it has "retail cost" for these prescriptions.
Medicare's fact sheet gives more detail, saying it includes,
After seeing which drugs a doctor prescribes, you can find drug safety and effectiveness from the main drugs page here.
Doctors identified 25 procedures and tests which may be wasteful, since they usually have low value for patients. They were given to 25% to 42% of Medicare beneficiaries each year, depending on definitions, but they only cost 0.6% to 2.7% of total Medicare costs.
High spending at end of life?
In the United States,
Vox quotes economists that the US health care prices per item are abnormally high. So other countries get more health care for less cost:
"When you’re paying the highest prices in the world for basic services, for scans and drugs, it will undoubtedly be a struggle to provide all citizens with health care...
A 2018 JAMA article compares insurance systems, and a 2008 JAMA article shows the same cost issues in 2004-6, with US doctors' salaries double the level in other countries.
DailyKos has more detail on the range of costs.
Government Approaches which Could Save Money Include:
The government pays a lot for people at all income levels. Medicare Part B (doctors) and Part D (drugs), are not paid by the payroll tax, and are paid by premiums and government aid. (Part A, hospitals, is paid by the payroll tax.) Currently the Part B premium is $105 per month per person, and the cost is 4 times as much, $420 per month, so taxpayers pay a 75% subsidy. Premiums go up with income and subsidy is reduced, in several bands of income, but even the highest income participants get 20% subsidy.
The current premium is about 2% of income (red line above). It is
The Bipartisan Policy Center recommends starting bands at lower incomes (p.59 of full report), which result in higher premiums (and lower subsidies - green dashes above):
Kaiser summarizes a variety of 2014 Budget proposals involving 15% increases in the premiums paid by high income participants, starting the first band lower, and slowly lowering all bands by not adjusting for inflation for several years (red dots above). Premiums would be:
A Tucson blogger recommends charging 5% of income, up to the full cost (purple line above). Dots show bands of income, where people pay
This option charges low income people the current $105, since Medicaid already pays the premium for most of them. Dropping the premium to 5% for low income people would cost Medicare more, but save an equivalent amount in Medicaid assistance, so the $19 billion overall savings would remain. It is far more than the $1.5 billion saved by the readmission penalty. Incomes can be adjusted for cost of living (purchasing power parity) by using US government locality pay. AARP presents arguments for and against basing premiums on income.
In the spreadsheet you can try different percentages and bands. A 3% charge could have bands of income where people pay
The graphs show subsidies people would receive from various proposals. The current Medicare subsidy is large, even at incomes well over $100,000. The government does not subsidize food or housing for people at those incomes. The highest income limit on Food Stamps is $15,000 for one person, $20,000 for two; in subsidized housing it is $55,000 for one, $63,000 for two (Honolulu). Housing tax benefits do go to higher incomes, but people still have to pay the basic cost themselves. Why does the government make such large direct payments for health insurance for people with incomes over $100,000?
When a patient or representative disagrees with a hospital doctor's plan of care, either can appeal to the hospital's ethics committee, which has 1 or 2 people on call to listen and advise. If patients are in a hurry they need to decide whether to spend a few hours on this internal procedure or go straight to court, based on a lawyer's advice.
Loyola University has 3 free video case studies, which use actors to train ethics committee members. Loyola says the committee should get the doctor's story first, and prepare the doctor before the meeting, "prepare any health-care team members for participation in the conference." No one prepares the patient or representative. In 2 of the 3 cases the doctors get what they want by their forceful arguments. Ethics committee members' goal seems to be getting a decision made and accepted by doctor and representative. Rubin says mediation by untrained mediators subverts ethics, and adds, "it would not be unexpected to find more disagreement than consensus surfacing as difficult cases are discussed in the ethics consultation process."
The case studies never address the financial incentives everyone has: the hospital (which employs committee members) is generally paid a flat fee for each hospital stay, based on the patient's main diagnosis, but not based on the length of his/her stay, so shorter treatment saves the hospital money, and death prevents future readmission penalties. Furthermore enrollment in hospice will remove the death from the hospital's death rate, as tracked by Medicare.
In all 3 of Loyola's training videos, the representative goes into a room with 3 hospital staff, and there's no discussion of getting a second opinion from an independent doctor. The representatives are tired from care-giving. One says she's been with her mother for 30 hours. The doctors are understandably in a hurry to get back to other patients. The ICU doctor has either left the ICU for the meeting, or has stayed for a meeting after the end of her 12-hour shift, and she'll have to take the decision back to the next doctor to carry out. To avoid medical errors, representatives are advised to keep someone in the patient's room at all times, so if the representative has an ally at the hospital, that ally is probably in the patient's room. For these life and death decisions, a representative really needs an ally who's been through the process before, like a former ethics committee member, a nurse-advocate, or a lawyer.
The chair of U of Michigan Medical Center's ethics committee describes how his committee works (starts at 2:15 minutes into the video and goes to 17:15 minutes). He says that two committee members discuss the issues with doctors and representatives or patients, then post their draft report on an internal website for other committee members to post comments.
Some doctors criticize modern ethics practice, because "the ethical interpretation of patients’ best interests at the end of life has been reduced predominantly to an external agent’s assessment of quality of life."
TALKING WITH DOCTORS
"But most people die in the healthcare system. Indeed, most of them die as the result of a deliberate decision to stop medical treatment that might have prolonged their life" (Pope, 2011, Widener Law Review)
When a patient enters a hospital, s/he is sick, weak and/or in pain, and has often forgotten to wear hearing aids. Hospitals may not let the representative in the room at first. At that moment an unknown doctor asks orally whether the patient wants CPR, electric shocks or a breathing tube if the heart or breathing stops. The questioning occurs even if there is an advance directive, since the patient's choice might change. Miscommunication is possible.
Hospitals and doctors have trouble talking to patients about the end of life. This section gives examples from the American Medical Association, Los Angeles. and Canada.
Six professors and doctors from the University of Chicago, Johns Hopkins, Northwestern, St Luke's-Roosevelt and Massachusetts General say (J of the Am. Geriatric Soc. 1/2013), "clinicians lack sufficient understanding of the predictors of survival after CPR to assist in such discussions." There are ways to estimate life expectancy, accounting for patient health, but these are little better than chance.
The medical representative must deeply probe for possible treatments, probably by reading UpToDate from Wolters Kluwer, since many doctors do not offer complete options to older people.
AMA Code of Medical Ethics Opinion 5.5
(b) Reassure the patient (and/or surrogate) that medically appropriate interventions, including appropriate symptom management, will be provided unless the patient declines particular interventions (or the surrogate does so on behalf of a patient who lacks capacity).
(c) Negotiate a mutually agreed-on plan of care consistent with the patient’s goals and with sound clinical judgment.
(d) Seek assistance from an ethics committee or other appropriate institutional resource if the patient (or surrogate) continues to request care that the physician judges not to be medically appropriate, respecting the patient’s right to appeal when review does not support the request.
(e) Seek to transfer care to another physician or another institution willing to provide the desired care in the rare event that disagreement cannot be resolved through available mechanisms, in keeping with ethics guidance. If transfer is not possible, the physician is under no ethical obligation to offer the intervention.Comments on AMA Ethics
A bioethicist for Mercy Health (4 hospitals in and near Philadelphia) notes (AMA J of Ethics May 2007 emphasis added):
"If agreement is not reached between the physician or hospital and the patient or surrogate, either party may seek injunctive relief from the courts, or the patient/surrogate may file medical malpractice action... the threat of litigation alone will deter some physicians from ever invoking a futility policy... a consensus among physicians can then be submitted as evidence in legal proceedings to demonstrate that the standard of care was not breached."
Other chapters of the AMA code of ethics include the following:
Nine major Los Angeles hospitals and medical groups issued a press release promising "shared-decision making with patients" at the end of life. They did not release the actual guidelines, so I got them from UCLA under California's Freedom of Information Act. The guidelines cover 33 hospitals, 10,000 doctors and 7,000,000 patients.
Surprisingly, the new guidelines call many standard treatments "non-beneficial," (emphasis added in all quotes in this section) and encourage doctors not to discuss them with patients. They say: "In patients with late-stage terminal illness, use of interventions such as
Problems with this Los Angeles guidance include:
(A) there is no definition of "late stage," and
(B) "terminal illness" is so broadly defined it covers most older people: "any disease affecting one or more organs whose progression is not preventable, and commonly leads or contributes to death or manifest deterioration (mental or physical) within a predictable timeframe" (footnote 3). This definition of terminal illness covers:
The Los Angeles guidelines apply during "late-stage terminal illness." This appears to include:
They are allowed to deny dialysis, tube feeding, CPR, ventilation or ICU, so the doctor earns Medicare rewards for saving money, and so patients don't survive to cause very expensive readmission penalties at the hospital.
By not offering these standard treatments, doctors deny patients the choice of more time with family and friends. A single dialysis session can clean a patient's system, giving a few more days to make decisions on continuing care or to say goodbye. A single CPR has a 23% chance of success, and gives a median of 2 more years of life, in about the same state of health as before.
After a treatment is called non-beneficial California law lets a doctor be silent about it, except when a patient or representative directly instructs it be done. Then the doctor must give the treatment or offer to transfer the patient elsewhere. But patients almost never have independent advice to make such a direct instruction, so doctors are allowed to stay silent while shared decision-making and life disappear.
The Los Angeles guidelines say, "Decisions not to comply with a patient or legally recognized healthcare decision maker's request for medically non-beneficial treatment should be undertaken in accordance with California probate code sections 4734-4736" (footnote 5).
California probate code says, "4735. A health care provider or health care institution may decline to comply with an individual health care instruction or health care decision that requires medically ineffective health care or health care contrary to generally accepted health care standards applicable to the health care provider or institution."
Thus the effect of the new guidelines is to permit the silent denial of dialysis, tube feeding, CPR, ventilation and ICU whenever doctors want to deny them to patients with chronic illnesses.
The guidelines cover 33 hospitals, 10,000 doctors and 7,000,000 patients in southern California:
Canada distinguishes 3 types of patients:
A. Accountable Care Organizations
B. Antitrust, Investment and Power
C. Bonus to ACO for Cutting Costs
D. Changes in the Bonus (with comparison of rewards before and after 2015)
E. Medicare Worries that ACOs Will Hurt Health
F. Cancer Doctors Worry ACOs Will Hurt Health
Informing Patients about ACOs (FOIA for more detail)
Special ACOs and Insurance Issues
Technical Bonus Calculation and Risk Adjustment
A. Accountable Care Organizations
ACOs are groups of health providers who get waivers of rules on competition and kickbacks. They also may get paid more if they reduce spending on their Medicare patients, and sometimes patients of other insurers.
Patients do not sign up. Medicare tracks 9 million patients who get most of their primary care from an ACO. Medicare shelters ACOs from antitrust rules. When an insurer saves money on ACO patients, the ACO can keep half the savings, but when the insurer pays more for ACO patients, the ACO often keeps all the extra income. There were 32 million patients overall in ACOs, Medicare plus private, on 3/31/2017, 10% of the US population. A recent JAMA article maintains the myth that ACOs' goal is cutting costs, rather than reducing competition, and reducing care for expensive patients.
Medicare provides a current list of ACOs updated through 2017.
Health providers who join an ACO have incentives to refer to affiliated specialists so payments are kept within the group. Quality measures slightly discourage hospital admissions (pp.13-15) and readmissions (p.11), but if the doctors' practice is owned by a hospital, extra income for the hospital more than makes up for any quality measures. They face no loss from patients' deaths or from diseases getting worse.
Patients are poorly informed about which doctors are in an ACO, and about their doctors' incentives. Medicare took three years to answer my request for some of this information under the Freedom of Information Act.
According to Medicare, patients who don't want a doctor with ACO incentives and pressures can "seek care from another provider." If they want to keep their doctor, they can avoid cuts by dropping Medicare part B doctor coverage and using other insurance, or they can accept that the doctor has incentives to recommend less expensive treatments and hospice. They can get second opinions from doctors who have not joined an ACO, who will have less incentive for cost cutting.
Harvard's Dr Herzlinger says,
Dr. Prince, CEO of Beacon ACO in New York, presciently said before Beacon became an ACO, "If they’re going to put the risk back on to the ACO and onto the physician, it’s going to be more difficult and we could start self-selecting which patients we want to include in our ACO." High cost patients can get more care outside an ACO.
61% of doctors plan to stay out of ACOs. 24% were members in January 2014, with another 10% planning to join in 2014. 91% of kidney dialysis patients are not in ACOs, so Medicare is setting up other doctor groups (End Stage Renal Disease Seamless Care Organizations - ESCO) just to cut costs for dialysis patients. "Members must place their fiduciary duty to the ESCO before the interests of any ESCO participant."
Medicare patients who use an ACO doctor cannot opt out as long as they have Medicare Part B, though they can opt out of letting that doctor see their Medicare claims from other doctors. (42 CFR 425.708). ACOs can maximize their inexpensive patients by reminding them to come in for checkups.
B. Antitrust, Investment and Power
ACOs are largely sheltered from restrictions on antitrust, kickbacks, and referrals to financially related providers
An April 2011 editorial in the New England Journal of Medicine (NEJM) said most medical groups spend money to set up an ACO, and cannot profit from it, unless they cut costs 20% or more. The large number of ACOs, all signing up after the editorial was published, shows managers want the kickbacks, referrals and antitrust waivers described above, or expect to cut spending on your care at least 20%, neither of which is desirable.
A July 2015 study in Annals of Family Medicine found that primary care doctors received very little pay for quality, whether they were in ACOs or not:
There is a revolving door between ACOs and the federal Department of Health and Human Services.
HOSPITAL POWER AND COST
A January 2012 discussion reported in the Wall Street Journal included a former Medicare administrator, Scully, saying ACOs would not work and would be dominated by locally powerful hospitals forming ACOs. "The biggest flaw with ACOs is that they are driving more power to hospitals—not to doctors. Very scary, and I am a hospital guy. The goal of ACOs was to organize doctors to focus more on patients and keep the patients out of hospitals. Instead, doctors are selling practices to hospitals in droves." A Virginia professor, Goldsmith, said ACOs had been tried 2005-2010 and failed, the same pattern noted by NEJM.
The professor, Goldsmith, also has written, "Hospitals and systems that became powerful in the marketplace through mergers and acquisitions aggressively shifted costs onto private insurers." Austin Frakt, a VA health economist and Boston professor writes, "If ACO formation proceeds with few checks... lower public-sector costs but higher private-sector premiums" are likely.
In fact integrated health care delivery networks (IDNs) raise both public and private costs. A 2015 study found "there is growing evidence that hospital-physician integration has raised physician costs, hospital prices and per capita medical care spending... Diversification into more businesses is associated with negative operating performance. This is consistent with the management literature, which shows that diversification increases a firm’s size and complexity, in turn increasing its cost of coordination, information processing, and governance/monitoring."
A 2017 report says, "Not only did sixty drug companies combine into ten, but hospitals, outpatient facilities, physician practices, labs, and other health care providers began merging vertically and horizontally into giant, integrated, corporate health care platforms that increasingly dominated the supply side of medicine in most of the country... Even nominally independent surgeons, for example, can’t stay in business if the only hospital in town won’t grant them admitting privileges, or if it grants “affiliated” surgical teams better terms... A full 40 percent of all hospital stays now occur in health care markets where a single entity controls all hospitals... not a single highly competitive hospital market remains in any region of the United States."
Hospitals are rapidly buying doctor practices, so the doctors become employees and refer patients to the hospitals, not necessarily saving money, but strengthening the hospital.
C. Bonus to ACO for Cutting Costs
Medicare has lost money on ACOs every year. In each year some ACOs raise Medicare's costs, others get small bonuses. The most expensive ACOs look as if they save the most money, but their costs are still higher than less expensive ACOs, which do not get bonuses. A 2018 report analyzes costs, risk adjustment and alternatives.
An ACO gets a bonus payment of up to 50% of the cost savings from Medicare Parts A and B for its patients. By 2015, half the ACOs have raised Medicare's costs, an average of 3%. The other half of ACOs have cut costs, an average of 4%. Among all 392 ACOs, 30% cut costs enough to earn a bonus. The bonus received by these ACOs averages 3% of their costs. During 2014 there were 353 ACOs, and a quarter, 97, saved enough money to get bonuses, though not necessarily enough to pay back the set-up costs. During 2012, the initial year, there were 114 ACOs, and a quarter, 29, saved enough money to get bonuses.
A rational ACO with professional management knows these 30% odds of getting a 3% bonus, which seems so small that it is unlikely to be the reason for forming an ACO. The other main benefit of an ACO is obtaining federal waivers.
Three ACOs have signed up for a version of the program where they can get up to 60% of the savings, but they share losses. One cut costs 17% (third biggest cut in the country), giving them a 12% share. One cut costs one percent, and the other raised costs half a percent, not enough to share. They have an incentive to avoid expensive treatments, which give them losses.
Theoretically bonuses can be large, so some ACOs may cut aggressively, like the one which cut costs 18%. Five small ACOs (average 7,000 patients) in Florida and Texas cut costs over 15%, averaging $1,000 per patient.. A cancer practice saved $1,000,000 per year per doctor, without even signing up for an ACO.
Detailed steps and definitions for calculating cost savings and risk adjustment issues are in another section.
Each year some doctors and patients in any ACO will chance to have above-average costs, reducing the bonus for everyone else. How will the ACO and peer pressure penalize these doctors and their sicker patients? The articulate Dr. Prince, CEO of Beacon ACO, says about their doctors,
Doctors are seeking ways to avoid these programs. A third are in ACOs. 61% plan to stay out of ACOs. 6% refuse insurance and 3% charge concierge subscriptions starting at $600 per adult per year and $120 per child, or more typically $1,500 per adult. 10% of Texas doctors do not take insurance, and instead charge for each visit, starting at $50 per visit.
D. Changes in the Bonus
The bonus percentage, up to 50% or 60%, depends on quality scores. ACOs get a few percent for each quality standard they meet (if 2-sided, you would increase each percent below by a fifth, so they total 60%).
Within each measure, the ACO gets only partial points if it is below the 90th percentile (p.67899, see graph below), so most will not get the full 50% (60%) of cost savings. Many of the screening standards are so easy that ACOs and other doctors will be clustered closely. The circulatory and hospital admission standards are the main "quality" measures where ACOs may distinguish themselves.
Penalties for readmissions after a nursing home stay will reduce the number of good nursing homes willing to accept risky patients, as well as deterring needed hospital treatment. More discussion and evidence are in the Nursing Home section.
Patient surveys have pros and cons. The surveys are here.
Electronic health records are problematic, since they have enabled vast breaches of medical privacy for 30,000,000 patients. Great systems are rare, though ideally they would show key information clearly in the way that each clinician needs it. Bad systems are not read by clinicians, are full of errors, generate erroneous prescriptions, and interrupt doctors when listening to patients.
Checking medications at an office visit is problematic, since hospital stays are the main cause of prescription changes, and the office visit is too late. Medicare says (p.19), "28% of chronic medications were canceled" during hospital stays, so immediate coordination is important and needs to be required. Office checks are also incomplete, since the patient rarely knows what medicines are given at the dentist, dermatologist, dialysis center, chemotherapy session, and other specialist locations.
E. Medicare Worries that ACOs Will Hurt Health
Medicare has a ceiling to protect patients from doctors' excessive cost-cutting incentives. (pp.67935-6). They worry if the ceiling is adequate.
The first graph below shows what fraction of the theoretical bonus an ACO gets, depending on its quality ranking (p.67899). The second graph shows threshold savings ACOs must reach to earn any bonus (p.67928-9). Large ACOs need to save 2% to earn any bonus, while small ACOs need to save at least 3.9%, to avoid payments for random variation. (ACOs which risk losses need 2% savings regardless of size.)
A doctor with a $21 million grant from Medicare to achieve "lower costs with better outcomes" says "Significant improvements in cost and quality may not be felt until fee-for-service falls below 50% of provider reimbursement," which means a ceiling on bonuses not 10%, but over 33%, leaving 33% for Medicare and 33% in direct costs, which is far too little to pay for needed care.
From a doctor's point of view, doctors are subject to "whatever cost-savings techniques the ACOs use, e.g., not accepting doctors who have too many elderly patients or patients with expensive chronic diseases. The days of searching out rare and unusual diseases to care for are over: these unfortunates will be obliged to find whatever comfort is available under the nearest bus. If the ACO is well managed from a fiscal perspective, providing participants will share in the savings as a second source of income. Quietly, with as little fanfare as possible, physicians and hospitals will be encouraged to avoid the sickest, oldest, and most complicated patients."
F. Cancer Doctors Worry ACOs Will Hurt Health
Cancer doctors have been especially concerned about quality and cuts, since cancer represents 1% of patients and 10% of medical costs.
Dr. Cary Presant, chair of the Medical Oncology Association of Southern California, said, "The unspoken word is 'try and find a way to get these patients to not utilize these drugs, and consider whether this patient who is going to be a big expense should go into a hospice earlier rather than later.'" Groups can also discourage expensive patients by limiting their appointments or recommending palliative care.
A similar concern applies to Medicare Advantage (Part C) plans. Newell Warde, RI Medical Society director described a big Medicare Advantage plan dropping specialists who served expensive patients. "They look at your patient mix... They’re not just dumping doctors. They’re dumping patients. These may be expensive patients."
Case Western researcher, Anish Mehta, and Dr. Roger Macklis, a Cleveland Clinic cancer doctor write, "cancer-specific guidelines are not included in the quality measurements... Oncologists may feel pressured to curb the use of costly drugs and expensive procedures. New treatments from across all branches of oncology—from proton therapy to hyperthermic intraperitoneal chemotherapy to sipuleucel-T—will now reﬂect directly on the PCP... Pathway-driven medicine may lead to bare-bones cancer care, significantly reducing the universe of treatment options used by specialists."
A cancer lobbyist, Matt Brow, wrote, "There is another great risk that the ACO will not be held to delivering quality oncology care in any way, leading to the desire to see oncologists use the least costly type of therapy or no therapy at all.”
At the same time Medicare creates a shortage of cancer doctors by not training as many as the number retiring.
Aside from ACOs, insurance plans for non-Medicare patients are beginning to exclude specialized cancer treatment centers.
Informing Patients about ACOs
Special ACOs and Insurance Issues
ACOs are entitled to exemptions from several laws, which for many years have promoted good care and prevented conflicts of interest:
The Justice Department has issued policies protecting ACO members from anti-trust enforcement if they cooperate in an ACO with up to 30% of the local market.
A. SUPPRESSION OF PUBLIC INFORMATION
Many doctors, hospitals, therapists, etc. have joined Accountable Care Organizations (ACOs). These have important features which patients need to understand. However Medicare does not let ACOs tell patients about some features, and requires very unclear wording for the others. ACOs cannot write their own wording:
Medicare has prepared a sign which is supposed to be posted at "a limited number of locations in each ACO" (Federal Register 11/2/11 p.67946) (42cfr425.312(a)). The sign virtually denies that Medicare discloses private information. It says:
B. NOTICES AND SIGNS AT THE POINT OF CARE
A patient arriving for an appointment may or may not suddenly see a sign that the doctor is in an ACO, with minimal explanation. Medicare's theory is that the patient can "seek care from another provider". The patient is supposed to decide suddenly whether to see the doctor, based on minimal information, often sick and in pain, and maybe facing a cancellation fee.
On June 8, 2016 Medicare gave me these standardized written notices and signs, which must be displayed to patients when they get care. I had requested these copies under the Freedom of Information Act in July 2013. They include:
Based on Medicare's rules, patients may have no effective notice. ACOs are permitted to mail notices to patients in advance. Otherwise patients will only learn about the ACO "when you visit the office. A poster with information about your doctor’s participation in an ACO will be displayed. At your request, the doctor will also give you this information in writing" (p.119 of Medicare and You Handbook, 2017, emphasis added). The poster/sign does not say that written information is available. The sign just says you can talk to your doctor or Medicare about it. Medicare in 2014 proposed making the sign more complex, with information on opting out of data disclosures (p.72789, 12/8/14), but the final rule (6/9/15) did not state whether they would change the sign, and disclosures are still not mentioned in the sign released in 2016.
Medicare's Written Information for Patients Makes These Points:
The main topics in these 19 points from Medicare are:
Revealing confidential medical information is the focus of items 1, 5, and 10-17.
The ACO's organizational structure, which may direct referrals to particular doctors, is the topic in items 3 and 9. However the material does not mention that doctors in ACOs can get kickbacks from referrals and can refer where the ACO doctor has a financial interest. Medicare approved waivers of referral and kickback rules for ACOs. So Medicare patients in ACOs are no longer protected by normal rules against kickbacks and "self-referrals," where the doctor has a financial interest. Furthermore, the Justice Department has issued policies protecting ACOs from anti-trust enforcement, similarly left unmentioned in the written material.
Medicare mentions quality of care in items 4 and 7. Medicare has a narrow and changing concept of the quality measures it looks for. The patient is not given any link or place to see what Medicare means by quality.
The ACO's incentive to cut costs is mentioned in items 6 and 7, without mentioning:
Readers will decide for themselves whether Medicare's wording covers what patients need to know. On the other hand, ACOs cannot decide for themselves. Medicare requires ACOs to use Medicare wording when giving information about the ACO (42cfr425.310(c)(1)), so they keep tight rein on the public spin about ACOs. However non-ACO members are not constrained in what they publicize.
C. REQUIRED WEB PAGE
Medicare requires ACO websites to have a page or pages showing staff, quality measures and "Shared Savings/Losses" (Public Reporting Format), though the web page does not have to be linked from anywhere, and sometimes can only be found if you know to search for it. Some also have an older page about "How Shared Savings Are Distributed." The examples below are from the biggest ACO, but Medicare requires every ACO to have the same wording.
1. ACOs usually include group practices, and the required web page must list them by corporate name, like "Access Neurocare PC," not the individual doctors who work there.
2. Medicare and ACOs talk about quality care, but the quality standards do not measure deaths, cures, or good or bad outcomes from treatment. Patients will not realize how limited the quality measures are, since quality measures shown to patients must use Medicare's opaque wording, such as:
3. On this same obscure web page Medicare requires ACOs to tell patients the how many millions of dollars are "Shared Savings/Losses" without definition, and without context on how this compares to total spending. For example:
Special Types of Accountable Care Organizations
About 30 ACOs are Pioneer ACOs (Phase 0 in list) with even stronger incentives to save money than the more common "Shared Savings." Differences include:
About 35 ACOs are Advance Payment ACOs ("a" in list) where Medicare lends money to start and operate the ACO.
How Does Other Insurance Control Cost?
CIGNA health insurance has 66 ACOs, and Premier has 23. Blue Cross has them in New Jersey, and in an AQC program with 9 ACOs in Massachusetts. Aetna promotes the idea and has them in Arizona, San Diego, Maine, New Jersey (also here), Pennsylvania (also here), and Virginia (also here).
15% of people with health insurance from private employers have a flat fee per patient for each doctor, regardless of the amount of treatment provided (capitation).
Homeowners' insurance is like health insurance in that few people have big claims, and everyone wants low premiums. Companies frequently reword policies to avoid unexpected costs, and customers theoretically can compare policies, but often have gaps in coverage.
Many types of non-healthcare insurance have premiums based on experience or risk. These varying premiums (unlike Medicare) give incentives to reduce claims: car, workers' compensation, unemployment insurance, FDIC, etc.. The person buying the insurance thus chooses between higher risks, claims and premiums, or lower claims with lower premiums.
Some types of insurance collect property to reduce losses and provide a disincentive to claim: car, mortgage. Many claims are inherently unpleasant, so have incentives against overuse: sickness, death, car accidents, house damage, and theft.
Some insurance companies make it hard to collect: Social Security Disability Insurance initially denies claims, and the disabled need to appeal. Car insurance is regularly rated by Consumer Reports on claims services. Private health insurance faces frequent complaints from patients and providers about difficulty getting payments. Long term care insurance has a risk of being similar, but there is too little experience to compare the insurers.
Moral hazard is the risk that an insured person or company will incur extra risks and losses because of having insurance. Banks are subject to moral hazard because of FDIC and bailout funds. However people rarely get sick or want more invasive tests voluntarily, so moral hazard rarely applies to health insurance.
How Do Other Entitlement Programs Control Costs?
Governments reduce budgets and cut services of entitlement programs overtly or covertly. Home health services and services for foster children are targeted and reduced.
Advocates limit cuts by asking voters or courts to insist on more money. Prisons are overcrowded until prisoners get courts to order improvements.
Medical care is subject to malpractice suits as an incentive against cost-cutting, though these are expensive with expert testimony, and many states restrict awards for suffering, so they are not as useful for elderly (Medicare) patients as they are for highly paid younger patients who can claim lost earnings. Class actions may be a way to aggregate enough awards to make legal enforcement worthwhile.
ERISA preempts many claims for damages against employer-provided health insurance, even HMOs, though not necessarily against independent doctors and hospitals (legal history to 2003).
Direct link to this page: foia.globe1234.com
General FOIA Links
Filing for Federal Information:
How Long Will You Wait for Federal Information?
Will it be faster if you go to Court?
How to Find and Learn from Similar Cases in Federal Court?
Represent Yourself in Court?
US Justice Department:
Besides the law, each federal agency publishes regulations (also called rules) to carry out the law. To find them try a search engine, after you change name_of_agency to the agency you want:
FOIA at Medicare, Health and Human Services
Like other agencies, the Department of Health and Human Services (HHS) has rules for FOIAs, and each major office in HHS also has rules. The overall HHS rules on FOIAs, adopted in 2016 are at:
Former rules at HHS were in effect for decades and are at:
There were lots of changes. For example on appeals, after they deny a FOIA, an improvement in the new rules is:
It is not clear how these HHS rules interact with separate FOIA rules at sub-agencies of HHS. For example the Centers for Medicare and Medicaid Services (CMS) has its own rules, which still say 30 days to appeal, and do not address the freeze in processing during a lawsuit. CMS rules are at
and CMS also has policies at
Example of a FOIA for Documents which Medicare Gives to Accountable Care Organizations
An ACO gets a bonus payment of up to 50% of the cost savings from Medicare Parts A and B for its patients. (If an ACO is willing to risk losses as well as bonuses (2-sided), they get up to 60% of the savings instead of 50% 42 CFR 425.606.
Medicare requires ACOs to have at least 5,000 Medicare patients. With 260 Medicare patients per doctor, this means at least 20 primary care doctors in each ACO. Most ACOs are larger. However 3-8 doctors give better care, because they take more responsibility and have fewer managerial distractions than big practices (Kussin 2011, p.36). With at least 20 doctors, each doctor has little effect on the ACO's bonus, so the ACO needs internal incentives to motivate doctors, such as reviews of doctors, limits on expensive procedures, and rewarding individual doctors for cutting their costs. Much like an HMO.
Also see lists of US Doctors:
Who offers long appointments?
Who treats you in both hospital and office?
Who has wide experience with procedures you need?
And data on Hospitals or Medicare and other patients
A. Financial Conflicts of Interest
(Many sites below track your IP address; you can check their privacy statements.)
While searching for doctors, be aware of the stress they are under. A cardiologist writes, "We can't be perceived as less than 100% capable. We can't take medications in case it will affect our performance. We find it difficult to admit that we aren't the perfect person that our patients expect us to be. We belong to the only profession on the planet where we are accused of thinking we are God and then sued when we are not."
A. Financial Conflicts of Interest
Doctors get many pressures which affect patient care. The Journal of the American Medical Association (JAMA) May 2 2017 summarizes a lot of research and has a proposal that doctors be paid by salary, to avoid:
Practices with 2 or more primary care doctors were analyzed in a July 2015 study in Annals of Family Medicine (632 practices surveyed 2012-13):
Doctors' average incomes (after expenses) by specialty range from $200,000 per year for Public Health and Pediatrics to $500,000 for Plastic Surgery and Orthopedics, with wide variation. Concierge (2% of doctors) and cash-only (5%) doctors earn slightly more than average, comparable to other self-employed doctors. 13% are direct primary care doctors, generally subscription-based but lower fees than concierge. Three quarters do not charge for no-shows, whatever their policies may say. 70% see patients for 45 hours per week or less, but they spend 10 hours or more on paperwork and administration. A fifth to a quarter of most specialties would not choose medicine again if they had the chance. Wealth averages $1-2 million, depending on specialty and age. A quarter of doctors have over $1 million by the time they are 35, and two thirds do by the time they are 50.
Most doctors at hospitals work for large groups (TeamHealth, Schumacher) which contract to provide hospitalists, radiologists, emergency doctors, etc. Some companies provide doctors to hundreds of hospitals (Envision + Amsurg). Hospital doctors earn $200,000 - $400,000 per year. About half feel fairly compensated. Only a quarter "regularly" discuss the cost of treatment with patients.
Payments from industry to doctors are discussed on the drugs page.
B. DOCTORS REVIEWED BY DOCTORS
Patients can use published surveys to find doctors recommended by other doctors.
Consumer Checkbook asks doctors to recommend other doctors in big metro areas, and provides the counts for doctors recommended most often (list of counties). They also count patient recommendations for primary care doctors (in Boston, Chicago, DC, Delaware Valley, Puget Sound, San Francisco, and Twin Cities areas), so you need to read column headings carefully to be sure whether you are seeing ratings by doctors or by patients. In "more filters" you can sort by number of recommendations or distance from a zip code (if you selected "search by zip code").
"We regularly send surveys to all actively practicing physicians in the 53 largest metropolitan areas in the U.S. and ask them to tell us which one or two specialists in each of 35 or more different specialty fields they 'would consider most desirable for care of a loved one.' " ($28 online). Their research says that in general these doctors also:
ABCNews reports that other lists are not competitive and include many bad doctors: TopDocs, Consumer's Research Council of America, etc.
A 1999 study found that doctors were more likely to be in such lists "if they trained in prestigious residencies (P<0.01) or fellowships (P<0.05), or if they had an academic appointment (P<0.05) or 15 or more years of experience (P<0.001)."
Referral services also select doctors they think are high quality, and you pay for the referral.
Malpractice and disciplinary cases (rare) are another place where some doctors are reviewed.
C. DOCTORS REVIEWED BY STATISTICS
The best statistics are at the following separate links:
Doctors' Experience with a procedure
Average Time spent with patients
Less helpful are:
Outcomes are described in the following paragraphs, but first a warning: All statistics on outcomes create pressure to "cream" or "cherry-pick," i.e., treat the healthiest patients and deny treatment to the sickest patients (saying, "you're not a good candidate for treatment" or having long delays even for urgent appointments). Deadly examples are in two sample articles in The Guardian and the New York Times. Measuring and rewarding doctors can also backfire and reduce quality by reducing motivation (see a very good, broad article on these effects).
Skewing Outcomes: CHQPR gives good examples of the harmful effects of using outcomes to measure doctor quality, and recommends instead using (1) compliance with Clinical Practice Guidelines or documneted reasons to differ, and (2) monitoring all patients with a validated tool such as WMI. Such monitoring also needs a measure of maximum wait times for existing patients, which could drive the sickest patients out of the practice, and a measure of excess referrals to hospice and palliative care.
Studies find that doctors avoid treating risky patients, when there is public reporting of outcomes. For example doctors who treat narrowing of the coronary arteries (for example to treat or prevent heart attacks, PCI-Percutaneous Coronary Intervention) in New York and Massachusetts have the death rates of their patients publicly reported, and these doctors avoid PCI on the riskiest patients, even if it might help the patient, since the higher death rate will hurt the doctor's or hospital's reputation.
Groups which report outcomes often say they adjust for initial health to put all patients on a level field, but the adjustments are very weak. They have low explanatory power, and few variables: "the most assiduous work on risk adjustment has produced tools of only moderate power. The prospects for solving this problem with improved risk adjustment are not promising.,"
Consumer Checkbook rates individual surgeons on death (within 90 days) and total bad outcomes, SurgeonRatings.org. They use Medicare patients 2009-12, and only report surgeons with results significantly above average. Unlike their hospital data, they unwisely exclude hospice patients from the surgeons' results (p.3). Few patients would have these surgeries if they were on hospice, so they must have gone on hospice after surgery. These deaths are no more or less attributable to surgery than any other deaths in 90 days. They acknowledge a random level of deaths in any population, unrelated to surgery, and exclude it with statistical tests.
Surgeons' total bad outcomes for Checkbook include deaths within 90 days, atypically long hospital stays (indicating major complications), and readmissions within 90 days of initial hospital discharge. They seem to include all readmissions, even unrelated to the surgery, so they penalize surgeons who take on patients sicker than average. They say they adjust for patient riskiness, without details about which variables they use. They do list the "c statistic" for each adjustment, ranging from 0.626 to 0.913 (pp.14-39). The c statistic ha a scale of 0.5 to 1, where 0.5 means their equations do no better than chance, and 1 means their equations are perfect. "Models are typically considered reasonable when the C-statistic is higher than 0.7 and strong when C exceeds 0.8 (Hosmer & Lemeshow, 2000; Hosmer & Lemeshow, 1989)." So some equations are little better than chance, and they still rate surgeons with them. They cover (definitions on pp.9-13):
ProPublica almost simultaneously with Checkbook in 2015 released death and complication rates for all surgeons with at least 20 surgeries during 2009-13, in the categories below. They count deaths during the same hospital stay as the operation, and wisely do not exclude hospice deaths (p.5). As "complications" they count readmissions within 30 days if these are for diagnoses considered likely to be related to the original surgery. These are 46% of all 30-day readmissions (p.6). They count a surgeon as having a "high" complication rate, based on their best single estimate, even if his/her confidence interval extends all the way into the "low" range.
ProPublica limits the data to elective surgeries, which usually involve healthy patients, but can include patients with other serious conditions, as long as these do not prevent the operation, conditions such as diabetes, dialysis, weak immune systems, etc. They say they adjust data based on the sickness of the patients, but they tried only one summary measure of all health conditions, and it had little effect (pp.10-11, with column heads defined on p.4). Age has the most effect, but they group it into 5-year categories, instead of using exact years of age (maybe because of data availability?). They do not provide summaries of their equations' power, but do acknowledge that their adjustments for surgeons' differing patients make only a "small difference" (p.13). For each equation they provide the standard deviation of the random effects (ranef sigma), which they interpret to mean most of the variation is among surgeons, not hospitals (p.15). They cover (definitions on App.1-3):
Levy says the profession keeps secret a better scorecard, NSQIP.
Chest surgeons show 3-star ratings on about 500 hospitals and 500 group practices (typically the group of surgeons operating at a hospital), for
Cardiologists show 4-star ratings for use of recommended drugs by a few hospitals after
California has a rating system for doctor groups with HMO members:
New York shows deaths within 30 days after a procedure for individual heart surgeons and cardiologists. You can filter by name of doctor and/or hospital, and region of the state. They describe methods and definitions for the surgeon and cardiologist data. Another NY site has profiles of all doctors, but does not link to the death rates.
Other databases are described by JAMA Surgery.
CMS Qualified Entities are allowed to use Medicare claims data, in order to provide quality measures on doctors, but it is not clear if any have yet released quality measures.
Delayed appointments are frustrating and can drive the sickest patients out of a medical practice, which would ironically improve its quality statistics
D. DOCTORS REVIEWED BY PATIENTS
Patient reviews tell if a doctor speaks clearly and listens, as well as giving early warning of problems. Dr Wen of George Washington U and Dr Kosowsky of Harvard say doctors need to communicate well with patients to get information for a good diagnosis:
Wen's and Kosowsky's book goes on to describe in detail how patients need to prepare before seeing a doctor.
Patient reviews tell you the style of different doctors, especially in the written comments.
Some doctors and hospitals "aggressively combat negative social media posts, casting a pall over one of the few ways prospective patients can get unvarnished opinions of doctors... consumers need to know there can be consequences if they post factually incorrect information." Some doctors have required patients to sign contracts which prohibit negative reviews or let doctors remove negative reviews. The "Consumer Review Fairness Act of 2016" makes those clauses unenforceable. 3,000 doctors had these contracts available in 2011, though not all used them. These doctor-patient contracts are not mentioned by any of the review sites as a reason for removing reviews, but one assumes they do it, or doctors would not bother with the contracts.
Before patients choose any doctor based on positive reviews, it is important to ask the doctor's office: Do patients have to sign a contract controlling patient reviews?
Rules about the reviews they keep are important. Below are rules at the 3 biggest sites:
Dentists are reviewed at several sites.
Allowable reviews: They have few restrictions: "post only truthful, non-libelous, and relevant ratings and posts."
Removing reviews: "We remove ratings for a number of reasons, but it is usually due to one of our automated spam filters thinking there were multiple ratings coming from the same rater... We generally do not remove ratings. This site is for people to report on their experiences...
Are reviews anonymous? Possibly. They keep patients' names anonymous unless subpoenaed, but they let advertisers and social media companies track which pages you see, so those companies can see your IP address when you post reviews. You can be anonymous if you post your reviews from someone else's computer, like a library, and don't identify yourself on that computer (eg. logging in to Facebook or email). Using your computer at a coffee shop gets you a new IP address, but your computer probably has persistent identifiers which their advertisers can track.
Are searches anonymous? Only if you use someone else's computer. Their advertisers track IP address and every page visited, so they can see what you're searching for. To foil advertisers you can turn off cookies, but not necessarily beacons. Buttons for Facebook, Twitter, and Google+ on every page presumably report every page visit to those companies.
Multiple ratings and updates: They limit patients to one rating "for the same doctor from the same computer or user." "If you were logged into your account when you submitted the rating, you can edit your star rating in your profile. Comments are not editable, but you can leave a new comment... If you were not logged in when you submitted the rating, the only thing you can do is to try to remove it and then enter a new rating."
Can patients report why they didn't go to a doctor? Yes.
Allowable reviews: They have woolly restrictions: "accurate, truthful and complete in all respects" (10) and not offensive, harmful or distasteful, among many other criteria (16).
Removing reviews: They pose the question and answer it several different ways: "Angie's List may modify, adapt, or reject Your reviews if they do not conform with Angie's List's publication criteria, which may change from time to time at Angie's List's sole discretion" (10g). "we never remove reviews unless the member who posted the feedback contacts us to delete it." "If ever we question the legitimacy of a review, we take it down."
Are reviews anonymous? No. They reveal the author of each review to the doctor (10f), though not to other members. Writing any review waives privacy and lets doctors publicly post "Your private or confidential health information in response to Content You submit" (15). "Angie's List may in our sole discretion share your User Generated Content with others."
Are searches anonymous? No. They disclose personal information when "permitted by relevant law," and they have four tracking companies on their search pages (see a table at the bottom of this page), so those companies know what you're searching for. They allow themselves to "link the information we record using tracking technologies to Personal Information we collect."
Multiple ratings and updates: "You have the right to share your honest opinions at any time."
Can patients report why they didn't go to a doctor? Yes. Reviews by people who checked out a doctor but did not go there are posted, but not weighted as heavily as people who did choose the doctor. So good or bad experiences before getting care can be read, though the doctor's average rating is not much affected.
Allowable reviews: must be "true and accurate" and not offensive, harmful or "otherwise objectionable," and not "deemed confidential by any contract or policy," among many other criteria.
Removing reviews: They say they provide "The complete list of all reviews from patients just like you." However they'd suppress reviews that violate their lengthy criteria, so it is not really "all." They sell to doctors a service called: "Reputation Management." It "enables providers to append responses to specific reviews [and] Opportunities to encourage patients to write additional reviews." Vitals' CEO is quoted in Buzzfeed saying the site can remove an "outlier" negative review at the doctor's request.
Multiple ratings and updates: "post only one (1) Submissions regarding the same Healthcare Provider, entity, procedure or subjectduring any thirty (30) day period."
Can patients report why they didn't go to a doctor? No. "By clicking Submit, I... verify that I have received treatment from this doctor."
E. PATTERNS OF COMPLAINTS BY PATIENTS
Consumer sites carry complaints about doctors, justified or not. Also, some doctors are formally charged by authorities or investigative reporters, correctly or not. The complaints on consumer sites often give early warnings about doctors who are later investigated. Second opinions are almost always a good idea, and especially in any of these situations where others have reported concerns.
DOCTORS CHARGED BY INVESTIGATORS: What Their Reviews Look Like
The first list below summarizes consumer reviews for 8 doctors who have faced charges (and citations for the charges). All the doctors denied the charges. The second list shows there have been fewer complaints for a control list of doctors who have not been charged, and who do many knee replacements, a risky procedure. So consumer complaints do show a difference between the two groups of doctors.
DOCTORS WHO DO KNEE REPLACEMENTS: What Their Reviews Look Like
The following shows the range of consumer reviews for 5 surgeons who do high volumes of knee replacements. These have not been the subject of investigations and may be considered "normal" high-volume doctors:
F. NO PRIVACY ON THE WEB: TRACKING YOUR SEARCH FOR DOCTORS
Spreadsheets on This Site:
If the spreadsheet was slow to download, click File/Save As a couple times with new names, so you can get back to the original version without downloading again.
If you need extra help, many people who work in bookkeeping or finance are good with Excel spreadsheets, or you can search the web.
Basics. Most of you already know these:
- Find Records by pressing Ctrl and F at the same time, and type what you want into the search box. If you know which column it's in, Highlight that column by clicking the letter atop the column, before you press Ctrl-F, and the search will be much faster.
- Rows start with 1, and Columns start with A. You can move around the spreadsheet with the arrow keys, the page down and page up keys, and the sliders on the right and bottom sides of the window, if they appear.
- Click a Cell and a little window just above the letters at the top of the columns shows you the number or formula in that cell, or Type something new to replace what's there.
- If small ▼Triangles already appear near the top of each column, skip to step 5. If you don't see triangles, start with step 2.
- Click the letter at the top of the column showing State, or whichever column you want to select on.
- Click Data. The Data menu is found alongside File, Home, Insert...
- Click Filter (you may have to first click Sort-and-Filter). After you click Filter, a small ▼Triangle will appear near the top of the selected column(s).
- Left-click the triangle, to see a little menu where you can de-select All, then Click the state(s) or specialty(ies) you want. Click OK, and only your state(s) or specialties will appear. You can get the others back, by clicking the little triangle again and selecting All. The little menu under the triangle has its own little slider to go up and down the list; All is at the top of the list.
- The triangle may hide some of the column heading. You can remove the triangle by again clicking Data, then Filter.
- To select a range of records, such as costs over $1,000, click Number Filters in the little menu under the triangle in the costs column, then click Greater Than, then fill in $1,000 ($ and comma are optional), then click OK. Number Filters can even give you Between 1,000-2,000, or Top 1 to 500, or Above or Below Average. Sometimes they're called Text Filters, with similar choices.
- You can filter several columns, like female Pain doctors in Virginia and DC.
- Choose cells to sort: Highlight any area by left-clicking the upper left corner, then shift-left-clicking the lower right corner, or Drag your mouse from one corner to another while holding the left key , or Click the letter atop any column to highlight a column, or Click the number left of any row to highlight a row
- Click Data at the top of the screen, then click Sort. Answer the questions to expand to all columns or rows. Then you will see a window of sorting choices.
- To keep headings at the top, be sure the box is clicked for "My data has headers"
- Normally it moves Rows up and down to put them in order. Click Options to move Columns right and left into order
- In the Sort By box, click the ▼ triangle, and choose a column (or row) to sort by
- If you want subsorting (such as by state and then by revenue within state), you may need to click Add Level and fill in the second item to sort by
- Click OK. A file over 100,000 records may take a few seconds to a minute to sort, depending on your computer's speed.
Undo a Sort or anything: press Ctrl and Z at the same time. You can do this repeatedly to back up to previous versions, sometimes as far as the last time you saved the file
Save Frequently, with new names, so you can go back to previous versions if you need to.
Calculate an Average or Sum: Suppose you want Average of Column T
- Insert a new row to hold the average, by right-clicking the Number to the left of a row, like row 2: On the menu which appears, left-click Insert
- Click a cell in the new row, probably in column T
- Type into that cell (don't forget the equals): =Average(T3:T50000)
- Include the full range you want, which depends how big your spreadsheet is
- Press enter, the formula should disappear, and a number will appear.
- =Average( ) gives the average of numbers, including zeros, but ignoring blanks. It includes rows you hid with Filter. To do a lot of work on one state, you may want to delete all the others, so your averages or sums are just that state. Save Frequently.
- You can also use =Sum( ) or =Median( ) or many other functions (click Help)
- Insert a new column by right-clicking the Letter atop a column: On the menu which appears, left-click Insert
- Click a cell in the new column, on the row where you want the first ratio, such as row 2
- Type into that cell the ratio you want from that row (don't forget the equals): =K2/L2
- Press enter, the formula should disappear, and a number will appear.
- Then put your cursor over the lower right corner of the cell. Your cursor becomes a +; double-click it and blank cells below it will fill all the way to the bottom. Click some of those to see how the formula appears as it goes down the page.
- Formulas can use / * - + ( ) and many other functions described in Help.
- If cells have too many decimal places, right-click the cell, column or row: On the menu which appears left-click Format cells: In the window of format choices which appear, click Number and the number of decimal places you want, then OK
- Select state and revenue columns by left-clicking the letter of the left column, then shift-left-clicking the letter of the right column (every column in the range must have label in first row)
- Excel 2010: Click Insert (or in Excel 2003: click Data) then click PivotTable. Answer any questions, and it will open a new page.
- 2010: On the right side of the screen, drag a category, like State, down to Row Labels or Column Labels. (2003: click a category, then use ▼triangle to add the category to rows, columns, or data.)
- Move any variable, maybe State again, to Values (called Data in 2003). Be sure it appears there as "Count of.." Notice the summary table on the left side of the screen now shows the count of rows for each state
- 2010: Drag a numeric variable, like revenue, to Values. It will develop a little arrow, Left-click the little arrow to choose "Value Field Settings.." and then Sum, Count, Average, Max, Min, etc. (2003: Add a numeric variable, like revenue, to Data. See where it appears on the table as Count of. Right-click it: On the menu which appears, left-click Pivot Table Field and then Sum, Count, Average, Max, Min, etc.)
- The summary table on the left can give you the count of rows in each state, and the average and/or sum of as many variables as you wish, for each state.
- You could also do rows for each type of hospital or other category in your data
- 2010: If the menu of variables on the right side of the screen disappears, click anywhere in the table on the left side of the screen, and the right side will reappear. (2003: A Pivot Table bar floats on the page, with a button on the right end to hide or show the Field List.)
- 2010: If you want some states, but not others, move your cursor to the upper right corner where the state variable is listed. When you point at a variable there, a ▼triangle will appear to the right of the variable name. Click the triangle, then de-select as many states as you wish.
- ^ means exponent so =2^3 means 2 cubed or 8, and 2^.1 means tenth root of 2
- You'll get warnings in cells where you divide by zero. You can avoid them by typing conditions: =IF(condition , result if condition is true , result if false): =IF(sum(L2)<>0,K2/L2," ")
- Excel often objects if you compare text to a number, but the sum of text is zero, which can be compared to a number as shown above. <> means "not equal to"
- When you copy a cell down a column, cell references generally change: K2/L2, K3/L3, K4/L4, etc. If some should not change (suppose L2 is a national average, and you want all the Ks as a ratio to that national average), then put in the first cell K2/L$2, and it will fill down as K3/L$2, K4/L$2, etc. The $ does not affect the value, and does not turn it into cash (which is done with Format Cell). The $ just says not to change 2. Similarly $L2 means to keep L, and $L$2 means to keep both L and 2.
- Besides clicking the bottom right of a cell, you can copy it by using Edit, or highlighting an area and using Ctrl-R to copy to the right, or Ctrl-D to copy down
This site uses Excel, since Google Sheets are limited to 2 million cells and Open Office is limited to 65,536 rows. The files here have hundreds of thousands of doctors with 20-60 cells for each, so they need the size of Excel (up to 1,048,576 rows and 16,384 columns) or QuattroPro (1,000,000 rows and 18,276 columns). These instructions cover Excel, since more people have it. You can do the same work in QuattroPro.
Help with Statistics
- when randomly selecting a card from a deck, the probability of selecting a spade is 13/52 = 25%.
- The odds of selecting a card with a spade are 25%/75% = 1:3.
- Clinicians usually are interested in knowing probabilities, whereas gamblers think in terms of odds...
- Differences between 2 different groups... can be compared using odds ratios [or]... relative risk ratio, which is the ratio of 2 probabilities...
- The odds ratio... can be interpreted as whether someone with the risk factor is more or less likely... to experience the outcome of interest... For example, an odds ratio for men of 2.0 could correspond to the situation in which the probability for some event is 1% for men and 0.5% for women. An odds ratio of 2.0 also could correspond to a probability of an event occurring 50% for men and 33% for women, or to a probability of 80% for men and 67% for women.
- Second, and less well known, the magnitude of the odds ratio... is scaled by an arbitrary factor (equal to the square root of the variance of the unexplained part of binary outcome)... [A]dding more independent explanatory variables to the model will increase the odds ratio of the variable of interest (eg, treatment) due to dividing by a smaller scaling factor.
There are excellent articles on statistical analysis of health data in the British Medical Journal, though it requires a subscription, which you may find at a university or hospital library.
CONTENTS OF THIS PAGE
1. Hospital Quality measured by:
Experience with Each Procedure
Medscape Survey of Doctors
US News and World Report
NICHE (Nurses Improving Care for Healthsystem Elders)
Old Review Article (2010)
2. Other Incentives to Leave Patients Untreated
3. Doctors' Quality
1. Hospital Quality
- Breast Cancer: Oncologists recommended: Dana Farber-Boston, Mayo-Rochester, MD Anderson-Houston, Memorial Sloan Kettering-NYC, U of Michigan-Ann Arbor. All doctors recommended: Memorial Sloan Kettering-NYC, MD Anderson-Houston, Mayo-Rochester, Dana-Farber-Boston, Cleveland Clinic-Cleveland, Hopkins-Baltimore, Stanford Health Care-Stanford (CA), City of Hope Helford-Los Angeles, Duke-Durham, U of California-San Francisco, Brigham+Women's-Boston.
- Prostate Cancer: Oncologists recommended: Dana Farber-Boston, Hopkins-Baltimore, Mayo-Rochester, MD Anderson-Houston, Memorial Sloan Kettering-NYC. All doctors recommended: Memorial Sloan Kettering-NYC, MD Anderson-Houston, Mayo-Rochester, Hopkins-Baltimore, Cleveland Clinic-Cleveland, Dana-Farber-Boston, U of California-San Francisco, Massachusetts General-Boston, Duke-Durham, Stanford Health Care-Stanford (CA).
- Lung Cancer: Oncologists recommended: Dana Farber-Boston, Hopkins-Baltimore, MD Anderson-Houston, Mayo-Rochester, Memorial Sloan Kettering-NYC. All doctors recommended: MD Anderson-Houston, Memorial Sloan Kettering-NYC, Mayo-Rochester, Dana Farber-Boston, Hopkins-Baltimore, Cleveland Clinic-Cleveland, Duke-Durham, City of Hope Helford-Los Angeles, U of California-San Francisco, Stanford Health Care-Stanford (CA).
- Hip Replacement: Surgeons recommended: Cleveland Clinic-Cleveland, Hospital for Special Surgery-NYC, Mayo-Phoenix, Mayo-Rochester, New England Baptist Hospital-Boston. All doctors recommended: Hospital for Special Surgery-NYC, Mayo-Rochester, Cleveland Clinic-Cleveland, Rush Univ-Chicago, New England Baptist Hospital-Boston, Hopkins-Baltimore, Massachusetts General-Boston, Duke-Durham, U of California-San Francisco, Cedars-Sinai-Los Angeles.
- Cardiac Conditions: Cardiologists recommended: Brigham+Women's-Boston, Cedars-Sinai-Los Angeles, Cleveland Clinic-Cleveland, Mayo-Rochester, Mount Sinai-NYC. All doctors recommended: Cleveland Clinic-Cleveland, Mayo-Rochester, Presbyterian-NYC, Massachusetts General-Boston, NY, Hopkins-Baltimore, Cedars-Sinai-Los Angeles, Brigham+Women's-Boston, Stanford Health Care-Stanford (CA), Duke-Durham, U of California-San Francisco, Mount Sinai-NYC, U of Pennsylvania-Philadelphia.
- Interventional Cardiac Surgery: Cardiologists recommended: Brigham+Women's-Boston, Cleveland Clinic-Cleveland, Hopkins-Baltimore, Mayo-Rochester, Stanford Health Care-Stanford (CA). All doctors recommended: Cleveland Clinic-Cleveland, Mayo-Rochester, Presbyterian-NYC, Massachusetts General-Boston, NY, Hopkins-Baltimore, Stanford Health Care-Stanford (CA), Brigham+Women's-Boston, Cedars-Sinai-Los Angeles, Duke-Durham, U of California-San Francisco, U of Pennsylvania-Philadelphia.
- Stroke: Cardiologists recommended: Brigham+Women's-Boston, Cedars-Sinai-Los Angeles, Cleveland Clinic-Cleveland, Mayo-Rochester, All doctors recommended: Mayo-Rochester, Presbyterian-NYC, Massachusetts General-Boston, NY, Cleveland Clinic-Cleveland, Hopkins-Baltimore, U of California-San Francisco, Duke-Durham, Stanford Health Care-Stanford (CA), Northwestern-Chicago, Brigham+Women's-Boston. Cedars-Sinai-Los Angeles.
- Infectious Disease HIV and Infectious Disease specialists recommend: Cedars-Sinai-Los Angeles, Emory-Atlanta, Hopkins-Baltimore, Massachusetts General-Boston, NY Presbyterian-NYC. All doctors recommended: Mayo-Rochester, Hopkins-Baltimore, Massachusetts General-Boston, Cleveland Clinic-Cleveland, NY Presbyterian-NYC, Emory-Atlanta, U of California-San Francisco, Duke-Durham, U of Michigan-Ann Arbor, U Pennsylvania-Philadelphia.
- Multiple Sclerosis: Neurologists recommended: Brigham+Women's-Boston, Cleveland Clinic-Cleveland, Hopkins-Baltimore, Mayo-Rochester, U of Texas Southwestern-Dallas. All doctors recommended: Mayo-Rochester, Hopkins-Baltimore, Cleveland Clinic-Cleveland, Massachusetts General-Boston, NY Presbyterian-NYC, U of California-San Francisco, Brigham+Women's-Boston, Duke-Durham, Stanford Health Care-Stanford (CA), U of Michigan-Ann Arbor.
Medicare reports the death rate within 30 days after a hospital stay. However their death rate excludes patients who go on hospice. This exclusion reduces the apparent death rate, and creates a strong incentive for hospitals and doctors to urge the sickest patients onto hospice, whether they have a real chance of cure or not, since deaths on hospice don't hurt the hospital's statistics. As with most medical incentives, medical staff who urge hospice do not reveal their incentives. (methods)
Veterans' Hospitals have report cards from 2008-2013 on each hospital's size, volume, staffing, deaths, infections, readmissions, patient satisfaction, etc. Each hospital has an annual star rating, and quarterly spreadsheet (SAIL) from 2016 to 2018, but the explanations are opaque. Bosses get bonuses for good outcomes, and their death rates, like Medicare's exclude patients who go on hospice, so they press the sickest veterans to go on hospice, sometimes against their will.
US News and World Report does not show an exact death rate, but shows hospital death rates (within 30 days) in deciles for particular diseases. They do not exclude hospice or palliative care, so they don't create an incentive for hospitals to hide deaths by referring to hospice. They generally omit transfers from other hospitals, to avoid high death rates in major hospitals which receive many transfers of the very ill. So they are trying not to penalize hospitals which serve the sickest patients. They adjust to reflect all patients, not just the elderly, and slightly adjust to reduce random variation in the smallest quarter of hospitals. (methods)
Ratings of doctors by Checkbook, ProPublica and others are discussed on another page.
Hospitalinspections.org counts and describes "deficiencies cited during complaint inspections at acute-care, critical access or psychiatric hospitals throughout the United States since Jan. 1, 2011. It does not include results of routine inspections or those of long-term care hospitals. It also does not include hospital responses to deficiencies cited during inspections." (emphasis added)
Healthgrades does not show an overall death rate, but reports hospital death rates for over 20 diagnoses. For non-surgical diagnoses, they ignore deaths of patients discharged to hospice. Starting in 2014 they no longer ignore deaths of patients who saw a palliative care doctor in the hospital. Through 2013, for half of diagnoses, they omitted patients from the death rate who saw a palliative care doctor in the hospital (methods: 2014 and 2013).
Healthgrades has a risk calculator for 6 common surgeries, which shows hospitals near you with low rates of death and complications, and it shows high-volume doctors at those hospitals. Their definition of high volume is a mix of high volume on the procedure you need along with total volume for all procedures. You can get more specific information on experience with these 6 and all other procedures on another page.
NICHE (Nurses Improving Care for Healthsystem Elders) no longer lists hospitals which have adopted strong programs in Geriatric nursing, so here is a spreadsheet of their old data. Many of these hospitals have Acute Care for the Elderly (ACE) units. They encourage walking, try not to interrupt sleep, and they minimize prescriptions. They encourage hospitals to help caregivers as well as patients.
Commonwealth Fund brings together data, mostly from Medicare, and lets you compare hospitals in different areas. (methods)
Leap Frog Group asks hospitals how well they comply with certain quality standards, and has answers for about a quarter of hospitals. (methods)
QualityCheck has limited information from the Joint Commission (which accredits hospitals and other health care organizations).
Dartmouth Atlas has multiple lists with unique information on hospitals:
- Types of health care used during last 2 years of life by Medicare patients who died in 2010. Also some earlier years. This shows use of doctors, hospitals, nursing homes, hospice, home health: average days and spending. (methods)
- Readmission rate, and use of doctors during 30 days after discharge from a hospital, for Medicare patients who were admitted in 2010. Also some earlier years (methods)
Truven, (subscription) formerly part of Thomson Reuters, now uses Medicare data on deaths and readmissions (methods) at hospitals.
Consumer Reports (subscription $7/month or $30/year) groups Medicare data on readmissions into categories, and shows many hospitals at once, so it may be easier to use though less precise than the Medicare site. (methods). They also have heart surgery data on hospitals, described in the next paragraph.
Heart surgeons show 3-star ratings on about 500 hospitals and 500 group practices (typically the group of surgeons operating at a hospital), for
- Coronary artery bypass grafts (CABG) and
- Aortic valve replacements (AVR).
- For 60 hospitals they rate surgery on congenital heart defects
Cardiologists have a spreadsheet of 4-star ratings for use of recommended drugs by 550 hospitals after
- Implanting Cardiac Defibrillators, and
- Diagnostic Catheterization and Percutaneous Coronary Intervention (PCI/Angioplasty)
California rates hospital quality on:
- Hip/knee replacments: Medicare 30-day unplanned readmissions, all ages' surgical site infections, and 8 Medicare patient complications which are: heart attack within 7 days, pneumonia-7 days, sepsis/shock-7 days, surgical site bleeding-30 days, pulmonary embolism-30 days, death-30 days, mechanical complications-90 days, joint/wound infections-90days
- COPD (Emphysema or Chronic Bronchitis): readmissions and non-hospice deaths
- Childbirth: cesareans (spelling), episiotomies, breastfeeding in hospital, vaginal birth after cesarean, cesarean infections.
- Cancer screening of adults 50-75
- Lower back pain patients who had X-ray, MRI, or CT scan within 28 days of the diagnosis (fewer is considered better)
- Diabetes/blood: kidney function screenings, HA1c blood sugar testing, HbA1c <8.0%, blood pressure <140/90, cholesterol screenings, cholesterol LDL-C <100
- Pediatric care: upper respiratory infections and immunizations
Luxury Suites are available at many hospitals for $250 to $2,500 extra per day.
Review article in 2010 covered similar information at that date. It recommended that hospital staff should learn how hospice and palliative care affect the ratings from each group, so each hospital can get ratings as high as possible.
2. Other Incentives to Leave Patients Untreated
- "Patients who are not receiving adequate preventive care will be excluded [by doctors, from getting care], and providers who take on care of these patients can be financially penalized.
- "The patients most in need of care coordination will be excluded, and providers who provide coordination to complex patients may be financially penalized.
- "Providers can be financially penalized for keeping their patients healthy...
- "[P]erverse incentive for a physician not to become involved with a patient who already incurred significant healthcare spending earlier in the year, even though these are the patients who may most need additional help...
- "Spending Measures Do Not Distinguish Appropriateness of Services ...
- "Risk Adjustment Systems Do Not Adequately Adjust for Patient Needs"
Medicare publishes death rates to help people choose safe hospitals. However they omit your death if you have been in hospice any time in the past year. It is in the hospital's interest (even if not the patient's) to promote hospice for at least a day per year to patients who they think are most likely to die. Hospice takes them out of the reported death rate. Hospitals cannot ethically suggest coming off hospice after a day, so the patient's treatment shifts to hospice.
Medical groups (ACO - Accountable Care Organizations) have a quality standard to avoid high hospital-wide readmissions (HWR) of their patients, but patients who die within 30 days of the first discharge are excluded from that standard (p.11 and p.53523). Hospitals were rated on the same measure starting October 2014. In either case when a patient is readmitted in less than 30 days, the group or hospital looks better if the patient dies within the same 30 days, so the readmission can be excluded.
Hospitals are rated on hospital-wide readmissions from all causes, and some procedures have more readmissions than others, especially among the elderly, so hospitals have an incentive to minimize these procedures.
Healthgrades death rates ignore your death if the hospital has sent a palliative care doctor to see you, or if you are discharged to hospice. Hospitals know that some consumers use Healthgrades to evaluate hospitals, so they have an incentive to promote palliative care and hospice.
Consumer Checkbook hospital data, ProPublica surgeon data, and US News and World Report do not exclude hospice or palliative, so they provide a more complete picture, and less incentive to push patients into hospice.
The US Department of Justice prosecutes hospitals and doctors for billing Medicare for care outside Medicare guidelines, even if appropriate under other expert guidelines. The investigations chill the willingness of doctors to provide care.
3. Doctors' Quality
Most nursing homes offer limited social structure for residents, with most interactions dominated by staff.
- The Eden network works to expand quality of life in nursing homes by varied and freer social interaction.
- Green Houses are licensed as skilled nursing homes, with home-like layouts for 10 to 12 elders with low staff/elder ratios.
- Board and care homes are similar, without the skilled nursing, and in older buildings.
- Assisted living is a far larger, more professional version of board and care, usually large enough to have many activities, still without skilled nursing. Some have semester-long college courses, like the arts. They can be combined with home health services to avoid or postpone going to a nursing home.
- Village to Village is a network of local groups where volunteers and paid staff help elders at home get transportation, health and wellness programs, home repairs, social and educational activities and trips.
- PACE is a Medicare/Medicaid version of Village to Village, helping people stay at home even if they are eligible for a nursing home, in some states. Also at pace4you.org
- Senior cohousing involves homes clustered around shared facilities, run by the residents.
- Life care communities include a range of care levels, usually independent living, assisted, and skilled nursing, not run by the residents. If prepaid, they act like a long term care insurance policy, with limited reserves for long expensive nursing.
- Living in some kind of group or institution prevents the isolation of many old people at home, when their friends have died or become immobile.
- Private associations include: PioneerNetwork, LeadingAge, formerly Association of Homes and services for the Aging, and Action Pact (consultant).
- Few nursing homes take patients on ventilators or with dementia below age 60, since Medicaid does not pay enough to cover the cost
Medicare has had plans to pay Accountable Care Organizations to reduce the number of patients who go from hospital to nursing home and back to hospital within 30 days. This penalty discourages doctors both from sending patients back to hospitals and from sending risky patients to nursing homes ('You'll be better at home...").
Medicare's justification repeatedly cites a 2010 article (with 2006 data) by Mor et al. for the statement that 78 percent of re-hospitalizations from nursing homes within 30 days were potentially avoidable. The article made that statement without evidence. It said,
- "Specifically, MedPAC  has found that five conditions—congestive heart failure (CHF), respiratory infection, urinary tract infection (UTI), sepsis, and electrolyte imbalance—for which rehospitalization is potentially avoidable account for 78% of all 30-day SNF rehospitalizations."
- "Kramer and colleagues at UCDHSC identified five conditions for which rehospitalization is potentially avoidable in nursing homes... These five conditions are congestive heart failure (CHF), respiratory infection, urinary tract infection (UTI), sepsis, and electrolyte imbalance. Not all hospitalizations for these conditions are preventable; however, rates of hospitalization for these conditions were significantly lower in facilities with higher nurse’s aide and licensed staff levels as well as in facilities with higher staff retention, after adjusting for facility case mix" (Kramer et al., 2001, emphasis added).
- "Quality measures related to hospital transfer for potentially avoidable causes (e.g. urinary tract infections, sepsis, electrolyte imbalance) for a short-stay sample of Medicare SNF admissions."
Furthermore Medicare gives no hint of how many of the 78% potentially preventable readmissions can actually be prevented, nor why they penalize 100%, when many cannot be prevented.
The article Medicare cites, by Mor et al., focuses on how much states differed in 2006 in the rates of readmission to hospitals, from nursing homes (and other Medicare costs). The article says (again without evidence) the differences depend on "provider norms, practice patterns, bed availability, and presence and willingness to use hospice." They ignore the most direct explanation for variation in readmission rates, which is variation in health. The traditional broadest measure of health is life expectancy, which does explain 34% of the 2006 variation in readmissions from nursing homes. The reasons why some states have short life expectancies include a mix of environmental hazards, poverty, diets and other causes, all of which drive health problems too, and the average readmission rate in those states is higher. Including household income, along with life expectancy, would raise the explanatory power to 40%.
On financial incentives Mor et al. say "skeptics have raised a range of potential issues including the increased incentives for selection of the most profitable patients, withholding of patient care, upcoding and fraud, along with the technical difficulties of case-mix adjustment and quality measurement and monitoring" and they do not address these issues.
Nursing Homes Respond to Harmful Incentives
- "Selectively discharging patients prior to their 14th day of their SNF stay will bias report card scores; in the extreme, extremely good SNFs that avoid unnecessary readmissions to the hospital may appear to be of low quality, while low-quality SNFs that discharge sicker patients appear to be of high quality. While policymakers have expressed concern that almost half of SNF patients do not stay long enough to have a 14-day assessment and therefore will not be counted (Medicare Payment Advisory Commission, 2006), the manipulation of this margin adds a layer of bias to the problem of an already selected sample (p.350)
- it is uncertain whether the current SNF NHC [Nursing Home Compare] measures can induce broad quality improvement or whether they should be used by consumers to compare quality (p.350)
- Each system has to define a denominator for quality measurement, but there is generally room for gaming the denominator in one way or another (p.350)
- If gaming the denominator is a lower-cost response to the presence of public reporting than true improvements in quality, we should expect gaming of the denominator. (pp.350-1)
- Policy makers worry that providers will “game” the system by selecting patients of lower risk to make quality scores look better. If providers game the system, true quality improvement may not occur, and in the worst case net welfare may decrease as sicker individuals face reduced access to care (p.341)
- selecting healthier patients may be used as a lower-cost approach than true improvements in quality in many cases." (p.343)
Will Medicare Place Direct Penalties on Nursing Homes?
Even without the penalty, "Medically complex patients ... can be hard to place" (MedPAC 6/07 p. 208 ). Some SNFs are "selective about the SNF patients they admit" (3/12 p.195) choosing those with "lower severity of illness" (6/07 p.204).
MedPAC (an arm of Congress) explicitly recommends "hospice use and the presence of advance directives" as methods to decrease rehospitalizations (3/12 p.195). They give an example, "25 facilities undertook early detection ... in-facility treatment ... and improved end-of-life care strategies (such as advance care planning and palliative care) ... savings (from fewer self-reported hospitalizations) range from 17 percent to 24 percent" (3/12 p.196)
MedPAC had recommended the nursing home penalties in their March 2012 Report
- "Congress should direct the Secretary to reduce payments to skilled nursing facilities with relatively high risk-adjusted rates of rehospitalization" (p.199).
- This will lessen their current "incentive to rehospitalize high-cost patients as a way to shift costs they would otherwise incur onto hospitals" (p.194).
MedPAC reitereated the recommendation in March 2013
- "We have recommended readmission policies for hospitals (now in place) and SNFs [skilled nursing facilities], and we are working on similar policies for home health care and IRFs [inpatient rehabilitation facilities)" (p.153)
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