What Blood in Urine Can Tell Us About Healthcare Quality

There is a fantastic article in the July 2014 issue of The American Journal of Medicine by Dr. Friedlander et al from the Vanderbilt University School of Medicine.  The article is entitled, “Variation in the Intensity of Hematuria Evaluation: A Target for Primary Care Quality Improvement.”

Very short background:  The very first sign of bladder or kidney cancer is microscopic amounts of blood found in the urine—usually without any other symptoms.  No pain.  No difficulty urinating.  Nothing.  The amount of blood is so small that you cannot see.  Fortunately, there is usually another cause for the very small amount of blood—e.g. a urinary tract infection, inflamed prostate, etc.  However, if blood is found in the urine, the standard of care is to have two follow up tests: a cystoscopy and a CT scan of the bladder and kidneys.  The cystoscopy is a brief procedure performed by a urologist and the CT scan is typically ordered by the urologist as well.  So if microscopic amounts of blood are found in a urine sample at a primary care physician’s office, the patient should possibly be referred to a urologist for further evaluation.

Now to the article:  This study found that of patients who (1) went to see their PCP, (2) had a urine sample taken and (3) were found to have microscopic amounts of blood found in that urine sample—only 5.7% of the patients had the two recommended follow up tests performed to make sure there was no cancer present.

Approximately 94% of patients were not receiving recommended care.

What’s important about this study is that it is likely indicative of other guidelines that are not followed as well—and healthcare consumers are completely unaware that they are not receiving proper medical care.

These types of “errors of omission” also take place in a healthcare system where there are many “errors of commission” as well—e.g. too many MRIs being ordered for low back pain that will resolve on its own with pain medication and physical therapy.  The US healthcare system is stymied by too little of the right care and too much of the wrong care.

So what does this mean for employee benefits professionals and healthcare consumers?

  • One potential solution is to use a checklist—and to use doctors that use a checklist.  Healthcare consumers would benefit from a checklist of the general guidelines of what medical care they should have for their age and gender (e.g. cancer, cardiovascular disease, diabetes screening).  Employers and healthcare consumers should use physicians who themselves use a checklist, which is often incorporated into an electronic medical record and reviewed by the physician him or herself and the practice as a whole.  I know of one health system that used a checklist for something as simple as booster shots for adult immunizations (e.g. tetanus shot) and improved the immunization rates of their patients as a result.  As simple as they are—checklists work.

Click below to read more about Compass Professional Health Services checklist program, which we call Health Prompt:

I’m Not Going THERE—Location Bias in Healthcare

In speaking with a family member last week about some recurrent food allergy problems that she has been having, I suggested that she obtain a second opinion.  She has had certain food allergies for years, but they had become worse in recent months, resulting in a rash that would get better or worse depending on what she ate.

She had been seeing the same allergist for over a year for this problem.  The allergist had identified several foods that she was allergic to through allergy testing and had subsequently started her on a series of ‘allergy shots’ in an effort the fix the problem.

So I said to this family member, ‘If you aren’t getting any better, why don’t you see a different allergist?  You live near several academic medical centers and tertiary-referral hospitals, I’m sure you could find an allergist who could weigh in on your situation.’

The family member’s response: “Those places are too far away.  I’m not going over There.”  Of note, ‘Over There’ is about a 20 minute drive to an area that this person does not frequently go to.

Her response is not unique.  When given the option for a higher quality, lower cost or just different physician or hospital, many healthcare consumers don’t want to go very far.  There could be various reasons:

  • Don’t have the time to travel given a hectic schedule
  • Don’t have the means to travel—i.e. access to a car or other transportation
  • Unfamiliarity or ‘fear’ of the unknown—unknown traffic patterns, unknown places to park, etc
  • Inconsistency-Avoidance Tendency—this is a mental phenomenon described by Charlie Munger, the Vice Chairman of Berkshire Hathaway.  It states that once people make a decision they tend to not want to deviate from it subconsciously because doing so would be ‘inconsistent.’  Even if changing one’s mind is logical and provides benefits (like finding a new allergist), people will still not want to change for the sake of staying consistent.

But do not worry, there is a way to overcome Location Bias in Healthcare… and for that solution we turn again to Charlie Munger:

Mr. Munger would suggest the ‘Ben Franklin’ approach: An ounce of prevention is worth a pound of cure.

For healthcare consumers, that means finding high quality, cost-effective healthcare providers from the start—not having to switch to them later.  Many employers are working with Compass to ensure that employees use our service from the very beginning of their healthcare experience to find high quality, cost-effective providers through (1) video and curriculum campaign communications, (2) a CDHP plan design or even (3) an accountability plan model or incentives.  Our Compass concierge model is specifically designed to catch people very early in their healthcare decision making so that we can be involved from the get-go.

Compass also specifically finds providers that have appointment availability that matches our members’ availability and have offices that specifically meet the members’ needs—whether it be on a certain side of a river or along a certain bus or subway line.

To read a full article on Charlie Munger’s Psychology of Human Misjudgment—Click Here.

To watch a 5-min video on the services that Compass provides for employers and employees, Click on the link below:

Exchange Insurance ‘Narrow Network’ Bait-and-Switch?

The New York Times reported this past Saturday that many health insurance plans that consumers purchased through insurance exchanges have much narrower networks than many consumers expected.

The article by Robert Pear describes how the Obama administration and state insurance regulatory agencies will adopt a new way of ‘testing’ insurance networks sold on exchanges to ensure that they are ‘large enough’—i.e. have a sufficient number of doctors, hospitals and healthcare providers in them.

According to the article, what has happened is that insurance companies have offered health plans with narrow networks in an effort to keep premiums low.  Healthcare consumers are largely choosing health plans based on price and are not comparing the size of networks of available plans.  Therefore, consumers are preferring the cheap, narrow-network plans and then becoming unhappy with the results when they actually have to use the plan.

The solution proposed on ‘testing’ the size of the network to ensure it is ‘large enough’ is going to be similar to the process currently used to test Medicare Advantage networks to make sure that they are large enough.

Interestingly, insurance companies are already working to expand the size of their networks for plans offered on insurance exchanges.  Wellpoint has added 3,800 doctors in California alone, increase the size of its network by 10%.

Click HERE to read the full article.

What does this mean for employee benefits professionals and healthcare consumers?

  • As I mentioned in yesterday’s blog, “The ‘moving target’ of Obamacare may continue well into the future and employers and healthcare consumers should expect change.”
  • There will likely be additional consumer protections put in place over time as more individuals ‘kick the tires’ on their insurance exchange plans—insurance rules are complicated and many people will likely not understand what they are purchasing and have different expectations for what is actually written in their policy.
  • In my opinion, the INCREASING challenge of being a healthcare consumer is actually a good thing for individuals, health insurance companies and healthcare providers.  It will necessitate changes in consumer, insurance company and provider behavior that will improve quality, lower cost and improve the patient experience.  Of course, I am biased I think that my company, Compass Professional Health Services, eases that pain dramatically.

Click below to watch a 5-min video on how Compass provides tools and support for healthcare consumers:

NY Times Reports: US Appeals Courts Issue Conflicting Rulings on Federal Subsidies for Exchanges

The New York Times reported on Tuesday, July 22nd that a panel from the US Court of Appeals for the District of Columbia Circuit found that the IRS could NOT subsidize Federal Health Insurance Exchange premiums through tax credits, but could only do so for state run Health Insurance Exchanges.

On the same day, the US Court of Appeals for Fourth Circuit in Richmond, VA found that the IRS COULD subsidize Federal Health Insurance Exchange premiums through tax credits.

It is important to note that the article states that the ruling by the court in the District of Columbia does NOT change the status of Federal Subsidies for all exchanges (Federal or State) as they currently exist today—i.e. for now the subsidies will continue.

There are some interesting stats from the article as well:

  • 8 million Americans have selected private health insurance plans from October thru mid-April
  • Of those 8 million, 5.4 million obtained coverage through a Federal Exchange
  • Most of those on a Federal Exchange qualified for subsidies from the IRS

Click HERE to read the full NY Times article.

What does this mean for employee benefits professionals and healthcare consumers:

  • While nothing changes today as a result of these conflicting legal opinions, it is important to note that there are a series of law suits that have been brought to challenge Obamacare and there may be ongoing conflicting legal opinions in the future.
  • The ‘moving target’ of Obamacare may continue well into the future and employers and healthcare consumers should expect change and incorporate regulatory change into their future approaches to healthcare.

To read customer testimonials on how Compass assists employers and healthcare consumers navigate the complex waters of healthcare, click on the link below to our Compass Facebook Page.

Healthcare Consumer Survey Results: 70% Look Up Symptoms; 40% Look up Cost/Quality

The Altarum Institute conducts a semi-annual healthcare consumer survey.  Below are some statistics from their most recent Spring 2014 survey of 2,099 healthcare consumers:

  • 90% of healthcare consumers want to be in control of medical decisions or share decision making with their doctors.  Only 7% want the doctor to be in control.
  • As the title reads, 70% of healthcare consumers look up symptoms online before going to the doctor.  However, only 40% look up cost or quality information regarding healthcare.
  • Word-of-mouth is still the leading source of recommendations for healthcare providers—72% of healthcare consumers rely on it.
  • 90% of healthcare consumers are concerned about healthcare bills and costs.  80% say they would feel comfortable talking to their doctor about costs.  However, only 50% of healthcare consumers have ever asked their doctor about costs.

Read the full Altarum Institute Survey of Consumer Health Care Opinions by clicking here.

What do these statistics mean for employee benefits professionals and healthcare consumers?

(1)   Employees and their family members want to be in control of their healthcare decisions.  (2) They are concerned about costs.  (3) They want to talk to their doctor about costs, but… (4) only about ½ do.

So their seems to be this gap between desire and action.  That’s ok.  Being a healthcare consumer and consumerism is a paradigm shift and a cultural change and these things take time.  Before any change in behavior happens, there needs to be a change in thinking.  This Altarum survey, in my opinion, shows that the thinking is there and the behavior is slowly staring to change.  It will take time, but the movement from consumerism-thoughts to consumerism-actions is gaining momentum.

At Compass, we help employers accelerate that culture change through tools and support for healthcare consumers.  Click on the link below to watch a 5-minute video by me that discusses how Compass does that.

Top 3 Errors Made by Consumers When Receiving a Screening Colonoscopy

Not necessarily a fun thing to think about—but when most people turn 50 it is time for them to go and have a colonoscopy to screen for polyps and colon cancer.  There are 3 very common errors that we see at Compass as it relates to consumer understanding of the billing related to a screening colonoscopy.

Error #1 – The colonoscopy is screening and therefore will be paid for at 100%.

 This is an error, because depending on what is found during the colonoscopy and how the colonoscopy is billed, it could be classified as a ‘Diagnostic Colonoscopy’ and therefore, be subject to deductible and coinsurance.  Now some self-funded employers have written their plan documents such that even the diagnostic colonoscopies are covered at 100%, but across our hundreds of thousands of members at Compass, that is a rarity.  Almost all full-insured plans in our experience have diagnostic colonoscopies fall to deductible and coinsurance.

Therefore, it is important to understand before your screening colonoscopy, that if the doctor finds a polyp or some other lesion during the procedure, that it is likely that the colonoscopy will be billed as diagnostic and that you will usually have to pay some out of pocket cost—which could be upwards of $4,000, but we’ll get to that later on in the post.

Error #2 – I want to be ‘knocked out,’ but not knowing if it is the gastroenterologist or an anesthesiologist performing the sedation.

This is an error, because the ‘conscious sedation’ for the procedure can be performed by either the gastroenterologist (GI doctor that performs the colonoscopy) or a separate anesthesiologist.  If the gastroenterologist performs the conscious sedation, then usually you will not receive an additional bill strictly for the sedation.

However, if a separate anesthesiologist performs the conscious sedation, then you MAY receive a separate bill from the anesthesiologist for the sedation—especially (as described above) if the colonoscopy is not billed as preventive, but rather as diagnostic and therefore subject to deductible and coinsurance.  That additional anesthesia bill may be upwards of $800.

The important point here is that most gastroenterologists perform their own conscious sedation for the majority of their colonoscopies and with these physicians performing your procedure, you will not run the risk of the additional bill.  However, there are some gastroenterologists who routinely use a separate anesthesiologist to perform the sedation during the procedure.

So how do you know the difference?

You need to ask the gastroenterologists office.  They will likely know the answer and will be able to tell you, “if you are not a high-risk patient for sedation, then Dr. So-and-So, the gastroenterologist, will perform the sedation and there will be no additional bill.”

Error #3 – Not realizing that where you schedule your colonoscopy will potentially change your cost.

This is an error because the facility fees are very different depending on which hospital, endoscopy center or ambulatory surgery center you go to.  Some facilities cost over $4,000.  Others cost $500.  I will discuss in a future blog post why this price differential exists, but it is not necessarily because of an objective quality different among the facilities.  In fact, often the same gastroenterologist will perform colonoscopies at different facilities depending on what day of the week it is.  For example, he may perform procedures at the hospital on Mondays, where the facility fee is $3,800 and at the ambulatory surgery center on Tuesday, where the facility fee is $800.

This fee difference is important—again—because if your colonoscopy is billed as diagnostic, you may have to pay some or all of that cost yourself and that fee difference will affect your out-of-pocket cost.

So if you like your gastroenterologist and you do not want to change doctors, ask the doctor’s office staff if he or she performs procedures at different facilities and if he or she does, then contact the facilities to find out what their colonoscopy fee is—more on how to ask facilities for their fees in a later post as well.

Confused?  Don’t worry, most people are.  I hope this has at least helped a little to explain some of the nuances around colonoscopy bills and paperwork.  What do you think?  What are some challenges around medical bills that you have encountered?

Click below to view the Compass Overview YouTube video:

4 Questions That Will Help You Find the Right Physician

Finding a good physician is one of the greatest challenges for a healthcare consumer. It is also one of the most important choices a person makes when it comes to their medical care.  It is so important because, in my opinion, there is actually quite a bit of variability and subjectivity in medicine.  How you are diagnosed and how you are treated will vary greatly among physicians, which is why if you ever find yourself saying things like “I’m just not getting better” or “What the doctor said just didn’t make sense” or “Is that test/procedure/prescription really the right thing”—You should seek a second opinion.  Second opinions are good things.  Any physician worth his or her salt will not be offended if you seek a second opinion.

But how do you find a good physician in the first place?  The best approach may not seem as obvious as you think:

Call the doctor’s office and ask the following questions:

(1)    Is the doctor taking new patients?

(2)    Does the doctor see patients for _________ (insert your medical issue here: pain, check-up, rash, etc.)?

(3)    When is the first available new patient appointment?

(4)    Can you describe the doctor’s bedside manner?

You want to ask these questions for several reasons.  First, there are some basic, logistical answers you need to obtain.  Often doctors (especially good doctors) are not taking new patients, so you need to get that one out of the way up front.

Second, you cannot assume that the doctor will automatically see patients with your type of medical concern—you need to expressly ask.  For example, if you are interested in starting a family, you need to specifically ask an Ob/Gyn if she still delivers babies—not all of them do.

Third, getting an appointment may be 6 – 8 weeks in the future. If that is just too long for you, you need to know that up front so you can contact someone else.

Finally, most physician practices are small (only 1 or 2 doctors) so all the staff interacts frequently with the doctor and they know how they treat their patients.  Ask about their bedside manner.  Surprisingly, most of the time they will tell you the truth, and it is not always good.

What are some common red flags you need to look out for?

  • “Well, the doctor is very busy”: Translation-rushed.  All doctors are busy.  That is never an excuse to come across that way.
  • “Well, the doctor is very focused”: Translation- cold, impersonal. All doctors went into medicine because they want to help people and helping people means treating them with courtesy and establishing what is referred to as a therapeutic relationship.  Some doctors have lost interest.  The joy is gone.  The flame is out.  They become cold and distant.  Stay away!

There are also some positive comments you should search for.

  • “The doctor spends a lot of time with her patients”: Translation: meticulous, diligent, detail oriented.  Diligence is the top quality you want to find in a physician and the best way for that diligence to manifest itself is with time.  All of the best doctors I knew at Johns Hopkins took their time with patients.  I never witnessed a good doctor rush with his or her patients.

Also, if a doctor takes time with their patients, they likely also take the time to read and stay up to date.  Constant reading and learning is the hallmark of a great physician.  All physicians know this and you want a physician who takes the time to do it.  I knew a vascular surgeon at the University Of Illinois College Of Medicine who read two hours every night.  There was another general internist at the same College of Medicine that read the entire 1,800 page textbook on medicine every year.  On January 1st, he would start on page one and he would finish by December, repeating the process over on the January 1st of the next year.  Not surprisingly, he said he learned something new every time he read it.

  • “Doctor _____’s patients just love him”: Translation: the doctor is warm and caring.  Establishing a therapeutic relationship with a patient is vital—it literally helps the patient get better.  In my opinion, part of the reason for this is that where there is caring, there is better communication. Better communication leads to an accurate diagnosis and an accurate diagnosis leads to the correct treatment.

Another key reason why the above four questions are so important is that the WAY the office staff answers these questions is a good indication of the doctor’s ability and personality.  If the doctor is good, they will likely attract good employees.  If the doctor treats his patients well, they will likely treat their staff well—and the staff accordingly, will speak fondly of them.  If the doctor is diligent (there’s that key trait again), they will not tolerate rude or incompetent employees and will replace them.

So when you ask the above four questions, if the staff is rude, cold or impersonal—find another doctor.  If the staff is rushed and seems too busy to answer your questions—find another doctor.  If the staff is so thrown by your bedside manner question that they seem offended or turned off (yes, this does happen)—find another doctor.

Compass has phone screened hundreds of thousands of physicians so our members do not need to call the doctor’s office—we have done that for them.  However, regardless of if you have Compass as your personal healthcare advocate or not, the above approach will help you find the right doctor to lead you on the path towards good health.

What do you think?  What have you done in the past to find a good doctor?  What traits about a physician have turned you off in the past?

Below is a link to a 5-min video of me speaking about my company–Compass Professional Health Services.  Compass works with over 1,700 employer clients to make their employees better healthcare consumers through price-transparency and provider quality comparisons delivered through a personal healthcare concierge who will review and resolve problem medical bills and search out great physicians that meet the specific needs of each of our members.  Thank you for reading this blog post!

Incentive Best Practices for Employer Health Plans—Stanford Professor’s Framework on Behavior Modification

In order for employees and their family members to obtain higher quality care at lower cost—they need to change their behavior.

As Albert Einstein said, “The definition of insanity is doing the same thing and expecting different results.”  If employers and employees want more value—higher quality, lower cost—for their healthcare dollars, they need to do something different.  Whether that is: be more compliant with their medication regimens, get their age appropriate screenings, compare cost and quality when choosing a doctor or hospital, come prepared for office visits, use more generic medications where appropriate, lose weight or stop smoking.

The doctors, hospitals, government, pharmaceutical companies and insurance carriers may need to change their behavior too, but they are not as ‘impactable’ as an employer’s own employees.

Stanford Professor, Dr. BJ Fogg, has laid out an elegantly simple framework for behavior modification that directly applies to incentive best practices for employer health plans.  The professor’s framework has three parts.

  1. Motivation—the benefit that comes from the change in behavior.  That could be a dollar reward, avoidance of a financial penalty, personal recognition, better health, etc.
  2. Ability—the skill to perform the desired behavior.  This involves teaching, coaching and directly assisting the individual.  Essentially, “Show me how to do what you want me to do and help me do it.”
  3. Trigger—the reinforcement of #1 and #2.  Remind me of the benefit.  Explain to me again how I am supposed to do what you want me to do.  Repeat.  Again.

Interestingly, the professor states that if you are not achieving your behavior modification goals, the first place you should look is #3—The Triggers.  Are they frequent enough?  Are they reaching the right people?  At the right time?  Are they phrased in different ways through various media—in person, print, audio, video, individually, in groups?

Let me repeat that:  if you are not achieving your behavior modification goals, the first place you should look is The Trigger.

Here is a link to the professor’s site at Stanford for more information and a very good 2-minute video by him (if you scroll down):  BJ Fogg’s Behavior Model

Many employers think they need to increase the dollar amount of their incentive.  Others think they need to increase the severity of the penalty.  Still others think they need to improve the coaching (“it’s not working because our coaches and educators are bad”).  While these may be true, the low handing fruit is the trigger.

As you look to modify your employer health plan in the context of Health Reform and you want your employees to behave differently, think first about your organization’s current triggers and what you can do to improve them.

I have recorded a short 5-min video on best practices in employee engagement from what Compass has learned from supporting over 1,700 employer clients.  Click on the icon below to view the video.

Health Reform: Premium Amount that Defines a ‘Cadillac Plan’

Beginning in 2018, the Federal Government will tax employer health insurance plans that are especially ‘rich.’ These rich plans are also referred to as ‘Cadillac Plans.’ These types of health plans provide many benefits at little to no out-of-pocket cost resulting in premium costs (typically paid by the employer) that are very high.

The definition of a Cadillac Plan is the combined annual premium cost (i.e. paid by employer and employee together) of greater than $10,200 for an individual and greater than $27,500 for a family. See this release by the large labor union SEIU for more details: The Impact of the Excise Tax on High-Cost Health Plans

The types of employees that might have Cadillac Plans are employees that are part of a labor union—which is why the SEIU came out against taxation on Cadillac Plans. Other types of employees that might have Cadillac Plans are executives or those in other highly-compensated positions (e.g. computer programmers, investment bankers, engineers, etc.).

The Congressional Budget Office (CBO) expects the excise tax on Cadillac Plans to generate $10 Billion in taxes in 2018 and steadily increase every year to $35 Billion in 2023. Estimate of the Effects of the Affordable Care Act on Health Insurance Coverage (see page 2).

As employers, unions and broker/benefit consultants plan ahead, they will want to consider changing plan designs in advance of 2018 to avoid the excise tax. A way to make plans ‘Non-Cadillac’ is to increase the out-of-pocket costs paid by the employees. By doing so, the plan will be less rich. However, that cost-shift can be addressed and largely mitigated through concierge services like Compass that enable employees to be smarter, more supported healthcare consumers who are able to receive high quality care at lower cost providers. Compass already has multiple oil and gas clients that have used this strategy. Similarly, other employers may want to start resetting the expectations of their employees sooner rather than later.

Click below to access the Compass Overview YouTube Video:

What Doctors Do When They Make Their Own Doctor’s Appointment

The way that doctors themselves receive medical care and navigate the healthcare system is somewhat different from the way other people do.  Here is one thing many doctors do differently when they make their own doctor’s appointments:

Many doctors try to schedule their own appointment as the first appointment of the day.

There are two main reasons to do this:

  1. The appointment will most likely be on time.  Doctors are notoriously late and they ‘fall behind’ almost every day in their clinic schedule.  The reason: urgent/emergent things with other patients come up that the doctor must attend to, which slows them down, which makes them late for their appointments later in the day.  The later your appointment is scheduled in the day, the more likely it will not be on time.  It may start 30 minutes, 1 hour or even 2 hours after it was scheduled to.  I know a Rheumatologist in Baltimore who ran 2 hours behind schedule almost every afternoon and his patients would wait until 7:00 or 8:00 PM to be seen.
  2. Doctors are mentally ‘fresher’ at the beginning of the day than at the end.  Almost every doctor I know is exhausted and chronically sleep deprived.  If you see a doctor at 9:00 AM for an appointment, it is likely they have been awake since 4:30 AM and started seeing patients at the hospital at 6:00 AM (especially surgeons).  However, at least you saw the doctor when they had only been awake for 4 and a half hours.  If you see the doctor at 4:30 PM, they will have already been awake for 12 hours and seen 30 patients before you.  So you will have the doctor’s best ‘mental effort’ at the beginning of the day rather than at the end of the day.

If your appointment can wait a day or a week so you can schedule it at the beginning of the day, that might be a good idea.

For more information specifically on preparing for an office visit to an Orthopedic Surgeon or Orthopedist (doctor for bones and joints), I created this 5-min video.  It has some critical tips regarding what pitfalls to look out for.