We live in a very exciting time! Alzheimer’s medications that are more promising than past drugs are starting to hit the shelves, with others on the way. Eli Lilly’s new daratumumab medication has been suggested to slow the progression of early Alzheimer’s by up to 35%. So if it took someone five years to progress to more serious Alzheimer’s without medication, this could slow it, so it could instead take seven years, meaning more years being more present with one’s family. Lecanemab (Leqembi), from Eisei and Biogen, was also found to reduce cognitive decline, keeping our parents or ourselves fully present as we traverse life’s journey together!

In this article, I will talk about why these drugs offer society hope yet will also cause a big problem, at least in the short term (i.e., until generics become available when the drugs’ patents expire). As for my background, I earned my M.D. in the United States to soon earn my Ph.D. in Canada, focusing on Genetics. Today, I work as a postdoctoral scientist at Massachusetts General Hospital, studying the genetics of Alzheimer’s disease. In my medical training, I have seen the tragedy that can happen to people’s parents or themselves as they face newly diagnosed dementia and late-stage disease.

To be clear, these medications are a good thing. They could help many of those around us, whether a parent, sibling, or ourselves. Dementia is a horrible disease; until now, not much could be done about it. A family member is diagnosed with the disease in the office and told that they are showing signs of this illness and that very little can be done to help them. Over time, their personality changes, and they slowly become less like themselves daily, aware of what is happening.

This can cause significant distress for those with this illness and their family and friends. We spend years with these people. We are forced to watch, unable to make a difference, as they lose their ability to function and lose who they are. These medications could slow these changes, finally offering some semblance of hope for those with these diseases.

As with any medication, these drugs do not come without risks. One in four people who received Leqembi had a “transfusion reaction,” which in most people means that they may have had redness and swelling in the arm they received the medication. While such reactions can be severe, causing one’s airway to close up in an anaphylactic reaction, these responses are generally uncommon. Some individuals who received Leqembi or Donanemab experienced swelling in their brain, known as cerebral edema. While not necessarily a problem, in that it does not necessarily produce symptoms, one in four people who took Donanemab developed this swelling, one of four of which had symptoms. So if we considered a group of 1000 people who took this drug, using the study’s results, about 60 in 1000 could experience headaches or confusion. Some of these 60 individuals may develop bleeding in their brains. Around two could die from the swelling or bleeding. While concerning, 940 of these hypothetical 1000 people had no side effects. Even if you took this med and experienced side effects, you could be sure that your doctor would do everything they could to keep you safe, including discontinuing the medication that often resolves adverse effects.

So it sounds like my opinion is that these drugs sound promising. Why the doom and gloom article title? This is because these are or will be very expensive drugs. The price for a single person to receive enough Leqembi for a single year is forecasted to be $26,500. While Donanemab does not yet have an official cost, it is predicted to be over $26,000 annually. Think about that amount of money for a moment. The federal poverty line for a family of four, which could include a couple, a child, and a grandparent, is $30,000. More than one in 10 people in the United States are impoverished and struggling to make ends meet. This number is likely even higher, considering you do not have to be impoverished to have financial difficulty. What would happen if a couple’s loving grandmother or grandfather started showing signs of dementia?

While the elderly are entitled to Medicare, would Medicare cover such an expensive drug when it has to care for the entire country’s elderly population? Even if it pays for it, how much of it? After consulting physician colleagues of mine, we think it is unlikely that Medicare as is would pay this much. It would be great if they did, but there are likely not enough Medicare dollars to permit this.

Families could face impossible decisions or immense stress once these medications are more broadly available, and they have hope in front of them, yet this hope is financially inaccessible. While some private insurance may help pay for these cutting-edge treatments, perhaps with Medicare offering a small contribution, insurance is expensive, and we sadly do not all have health plans that enable us to not think about how we are going to make managing our health work, alongside taking care of supporting children, family, and parents.

There is also the concern that these medications may offer more benefit to those of certain ancestral groups, as reported by Reuters. This was not because the study’s designers or the company sought to exclude non-whites. For medical research to be approved, generally, one must communicate how the research will benefit a more diverse group. Describing how people are recruited into appropriately designed clinical trials and why medications may help people of European descent more than those of African descent is its own article, so I will not touch on this here. This is important because non-whites have higher rates of Alzheimer’s and have historically had less access to healthcare resources.

Such a financial predicament is not unique to these upcoming new medications (or healthcare in general in the United States). Research and development of new medications often cost over $2 billion when a new treatment is available for the general public. Companies need to give treatments a price that enables them to make up for what they spent and enable their other projects, which can also provide hope for better health management. While this approach is understandable (companies need to avoid going bankrupt. Even non-profits need to do that), it can still limit our access to treatments that could save or improve our lives.

The only fix that could address these issues is legislation, which the American Medical Association is consistently striving to improve people’s health in the United States, including driving healthcare reform and expanding (versus cutting) Medicare coverage. Your doctors are not just treating you in the office. They are going to Washington, D.C., and suffering the stresses of politics to improve your lives!

In conclusion, we have reasons to be optimistic about these new drugs. We are also facing the same problems that we have in the past, with promising treatments often being beyond the reach of those with less financial resources and those who have historically had limited access to treatments that could mitigate suffering.

The post New Alzheimer’s Drugs Will Worsen Inequality appeared first on Medika Life.

The complex relationship between medical diagnosis, treatments, and insurance reimbursement has sparked discussions on the accuracy and moral implications of medical procedures. This article examines how insurance reimbursement may affect medical diagnosis and treatments, as well as the stress it might place on both patients and healthcare professionals.

Start with one example I witnessed recently when a patient was going over their physician’s report after a visit and a medical test. The patient was shocked to see a diagnosis of neurodegeneration when the patient had never been told of that diagnosis. A brief discussion with the provider disclosed that it is often the case to indicate a diagnosis for which both the patient and the provider will receive payments. But even honest mistakes in billing can have dire results for practitioners. But what is known as “upcoding” is definitely not a mistake.

And in some hospitals, this has become the MO. But action is being taken to address this practice which may result in medical fraud by utilizing non-existent medical conditions for billing. The current action is by way of a bill, temporarily named “No Upcode.”

There’s also a problem here because not every disorder may be accurately reflected in the allowable billing codes from insurance companies or the government. Neurodegeneration may be another way of describing a medical issue that is not a major medical illness—or am I wrong here? There may be thousands of medical disorders that are NOT in the codes, so what does anyone do? Yes, you look for the closest code and use it, but it may be a frightening one or one that will affect future treatment.

How will this play out if the patient needs some type of emergency care in the future and is sent to an unknown medical facility? Reviewing the records, the medical team will not have accurate details of the patient’s prior health. Additionally, when software like EPIC contains false information, such as a medication issue that never existed and appears to be unfixable, it may be of no use. I know people who have tried for years to get their EHR errors fixed, and everyone claims helplessness on the issue, including hospital IT personnel.

On behalf of a patient, I contacted the health commissioner of my state, who assured me she would look into the issue and get back to me. That was about four months ago, at the time of this writing. I haven’t heard from her, and the patient is concerned about unknown issues that may arise if I contact this woman again.

So now we’re at a standstill after six years of trying to get the hospital in question to fix the error. BTW, medical records don’t have to be maintained after seven years at which time they can be destroyed. And medical malpractice is usually limited to two years for filing a complaint, but there are state differences and there may also be “discovery” issues involved.

Anyone wishing to contact their state’s health commissioner can do so at this link.

Not limited to medical care, I have heard clinicians indicate that, when family therapy is indicated, the therapist will note that the IP (identified patient) is the mother. She, then, is saddled with diagnoses that make her the bad apple in the basket, even though it’s the family unit that is in need. Is this ethical? It seemed that didn’t matter because reimbursement was the object and it was standard practice.

For clarification, let’s go over a few details. The basis for choosing a patient’s best course of treatment is their medical diagnosis. The connection between a diagnostic and insurance reimbursement, however, might occasionally have unforeseen results. Healthcare professionals are forced to balance their attention between the clinical features of a patient’s condition and making sure the diagnosis meets the requirements for insurance coverage. This may occasionally cause the emphasis to shift from strictly clinical issues to making sure the diagnosis is “billable.” If this sounds a bit troublesome to you, we’re in the same boat.

Insurance reimbursement, therefore, has an impact on healthcare professionals’ treatment decisions. Treatments that are more likely to be reimbursed in some circumstances are given preference, sometimes overshadowing those that could be better suited or more effective for the patient’s condition. As a result, it is possible for financial concerns to unintentionally take precedence over patient care, creating concerns about the morality of medical decision-making.

Patients may experience a great deal of stress as a result of insurance reimbursement and medical care. Not knowing whether an insurance company will pay OR deny a claim for a particular diagnosis or course of treatment can cause anxiety and worry. Many patients struggle with issues like “Can I afford the recommended treatment?” and “What if my insurance doesn’t cover it?” This uncertainty may discourage patients from seeking early medical attention or pursuing necessary therapies, which could eventually be harmful to their long-term health. Harmful seems to be putting it mildly because patients may forestall treatment and die because they believe reimbursement will be (or has been) refused. How much is a life worth?

Patients without comprehensive insurance may feel more stressed because they are aware of the close connection between their financial situation and their healthcare decisions. How many healthcare facilities depend on reimbursement for care, and how do they convey this to their staff? How often have you heard that a hospital is recruiting someone because they have a very large caseload and, therefore, ensure more-than-adequate funding for that person and their staff? How much charity care is provided?

When dealing with chronic or serious medical illnesses that call for regular treatments and interventions, this stress may be very acute. Patients may also feel pressured to make health decisions that are in line with what their insurance will pay for, perhaps compromising the best possible care in the process.

Patients may have significant administrative burdens while navigating insurance policies, coverage restrictions, and claim denials. Claims denials, too, are a hot topic since we know that some companies are using AI for denying claims. It reminds me of a physician who was making decisions on Social Security Disability benefits. Most clinicians take at least one-half hour per claim, but this man claimed he did 600 in an hour and was making an extraordinary amount of money doing it. Who was checking on the denials he was, most probably, making automatic denials?

Having trouble comprehending insurance terminology and being concerned about unforeseen out-of-pocket costs can cause frustration and bewilderment. As a result, patients may spend significant time and effort attempting to understand insurance-related issues, which would otherwise be focused on their own health.

Medical diagnoses, treatment choices, and insurance reimbursement are intricately linked, with significant ramifications for patient care and healthcare delivery. Recognizing insurance reimbursement’s possible effects on patient well-being and healthcare professional stress is critical because it helps keep the healthcare business alive.

Stakeholders can work toward a more harmonious strategy that emphasizes accurate diagnoses, efficient treatments, and overall patient health by acknowledging the ethical problems presented by this connection and promoting patient-centered care.

The post Is the Diagnosis Correct, or Is It a “Billable” for Charges for the Clinician’s Services? appeared first on Medika Life.

Or is it? Help is possible for both you and your employer. Companies can change how they pay for healthcare coverage so they and you get a much better deal — happier, healthier staff with employees and companies spending less. It’s as simple as paying for you to get outstanding primary care with a direct primary care or concierge physician.

You will get what you need in care quality and satisfaction, and your employer will have reduced total care costs and a healthier and more engaged employee. Good for both parties.

What does company insurance cost today?

The Kaiser Family Foundation reported a new high of nearly $23,000 per year per family for employer-provided health coverage in 2022. This is more than double the cost in 2004 and 43% higher than a decade ago. The employee portion is also rising steadily to over 30% of the total.

Bringing down the costs and improving quality

Can these intolerable levels be brought down and, at the same time, improve care outcomes? The answer is a definite “Yes,” but not using the techniques politicians and policymakers recommend. Conservatives would say it is a matter of needing more competition between insurers. Progressives recommend universal health insurance (“Medicare for All.”)

These approaches begin with the insurance itself rather than the actual care. But the problem is with care delivery; this is where the money is spent. It starts with primary care. Little recognized by politicians or policy gurus is that primary care is broken. This aspect of our dysfunctional healthcare delivery system results in the rapid escalation of costs, especially the 75–85% of the dollars spent on managing complex chronic illnesses.

Whatever is done regarding insurance coverage, it is clear that individuals today are getting less than adequate care, and America’s per capita costs far exceed other developed countries. The real and relatively simple fix lies in a dynamic primary care system. But primary care physicians (PCPs) are trapped in a non-sustainable business model, forcing them to see too many patients daily, usually 24 or more, meaning only 10–12 minutes of “face time” per patient visit. That is not enough time for a complicated problem, for patients on multiple prescription medications, or with impairments of hearing, mobility, and maybe cognition, nor for aiding a patient with substantial anxiety. PCPs are also reeling under the constraints of government and insurer rules, regulations, and responsibilities that further take time away from the patient.

Not having enough time with each patient results in PCPs referring far too many patients to specialists when they could have dealt with the problem, including managing most chronic illnesses with more time. They prescribe drugs when lifestyle changes would suffice because working with a patient on lifestyle issues takes time. PCPs often order many tests when more time with the history and examination could give the answer. There is no time for developing a close, trusting relationship so critical to effective care. And there is no time to address anxiety which accompanies at least 40% of doctor visits. Visits to the ER are frequent, and many hospitalizations could be avoided.

The result is higher and higher expenditures yet diminished quality of care. More than 50% of PCPs show signs of burnout, and patients are less than satisfied. PCPs are retiring early or seeking other career options, and medical students no longer choose primary care as a career. Yet somehow, America tolerates this highly dysfunctional system of medical, not health, care.

Direct primary care to the rescue

There is another way. It is being done very successfully by individual primary care practitioners. It is not being mandated from above down but rather developing from the grassroots up. It is called direct primary care or DPC. Other terms used are membership, retainer-based practices, or concierge practices.

Although each of these has some differences, the essence is as follows: the primary care physician reduces the number of patients under care from the current 2,500 to 3,000 to a more manageable 400 to 800 and usually accepts no insurance. The patient pays a fixed amount directly by month, quarter, or year. The PCP commits to same-day or next-day visits, appointments for as long as necessary, 24/7 cell phone, text, and email access, and an extensive annual evaluation focusing on wellness maintenance and disease prevention.

Direct primary care costs are not reimbursed by insurance. You must pay out of pocket, but your health improves, satisfaction rises, and doctor frustration falls.

Many DPC physicians purchase generic drugs wholesale and pass them on at little or no markup. They may also arrange for markedly reduced-cost laboratory testing and radiology procedures. These can help substantially if you have a high deductible policy.

With the added time available for each patient, most issues, including the management of chronic illnesses, can be resolved by the PCP without the need for a referral to a specialist. But when one is needed, the PCP has the time to call the specialist directly, explain the issue and request a prompt appointment. More time with your primary care doctor results in fewer tests and prescriptions and more attention to lifestyle modifications. The costs of primary care do become your responsibility but the total costs of care decline markedly. With DPC or concierge primary care, the result is better health, the development of a trusting relationship, fewer specialist and ER visits, and fewer hospitalizations. A win-win for everybody.

Here is what your employer can do for you

It is essential to understand that employers are generally self-insured. They use an “insurance company” to manage the costs. The “insurer” calculates the approximate costs for your company for the year ahead based on the previous year’s activity plus an inflation allotment. This almost always results in an increase in the premiums for the upcoming year. The employer decides how much to pass along to the employee to pay, and the employer also sets the yearly deductible with the assistance of the “insurer.” In the following year, the company’s costs will decline. Should the company’s staff have better health and hence use fewer medical resources, the company will see a reduction in premiums in the following year; this rarely, if ever, happens today. But it could.

Employers can embrace this approach by reimbursing the cost of DPC. Paying for DPC may seem like an added expense to your employer. Still, the result is improved employee health, reduced absenteeism, and sick leave while bolstering employee satisfaction and decreasing the total care costs for both employer and employee.

Here is how to make it happen

DPC’s time has come. It is time for employers to embrace it, but it won’t happen unless they are “nudged” into action. Here is my advice to you. Go to your employer and advocate for direct primary care/concierge care paid for by the company. Let them know why it is to their definite benefit. And get your co-workers to do the same. It is definitely to your advantage to advocate.

The post Your Company Health Plan Sucks and Costs Too Much appeared first on Medika Life.

In the last decade we have disbursed over 500 billion dollars to health related care, much of it on the African continent. In the next decade we will spend even more, if our global economy is able to support it. Why? Why, after decades of pouring eye-watering sums of money into what appears to be a bottomless pit, are we no closer to the espoused goal of Universal Health Care or at the least, more robust and independent health systems in the communities we assist?

The answer is a simple, yet unpleasant one. Out of choice. We choose to perpetuate these dependencies and where possible, create new ones. A profit driven Western health system dictates it and charities comply, whether out of complicity or a desire to serve these vulnerable populations in any way possible, even if the mechanisms are flawed. Charity is big business. Consider this 500 billion was spent on healthcare alone.

To understand how we’ve arrived here and why the historical actions of charitable health outreach have created global dependencies requires background knowledge of the healthcare sectors, the non-profit industry, and the mechanisms that enable and support global health outreach. Central to this is acknowledging the ever expanding elephant in the room.

Our inability to step away from the flawed systems that power healthcare and how these systems and policies impact our ability to deliver meaningful aid lies at the heart of the problem.

While this article uses the terms charity and non-profit organization they should not be considered as inclusive of the entire charitable industry. The terms are used here in the context of those organizations that provide health related care, services and support globally.

How Lucrative Is The Charitable Industry?

Separating health based donations from general charitable donations isn’t a simple ask, as many charities engage in activities that cover more than one aspect of aid delivery, catering to both health and humanitarian services. There are a few figures below to allow you to form a clearer picture of the numbers involved, keep in mind however, these are not all health related.

A landmark study in 2018 identified 250,000 foundations across 38 different countries. 72 percent of these were established within the past 25 years. The highest concentration of foundations is in Europe (154,271) while North America also has a considerable number (91,850). Unsurprisingly, they tend to be more common in high-income countries where they control serious levels of cash.

The following infographic shows the assets held by philanthropy foundations at country level. The United States leads the way with $890 billion while the Netherlands comes second with $108 billion and Germany is third with $93 billion. China is also present on the list, rounding off the top-10 with just over $14 billion.

Infographic courtesy of Statista

How is this money allocated? Another survey by BNP Parabas released in 2015 and published in Forbes in the same year, offers some insight. Refer to the infographic below. American individuals and companies donate hundreds of billions of dollars to charity every year. In 2016, donations reached an estimated $390 billion, according to a report by Giving USA.

Infographic courtesy of Statista

As is the case in most years in the US, religion was the sector that received the most money in 2016. It accounted for $122.94 billion or 32 percent of total philanthropic giving in the U.S. in 2016 Education came second with $59.77 billion while human services rounded off the top three with $46.8 billion. Where did this money originate? The public were in first spot, accounting for 72 percent of the $390 billion total – $281.86 billion. Foundations gave $59.28 billion and corporations donated $18.55 billion in 2016.

The chart below, courtesy of Giving USA, represents a breakdown of these figures for 2022. Note the growth from $390 billion in 2015. Beside the chart is a graph, reflecting the corollary effect of a strong stock market on giving, a link that currently threatens charitable giving for the first time in over a decade.

Government Derived Funding for Global Health

Donor government funding, including both the bilateral funding given directly to other countries (which may be given to a country government or provided to NGOs and other organizations to carry out work in recipient countries) and the multilateral funding given indirectly through contributions to multilateral organizations, accounts for most external health aid channeled to the developing world. As such, this donor support constitutes a major component of the global health response.

Donor government funding for global health has risen significantly since 2002, growing from $4.4 billion to a peak of $22.8 billion in 2013 (see Figure 2). However, funding declined for the first time in 2014 to $21.5 billion and has since remained relatively flat.

Donor government funding for health has generally increased as a share of official development assistance (ODA), particularly over the last decade. These increases were largely spurred on by the creation of several new funding initiatives and mechanisms such as the Global Fund and PEPFAR. However, this share has remained essentially flat in more recent years and declined in 2014 and 2015. This flattening and recent decline has raised concerns about the ability of countries to meet global health goals and targets, such as those of the Sustainable Development Goals (SDGs).

The U.S. has been the largest donor to health in each year over the entire period between 2002 and 2016, and has dedicated the greatest share of its ODA to health. The donor mix has shifted over this time, in part due to the entrance of new donors, particularly the Global Fund, which became the second largest donor to health after the U.S. in 2006 (and remains so today). The U.S. and the Global Fund combined accounted for more than half of total donor funding for health in 2016 (see Figure 3).

Totaling a Decade’s Charitable Giving

While figures are easy to find for individual countries, finding global ODA spends are more complex. To really quantify the efficacy of health based charitable activity, we need to understand how much money has been thrown at global health over the last decade and why we are still faced with increasing demands for ever more aid, despite the donations spent. The graph below shows a breakdown of ODA Health allocation by country for 2021.

Adding together figures for the last decade¹ (2012-2022), we arrive at the eye watering amount of $245 billion dollars, ODA funding, designated directly for charitable healthcare. This does not include billions more, raised directly from the public and foundations, earmarked for the purposes of improving health outcomes for disadvantaged communities across the globe. A more realistic figure that would include these donor populations would be in the region of $500 billion dollars.

Lets put that figure into context. It is the equivalent net worth of Bernard Arnault, Elon Musk and Jeff Bezos, the three wealthiest individuals on the planet, combined. If it were a country, it would rank 25th based on GDP, somewhere between Poland and Belgium. Yet, for some inexplicable reason, in 2023 we will require more funding than ever to address global health disparities, and in 2024, we will require even more money.

Why? What are we doing wrong?

Creating Global Dependencies

Almost all large charitable organizations tasked with the delivery of health to developing countries intentionally create delivery mechanisms that encourage dependency on continued donor aid.

This is fact, If the focus of their work had been enabling downtrodden countries to develop self-sustaining methods for delivery of care that included strengthening health systems in-country, $500 billion dollars would have been sufficient to put most of these charities out of business by now, which, in an ideal world, would be seen as a stunning success. The reality however, stands in stark contrast.

To FIAT driven enterprises, captive audiences matter. Few industries, if any, are able to eclipse the potential for profit shown by healthcare. Their global market of patients continues to expand, this expansion matched only by a sharp upturn in the maladies afflicting the burgeoning numbers. We are getting sicker, earlier, and in larger numbers, from an increasing number of conditions, many previously considered rare, now chronic.

Emphasis for care has pivoted over the last few decades from curative to treatment based. We no longer seek to drive back disease, merely manage it. From a business based perspective, managing a sick patient, sometimes for decades, represents the gold standard of “captured market” profitability. Charities play their own, if unintended role in this play for profit, providing a vital funnel to large, otherwise inaccessible markets in developing countries.

In 2019, in the US alone, charitable institutions and non-profits employed over 12 million people². Their payrolls eclipse other large industries, including finance and construction. Providing for those less fortunate has become big business and as is inevitable with any booming enterprise experiencing growth, problems abound, some of which are inherited or enforced from supporting industries (read healthcare) while others are self inflicted. It is the beneficiaries of these charitable health enterprises that pay the associated costs.

While protracted treatment has become the mainstay of modern healthcare in developed nations, in developing countries the emphasis is placed on creating dependency. Charities that encourage and promote funding dependent projects and outreach. Missions that are cyclic by nature, repetitive and that require a continuous influx of donor capital to deliver care. This creates the necessary cycle essential to cornering a captive market.

Dependency is the goal, rather than an unintended consequence.

While the argument exists that the delivery of care and saving lives trumps the flawed methods of delivery, the current system suffers from various weaknesses, weaknesses that expose communities that are forced into aid-reliant dependency to risk, often life threatening in nature. Weaknesses that, under the right conditions, could collapse global health efforts and the elusive goal of universal health care.

Why not then develop care delivery systems that encourage self-reliance and that are self-sustaining, that integrate with and strengthen local healthcare systems, and remove these dependencies? If you’ve been paying attention, much of what you’ve just read goes to the heart of the matter. Captive markets matter and no where was this more clearly illustrated than during the Covid pandemic of 2020 that shut down the entire globe.

These dependencies are furthered by funding directives for foreign aid. As an example, EU countries under duress to meet targets issued by organizations like the WHO, pay over billions of dollars each year. To avoid missing quotas and to minimize workloads, large scale donations are the norm. Amounts often in excess of a $100 million dollar are granted annually, to single charities. This encourages poor business practice and suspect oversight, where auditing and controlling donated funds at scale becomes an impossibility.

AT the other end of the table, the benefiting charities are faced with the need to dispose of these huge sums within a calendar year or run the risk of missing the following year’s handouts. The system is antiquated, littered with loopholes for financial exploitation (which occurs all to frequently) and clearly not fit for purpose. It is revolving door, disposing of capital to keep up with quotas at a dizzying rate, one that does not allow for circumspection, investigation and oversight.

It is fertile ground for exploitation for the sake of profits, by an industry (healthcare) that has shown itself all to capable.

Whole industries have grown up in and around the delivery of charitable health care, providing product to the captive markets who have come to depend on Western charity, often with their lives. Most who operate within this system recognize it for what it is, but will not rock the boat. The stakes are too high, the profits too enticing.

So how are the billions spent and where do they originate?

The OECD and WHO 0.7% ODA/GNI Target

The best known target in international aid proposes to raise official development assistance (ODA) to 0.7% of donors countries national income. In 1970, The 0.7% ODA/GNI target was first agreed and has been repeatedly re-endorsed at the highest level at international aid and development conferences:

• in 2005, the 15 countries that were members of the European Union by 2004 agreed to reach the target by 2015
• the 0.7% target served as a reference for 2005 political commitments to increase ODA from the EU, the G8 Gleneagles Summit and the UN World Summit

The OECD Development Assistance Committee (DAC) is a unique international forum of many of the largest providers of aid, including 31 member countries. In 1969, the Pearson Commission proposed a target of 0.7% of donor GNP to be reached “by 1975 and in no case later than 1980.” This suggestion was taken up in a UN resolution on 24 October 1970. The target was built on the DAC’s 1969 definition of ODA.

DAC members generally accepted the 0.7% target for ODA, at least as a long-term objective, with some notable exceptions: Switzerland – not a member of the United Nations until 2002 – did not adopt the target, and the United States stated that it did not subscribe to specific targets or timetables, although it supported the more general aims of the Resolution.

In 1993, gross national product was replaced by gross national income (GNI), an equivalent concept. DAC members’ performance against the 0.7% target is therefore now shown in terms of ODA/GNI ratios.

In 2022, official development assistance (ODA) by member countries of the Development Assistance
Committee (DAC) amounted to USD 204.0 billion. The United States continued to be the largest DAC member provider of ODA (USD 55.3 billion), comprising more than a quarter of total DAC ODA, followed by Germany (USD 35.0 billion), Japan (USD 17.5 billion), France (USD 15.9 billion) and the United Kingdom (USD 15.7 billion).

Problems Abound

The DAC has recently changed ODA reporting rules to include transactions that require no financial sacrifice. This deprives ODA of its meaning as a gauge of aid effort, and vitiates the point of setting the U.N. ODA target. The changes have also rendered ODA incoherent as a statistical measure, making it a faulty tool for monitoring and analysis. ODA now fails to meet basic statistical quality standards. 

According to a report issued in 2019 by the Brookings Institute³;

ODA was never perfect, and for years critics complained about the inclusion of items—such as the costs of students and refugees in

donor countries—which transferred no resources to developing countries. But since 2014, DAC decisions mean that ODA is not just counting debatable items, but inventing numbers that do not exist in the real world.Brookings Institute

The report continues to catalogue a list of flawed reporting mechanisms that reduce any meaningful data to spreadsheets of incomprehensible nonsense, with double reporting and other statistical anomalies. The bottom line? Reported donor amounts now need to be taken with a large grain of salt. While it appears on the surface that aid continues to flow in ever increasing amounts from ODA, the real world impacts have been seriously curtailed by an actual reduction in physical money flowing to charities.

As economies begin to contract globally, expect this trend to worsen, with governments taking full advantage of the loopholes created by DAC to claw back funds required at home.

Foundations

The favored vehicle of a new breed of billionaire philanthropists, charitable foundations are a force to be reckoned with in the charity sector, disbursing billions annually to various causes. The goals and beneficiaries of these foundations align with political leanings and a strong case can often be made about the wisdom of self-created health outreach projects embarked on by these foundations.

The Bill and Melinda Gate Foundation is perhaps most controversial, with ill-conceived vaccination drives in countries like Swaziland, where a focus on reducing maternal mortality by treating HIV led to near collapse of the Swazi healthcare eco-system, and shifted mortality risk from the mother to the infants. Tinkering with fragile healthcare systems comes with consequences.

These foundations are also able to expand and interject personal agendas, financial or otherwise, into global healthcare policy by way of massive donations to institutions like the WHO, and again, the Gates Foundation features prominently. In 2018-2019, the United States was the largest donor to the WHO at $893 million, accounting for around 15 per cent of WHO’s budget. The Gates Foundation came only second, with $531 million, a position the Foundation has maintained for a while.

Critics argue, and rightly so, that foundations like the Gates Foundation hold undue sway over global health policy because of their donations, not only to the WHO, but in the fields of development, policy and advocacy and U.S. education. In 2022 Gates added $20 billion ($5 billion for 2022 and $15 billion for past pledges) to the Gates Foundation coffers, making him the single largest global charitable donor for the year.

Some $8 billion in donations went to foundations in 2022, with $5 billion injected into the Bill & Melinda Gates Foundation alone. The benefit of these donations to the various industries they cater to will not be experienced immediately but rather over many years. U.S. foundations are required to spend only 5% of their assets annually, and most foundations try to preserve their holdings so that they may continue operating well into the future.

Charitable giving in 2022 declined from the highs of 2020/21 to pre-pandemic levels. This decline in giving likely had something to do with 2022’s stock market volatility – major indices lost as much as 33% of their value – and the onset of high inflation. Both financial markets and inflation can influence charitable giving.

How much of this giving translates into actual patient care and how much of it utilized to pursue influence is unclear. What is however abundantly clear, is that both health policy and agenda are for sale for the right price, exposing the global population to healthcare that is decided by a handful of unelected individuals. The dangers of this are self-evident.

Public Giving

In the United States in 2021, the largest source of charitable giving came from individuals, who gave $326.87 billion, representing 67% of total giving. There are numerous factors that threaten this figure’s growth. As global economies contract post Covid and trillions in aid is directed to fund the war effort in the Ukraine funding available for health related outreach will no doubt suffer. We are becoming poorer and one of the first things to feel the impact of this will be charitable giving.

The influence of social media and main stream media also influence giving, earthquake relief in Turkey and other breaking human tragedies are brought (rightly so) to the forefront, jumping the queue and effectively drawing away funding from traditional donations. Increasingly volatile weather patterns, political instability in Europe and other factors will also play a role.

While we may see increases in public giving in the coming decade, traditional charities are less and less likely to benefit as the limited pool of funding is placed under ever increasing pressure to address a multitude of new demands.

Donor apathy also affects giving patterns. We are exposed to visual extremes on a daily basis, numbing us to images of poverty, suffering and need and the constant deluge makes it increasingly difficult for charities to find a foothold for their cause. Without resorting to “poverty porn” to stress the need for funding, most emergent charities find it more and more challenging to raise funds from the public sector.

Building a New Ship (Innovation Versus Iteration)

To effectively address solutions to a problem, either mechanical or system driven, you require two essential components. The first is innovation and the second, is understanding. Why understanding? Simply answered, you cannot create lasting solutions if you do not possess an intimate understanding of current solutions, their histories and iterative evolution.

How we have arrived here dictates how we plan for the future.

The term “improvement” is frequently interjected into discussions. It is a subjective and misleading term. Do we seek to simply modify an existing solution to “improve” outcomes, ensure a tool or system is optimal, or build an entirely new tool? Improvement suggests utilizing an existing solution, system or tool to solve an historical problem by iterative adjustment. To innovators, the term is anathema.

Healthcare, and its delivery is analogous to the above. For the last two decades, iterative jumps in technology have seen existing delivery and supply mechanisms within healthcare “upgraded”, affecting the systemic delivery of care to patients and the ways in which this care is dispensed. Very little of what we have witnessed can be categorized as innovative. “Improvements” abound, and while this process is essential to modifying solutions, at what point do we acknowledge the obvious?

The need to repeatedly “improve” can only suggest one thing. Our healthcare tools, systems and solutions are not fit for purpose. Spillover from the healthcare sector directly impacts the charitable delivery of care. The emphasis of focus, in both industries, falls on improvement when it should, far rather be placed on innovation. We assume, erroneously, that current tools and systems are fit for purpose when history suggests otherwise. When $500 billion doesn’t change the charitable health landscape, we need innovation.

YOU DON’T CHANGE THE SYSTEM, YOU BUILD A NEW ONE THAT MAKES THE OLD ONE OBSOLETE. BUCKMINSTER FULLER

True innovation does not seek to improve but rather it reinvents, and to do this, its starting point is always a desired outcome to a problem and one driving question. How to best achieve that. Only then, can existing solutions be properly evaluated and their functional worth determined. This process is disruptive in the true sense of the word. It can threaten established financial models, undermine the status quo and realign entire sectors of an industry. For these reasons, in healthcare, a protectionist policy of iteration is favored over innovation.

Better not to rock the boat, even if it is sinking.

Healthcare and the charities providing access to care do not, historically, encourage true innovation, and this, primarily, is why we see diminishing levels of care, prohibitive pricing, dependencies, profiteering and other ills that befall both sectors. Patching a leaky ship has only one eventual outcome.

The desire to repeatedly apply the same patches to the same holes indicates there is more at play in the charity sector than just ill conceived or poorly executed projects.

References

1. Donor Tracker; US/Global Healthcare 2023, URL https://donortracker.org/donor_profiles/united-states/globalhealth
2. Pestle Analysis for Charities, 2019. URL https://pestleanalysis.com/pestle-analysis-for-charities/
3. A note on current problems with ODA as a statistical measure, 2019, Brookings Institute URL https://www.brookings.edu/blog/future-development/2019/09/26/a-note-on-current-problems-with-oda-as-a-statistical-measure/

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But what happens when goods and services are priced beyond the reach of the average person? Pandemic-fueled unemployment and inflation, and looming electricity, food and water shortages caused by climate emergencies, have provided an unsettling reminder that the basic things many people depend on to live can become unaffordable.

For most Americans and their employers, however, one of the single greatest threats to prosperity – even survival – is the uncontrolled cost of healthcare. In the past 20 years, the cost of the average family insurance premium has increased twice as fast each year as the annual rate of wage growth. In real terms, the average American family in 2002 paid $7,954 for health insurance but saw that figure skyrocket to $22,463 last year. Within a couple of decades, the cost to insure a family could be three to four times higher if nothing changes.

To put perspective to that calculation, assuming wage growth remains the same, it will require one parent to work full time just to cover the cost of protecting their family’s health. For many American households, this already is the case. Left unchecked, healthcare costs will significantly constrain economic growth as employers pass on costs to consumers and curtail investments, while governments at every level see a decrease in tax revenues that would fund a range of essential programs.

This bleak outlook should force a reckoning for the global pharmaceutical industry. While health companies must remain profitable to continue to fuel innovation, maintaining business as usual cannot come at the expense of the very customers who depend on functional healthcare to prosper. Such a conundrum poses a unique opportunity for pharma companies to live up to the credo of truly putting patients first by redefining how they lead on areas that are fundamental to strengthening health access and affordability for the long term. Among the many ways to achieve this outcome, some areas stand out:

Fostering greater cross-industry collaboration

Contrary to the views of some policymakers, the solution to averting the worst-case scenario of pricing most Americans out of affordable healthcare is not to increase competition. A better path may be to create greater incentives for collaboration between industry peers and government agencies through all stages of the value chain, from early discovery through manufacturing to patient administration.

The Covid-19 pandemic illustrated how collaboration can deliver speed and scale during an emergency. But despite the active involvement of the National Institutes of Health (NIH) in sponsoring early research for the most successful vaccine candidates and heavy government intervention to waive or reduce the costs of vaccination in many countries, the success of intra-industry collaboration has been muted by headlines of windfall profits from vaccine sales.

While many pharmaceutical and biotechnology companies already participate in the NIH’s Accelerating Medicines Partnership (AMP), more can be done to use this program as a launch pad for cooperation among industry leaders. With greater funding for the AMP and a commitment by participating companies to leverage the partnership to deliver cost-effective therapeutics, we could see a groundswell of pioneering products that provide lifesaving benefits without bankrupting patients. Such a push would support specific companies in their efforts to strengthen reputation among a variety of audiences.

Using digital tools to deliver increased transparency

From the rapid growth of electronic health records to the increase in clinical trial management solutions, information technology has been fully integrated into nearly every aspect of the pharmaceutical industry. But how can the array of digital tools be used to benefit patients?

As the health industry faces ever greater scrutiny over soaring costs, leading companies could forge a different approach by leveraging the power of their IT and storytelling capabilities to provide patients, advocacy groups and policymakers with important details on the drug delivery process. By bringing R&D to life and engaging patients in the various facets of drug development, companies may be able to spark a new dialog with informed audiences about realistic ways to lower the costs of care and focus on therapeutics with the greatest potential for public benefit without sacrificing the profits that are necessary to support medical breakthroughs.

Achieving health access equity by innovating for all

More than two decades ago, Merck’s CEO at the time, Dr. Roy Vagelos, took the bold step of restricting the company’s drug prices to match inflation. Under his leadership, Merck made efforts to price its drugs according to the economic benefits to patients. Years later, Allergan CEO Brent Saunders announced a social contract to adhere to single-digit percentage increases no more than once a year.

Few would argue that Merck or Allergan set themselves up for failure by staking patient-first positions on cost management and drug pricing. In fact, Merck’s stock price rose 22% annually during the Vagelos years. The moves likely strengthened employee morale and public perception, while serving as reputational insurance for each company against future issues.

These examples – and others – show that there is a middle path to developing innovative products with patient access and affordability at the center. This is the foundation to supporting a level field in healthcare, where patients enjoy equitable care and the health ecosystem becomes more accessible and sustainable.

It’s easy for health leaders to look at the growing crisis and kick the can down the road. That’s the playbook oil companies employed when confronted with clear evidence that their actions were causing global warming and fueling a public health crisis. Alternatively, they can recognize the moral imperative to move quickly and stake out bold pipeline, communications and pricing strategies that put cost sustainability and equitable access to care squarely in the center of everything they do. It’s worked before; it can work again.

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“It is all about vigilance and caring. We aim to put the caring back into healthcare, and we are serious about that. Our standards are not how many patients you saw today but how much quality you dispensed today,” Dr. Greg Foti told me about the comprehensive care center, AbsoluteCare, where he works in downtown Baltimore, MD.

Individuals with multiple chronic illnesses compounded by socioeconomic issues are perhaps the most difficult to treat, and the annual expenses can be exceptionally high. Success with these patients would be a story worth telling. Here it is.

Individual doctors and doctor groups have embraced the direct primary care approach with either a fee per visit (direct pay) or a fee per month or year (membership, retainer, and concierge). Mostly, they convert an ongoing practice of 2500–3000+ plus patients to a new model that encompasses about 500 patients. Their patient group usually spans a wide range of ages and the spectrum of some with serious chronic illnesses to those who are basically healthy. I wrote earlier in this series about the advantage of an all- gerontology practice that maintains a patient panel per PCP of about 400.

But what about a panel of patients that all have serious illnesses, who are socio-economically disadvantaged and cannot afford to pay a membership? A number of companies are addressing this need with a focus on the medically most needy; here is an example.

An infectious disease practice in Atlanta initially dedicated to HIV patients later expanded to a broad primary care program for those with multiple serious chronic illnesses — just those who are among the 5% of individuals for whom 40% to almost 50% of all medical dollars are expended. The company, AbsoluteCare, opened a second program in Baltimore — a 17,000-square-foot primary care office in a new building to manage the care of “the sickest of the sick,” whose average annual claims approach $40,000 per year.

Their model has one PCP or NP per only 300 patients working with a team of case manager, medical assistant, and nurse. Other on-site professionals include a mental health therapist, psychiatrist, and social interventions. They also deploy a community-based team that cares for patients in their neighborhoods and homes. In addition to medical care, they address social issues that may impact health status, such as food, clothing, housing, and transportation. For example, they will pick up the patient, bring them to the office, and return afterward.

In essence, the center staff is providing dramatically enhanced primary care at a substantial additional cost over typical primary care but with the aim to improve health and thus lower total costs. Most of the initial patients were on Medicaid or in a Medicare Advantage plan and lived in economically stressed areas. AbsoluteCare now also has contracts with both local and national health plans and has operations in 6 cities, and continues to grow.

It is important to be repetitive here. This type of primary care costs much more than traditional primary care but the result, besides for much-improved patient health and wellness, is a major reduction in total health care costs. That’s why health plans representing Medicare and Medicaid are willing to be supportive. Good for them to have opted to give it a try, and it is working in multiple cities.

The Baltimore office, which I have visited twice, is notable for its ambiance, cleanliness, exceptionally courteous staff, the sense of fun yet seriousness, and the clear message that everyone really cares about the patients and is determined to develop a trusting healing relationship with each. Not exactly what one might expect in an inner city medical office that caters to the socially-economically disadvantaged.

A major focus is on the family and social situation — are they living alone, having transportation, or are they having difficulties with rent, phone, and heating bills?

Same-day visits are the norm; basic blood tests are done on-site, and IV therapies are available, as is an in-house pharmacy. General radiology is transmitted to a nearby tele-radiologist. In addition, the center has a cadre of specialists they tend to call upon for referrals — chosen not only for their expertise but also for their willingness to work in close coordination with the care team.

As Chief Medical Officer Dr. Greg Foti told me: “It is all about vigilance and caring. We must call the hospitalist if the patient is admitted. We must follow up with skilled nursing if needed. We must transport them here to ensure they get the care they need. We want to fully wrap our arms around all the factors that affect their health. We don’t have any magic bullets, but we can give true love and care to our ‘members.’ That will make the difference in both quality and costs.”

The Baltimore office is focused on ensuring that they provide quality care as measured by some standard parameters. “Before AbsoluteCare intervention, our traditional member population scores in the lower 30th percentile with most quality- and value-based purchasing outcomes. After Absolute Care intervention, our members have increased their quality- and value-based purchasing outcomes [such as blood pressure control, HbA1c control, etc.] into the 75thth-95th percentile. Our culture demands that success be tied to quality- and value-based purchasing performance.”

For the payor, these numbers are impressive: a sharp reduction in hospitalizations (down 50%), ER visits (down 34%), reduction in specialists visits (24%), and total costs of care by perhaps a third, a remarkable decrease for these very challenging patients.

But most important, patients have, probably for the first time, found compassionate, thorough, comprehensive, meaningful care that has had a positive impact on their health and their lives.

Many pressures are driving the need for alternative approaches to providing primary care. Enterprising physician entrepreneurs are often the drivers of paradigm change. The fundamental concept of this center and others like it is to offer expanded primary care with heavy use of resources to improve health and lower total costs. As Dr. Foti noted, “We cannot always cure these individuals of their chronic diseases, but we can make a big difference in each person’s health, in their ability to enjoy life and be productive.”

The patient gets extensive primary care not just with a doctor or nurse practitioner but also with a team including attention to social needs as well as medical and mental health requirements. The result is that the patient becomes much healthier and will be using fewer medical system resources, especially those that are exceptionally expensive, like ER visits, procedures, imaging, specialist visits, and hospitalizations.

It is time for insurers to recognize and support this type of care. It changes the payment model but will lower their total care costs.

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Until now, you just sort of accept medical caregivers to be what it is, even if it frustrates you. But the time is rapidly approaching when you will expect an adequate period of time with your caregiver, that the caregiver will know you as a person and indeed know you as a person that is part of a family, a community, and a society. You will not tolerate any longer being treated as a “number,” a “case,” or as a “problem.” If you don’t receive the care as described, you will seek out care elsewhere.

An example of this is a friend, Rebecca, a physician’s wife, who developed breast cancer. She was seen immediately by a topnotch surgeon who did her biopsy and then lumpectomy in a very timely manner with plenty of discussion and “hand holding,” She then went to a highly regarded medical oncologist with the expectation that she would receive her drug therapy and radiation therapy at that individual’s hospital. She knew that the oncologist was well trained and very competent. However, the physician seemed pleasant enough but not engaging and not really focused on my friend as a person.

It seemed as though she went through a “checklist” of information in a “rote-like” manner. Rebecca felt like she was just “one more” breast cancer patient rather than an individual with a particular problem. She felt that perhaps the physician was just having a tough day or that she, the patient, was being seen at the end of a long line of other patients that day. But no matter, this was the physician who was to be her primary caregiver concerning an issue of utmost importance to her. The result: My friend went elsewhere for her medical oncology and radiation therapy care. The basic message, of course, is that patients now want and expect not only competency but also personal and professional care and will both pay for it and demand it. A bit of empathy doesn’t hurt either.

Compare that story to this one. A couple, Bob and Ruth, went to a small Caribbean island for a two-week vacation. On the last day of their vacation, the husband had a heart attack. Bob was taken to the island’s small 25-bed hospital. He and Ruth, who works at a major hospital in a patient care/advocacy profession, were immediately concerned that the level of care would not be up to the standards that they would have expected in their large U.S. city. However, what they found, to their obvious pleasure, was a highly skilled physician who was also highly interactive with the two of them. He did the appropriate diagnostic tests to demonstrate that it was a heart attack and then began the proper medical therapy. Concurrently he arranged for Bob’s air transport to a major Florida hospital.

Meanwhile, others at this small hospital helped Ruth cope with her concerns and deal with some practical issues of getting checked out of the hotel, returning the rental car, arranging medical evacuation flight and all the other details that needed to be done. In short, they looked after her as well as her husband. Ruth cannot speak highly enough of the care that her husband received.

Both of these patients were “connected” to the healthcare professions. So, if you think compassionate, attentive care always comes to such individuals, think again. Years ago, doctors offered their colleagues and families “professional courtesy.” No more. That will not change, but whether the doctor or family member is a patient or not, they will expect compassionate, attentive care just like everyone else. They may be the ones to push the system the hardest and, at the same time, “look in the mirror” at their own practice patterns and initiate change. Change will occur but never as soon as desired.

Both of these stories also illustrate the issue of complex, chronic disease. These diseases do not go away; they can often be cured, but the possibility of a subsequent problem [heart failure] or recurrence [cancer] is real. Many chronic illnesses will be with the patient for life. They require many different practitioners with differing skills to help care for them, which all need coordination.

But in America today, care for these complex, chronic illnesses, which consume more than 70% of all medical care expenditures, are definitely not addressed in a coordinated manner except in a few centers and practices. This means that the care is not up to the quality levels it could be given our knowledge base and our excellent practitioners, and it also means that the costs are much too high. We need to find a way to change our delivery system so that it delivers coordinated, compassionate, and safe care to individuals with these complex, chronic diseases.

Here is a “problem” which everyone needs to understand. If you are on Medicare, Medicare sets the payment for the doctor. He or she cannot bill you more than what Medicare allows. So, if you say to your doctor, “Look, I’d like to spend some more time to fully have you understand my situation or so that I can better understand your advice,” the doctor can say “OK” but Medicare will not pay any more for that extra time and the physician, by law, cannot bill you for the extra time spent. If you were doing a new will and wanted to spend more time understanding what the lawyer was recommending, the lawyer would say “OK,” but both of you would know that you would be billed for the added time. With Medicare, you don’t have that option.

Consider Renee. A few years ago, she asked me for the name of a physician who would give her the time needed for her situation as an older single lady with multiple chronic problems not being fully addressed by her all too many doctors. I suggested Gary Milles, MD MPH, who has a “concierge” practice. He charges a flat fee of $1850 per year and, in return, is available by cell phone 24/7, text, and email. He has only about 490 patients, unlike his original practice with 2700. So, he can offer same or next-day appointments lasting as long as needed.

Each year he does a very comprehensive evaluation lasting two hours, including multiple blood tests, a vision, hearing, and pulmonary analysis at no added charge. Importantly, if a specialist is needed, he will call that doctor directly, explain why he is referring you, and ask for a prompt appointment. That means you will be seen much sooner than if you called that doctor’s office and the doctor will understand why you are there when you come for your appointment. This all makes a big difference in care.

“You aced it when you referred me to Dr. Gary Milles! He has been terrific for me. First, he found out why I’ve had very high BP for four years, e.g., 250/160. Then, instead of all those blood pressure pills, he stopped them and put me on something less powerful and with less side effects and stopped some supplements recommended by a different doctor, adjusted my diet, and gave me some suggestions on stress management. As a result, blood pressure is now OK. So far, so good….we had to make only one adjustment after several months!

“But now I need to see a pulmonologist. The one he recommended did not work out. Great background and experience, but when I had my first visit, things started out poorly (very impatient and rude with me) and quickly spiraled downhill. He definitely is not for me. I will ask for another option.” Dr Milles was thankful that she reported the poor caring and sent her to another pulmonologist who had the appropriate medical but also personal skills. The first pulmonologist will not be getting referrals in the future.

This change to “patient first” is occurring slowly, beginning with primary care physicians, using the direct primary care or concierge models, regaining the time needed to give adequate, expert attention, and, when necessary, coordinating multiple specialists. This means much better quality of care, coordination when needed, all tied into genuine compassion and caring. In that way, it will be a return to my physician grandfather’s time when treatment options were limited. Empathy and caring will be uppermost while still preserving the incredible advances modern science has brought forth. It will mean better care, less patient frustration, less doctor frustration and burnout, and a huge reduction in total costs as an added, very important bonus.

It is a contract between the doctor and patient; no insurer is involved. But of course, if the patient does not feel well treated, the contract is voided, and they will move on to someone else.

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What patients know about saving money and improving care could provide your hospital with the answers it needs in relation to cost-cutting, improving operational efficiencies, and enhancing patient care. Accessing that information is achieved through the application of ethnography.

Ethnography is an innovative practice that studies the culture and habits of people in specific situations. In healthcare, it can be used to improve patient and family satisfaction and care coordination within a bundled payment model by gaining frontline insights from patients and their families.

Hospitals deliver enormous value to their communities with initiatives to promote health and well-being, prevent disease, and strengthen community partnerships. Building on these relationships with ethnographic techniques enhances that trust.

Your hospital will need a unique patient map and proven strategies to deliver robust and data-rich insights by:

• Targeting the true needs of your patients and their families.
• Revealing the frustrations for patients and families in their experience with your hospital.

These insights inform the implementation of an actionable roadmap with innovative ideas for improvement.

As CMS now reimburses hospitals based on the quality of their patient care, which incorporates the patient experience, I encourage all healthcare providers to carry out this process.

Here are three areas where patient insights can help to deliver cost-saving initiatives. These can be frequently overlooked in the pressured environment in which hospital leaders often find themselves.

The impact of silos in your hospital

The patient journey through your hospital is complex, often involving multiple departments. When teams work in silos, or communication breaks down, the patient experience suffers. Patients also express concern over this process.

The breaking down of silos improves patient flow through your hospital, especially in critical areas, such as the ER. This is a concern for physicians as well as patients, according to the American College of Emergency Physicians:[1]

• 60% said overcrowding forces the diversion of patients with urgent needs elsewhere.
• 28% stated this occurs more than 20 times every year.

Hospital-wide resources management can save your hospital money and improve care. Our comprehensive Patient Journey Mapping™ survey can help to reveal the vulnerable points in your hospital which are increasing costs and impacting patient care.

The patient discharge process

Clear communication at the time of patient discharge means that patients are less likely to be readmitted to your hospital. The average readmission cost per diagnosis back in 2016 was $14,400. Furthermore, it is estimated that one in six patients are now readmitted to the hospital within 30 days of discharge.

Patients want to know what to expect when leaving the hospital after treatment or surgery. Research shows that when patients clearly understand guidance around their medications and care when arriving home, readmissions fall. Frontline insights from your patients will reinforce the need for hospital staff to ensure they fully comprehend all instructions and guidance relating to their discharge.

It should also be noted that we strongly recommend confirming the patient’s social circumstances prior to the time of discharge. Social determinants of health can often cause patients to return to the ER with the same symptoms that resulted in their initial admission.

The overlooked patient billing experience

As I highlighted above, CMS reimbursement is becoming increasingly dependent on patient satisfaction and that satisfaction includes the billing process.

Their experience with billing is often both the initial and final interaction your patients have with your organization. If they believe they are overcharged or their expectations are not met, patient satisfaction suffers.
The extent of the impact on your operating margins is revealed in a study published in October 2019 which found that US healthcare consumers will change their providers over a poor digital experience — which includes online bill payment and e-mailed billing processes[2].

• 41% of consumers would choose another healthcare provider over a poor digital experience.
• Furthermore, 60% of consumers find healthcare bills confusing, which often results in delayed payment and less money to invest in your hospital.
• In addition, that poor experience can lead to lower patient satisfaction scores and lower reimbursements.

Gaining invaluable patient insights into this often overlooked area can help to transform your overall patient experience and save your hospital money, particularly in administrative costs involved in billing.

[1]http://www.ihi.org/resources/Pages/ImprovementStories/BetterPatientFlowMeansBreakingDowntheSilos.aspx
[2] https://www.prnewswire.com/news-releases/study-finds-us-healthcare-consumers-will-switch-providers-over-poor-digital-experiences-300934851.html

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Most of us assume that discharge is up to our treating physician or surgeon to decide when it’s appropriate for us to go home and what sort of in-home treatment or rehab we should have prescribed as part of our aftercare. We are, in that regard, totally in the dark because the day of discharge has been taken out of your physician’s hands and is controlled by a codebook; the DRGs are an all-payer guide with one section, another, the MS-DRGs, for Medicare patients.

What is this mysterious acronym? The acronym stands for Diagnosis Related Groups, a plan for codes for illnesses and procedures related to them. These codes (there are 740) are mandates for discharge, and physicians must abide by them unless there are extenuating medical circumstances.

Ask the older women in your family how long they remained in hospital after the birth of their children. Today, women may remain for one day or 48 hours. Previously, women may have been patients in the hospital for up to 10 days after childbirth. The DRGs changed all of that.

Specialized medical practices such as those for reproductive medicine have begun providing professional articles to assist physicians in coding and reimbursement. Patients who may wish to peruse the reimbursement rates for orthopedic procedures can find this information here. But note that there is no agreement among hospitals that would indicate they all bill at the same rate. Essentially, the patient is on their own when it comes to cost because of a lack of transparency.

The DRGs aren’t something new because the codes were designed and implemented as part of the prospective payment system for Medicare in 1983. How effective has it been at attaining its primary goal, and have there been problems with its design and utilization over the years? Psychiatrists began expressing their displeasure almost as soon as they saw the coding in 1986.

These issues include the problems of premature discharge, code manipulation, cost-shifting, and equitable patient access to psychiatric services. The potential effects of a DRG payment system on clinical practice are reviewed.

The psychiatrist’s view was relevant to the DRG and its application to psychiatric intervention. Based on limited data on the issue of discharge of psychiatric patients, it was believed that this information was not developed, tested, or applied in psychiatric facilities.

In fact, of the 14 psychiatric diagnostic groupings contained in the initial DRG listing, none were validated in any psychiatric facility, whether in a general hospital, a general hospital’s psychiatric unit, or a private psychiatric facility.

How could anyone, with such flawed data, decide when the discharge of a patient with a psychiatric disorder was appropriate? Considering that the listings were to optimize savings in terms of reimbursement, inappropriately released psychiatric patients would become a burden on local communities, and it was reasonable to assume they would be rehospitalized, potentially at a higher rate. Liaison psychiatry, found to be a cost-effective means of providing care, was not factored into the DRGs.

Another problematic aspect of this coding system is that it’s not uniform in its application for Medicare, Medicaid, and other third-party payment for hospitalization. Code manipulation is present in every form of care under the DRGs.

One aspect of code manipulation (at whose benefit?) is billing practices for reimbursement for patients with multiple disorders. The patient is treated and discharged under one DRG mandate and then re-admitted under another of their illnesses and treated again until that DRG mandate kicks in. Ethical, patient-friendly, or beneficial to the facility’s bottom line? Physicians in one study found this was used particularly with geriatric patients.

Another practice with psychiatric patients is DRG-creep, where a patient is diagnosed with a disorder that pays at a higher rate. When a diagnosis is restricted to a psychiatrist’s independent opinion, who can question this?

Consider another aspect of hospital discharge following DRG guidelines. Where does it indicate any provision for family care, appropriate follow-up services, or placement? If there’s no place for the patient to reside, what do you do, admit them to a rehab facility where another set of DRGs will be initiated? Is this cost-saving for whichever agency is paying for care?

The previous paragraph brought to mind two cases of lengthy hospitalizations. One was for a young woman, about 18, who had been an inpatient in a private psychiatric hospital for five years. I asked what her diagnosis was on discharge. The social worker said, “We’re meeting to decide that today.” That day? What were they using as her diagnosis for all those years? Of course, her wealthy family had private insurance, but didn’t the insurance company demand a working diagnosis? Was it DRG-creep here?

Another is a bizarre case that resulted in active media coverage and a book. It was about the life and hospitalization of Huguette Clark. Fabulously wealthy, she was a patient in a major New York City hospital for 20 years. No DRGs there?

Medical care is still ruled by reimbursement, and the DRGs hold an untenable place in that hierarchy.

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