Wednesday, March 17, 2010

Part II - Compare and Contrast: A Chance to Size Up Two Health Care Systems

BACKGROUND

For those who are landing on this page for the first time, be sure to read the background FIRST to these case presentations. The intent here is to compare and contrast two patients, one insured and the other uninsured, from the United States and England as care is delivered today. The US cases are described in detail in this blog and the corresponding cases, British-style, are described on Sarah Clarke, MD's blog from England.


CASE #1: The U.S. Case of Mr. Thurgood Powell

The ER radio sounds: (*bleeeeee, deeeeeeeeeppppp*) "Rampart, we have a 57 year old white male en route with a 45 minute history of substernal chest pain and diaphoresis. Initial single-lead EKG discloses ST segment elevation. One ASA given, nitro given, BP 96/47, pulse 110, respirations 22, pt diaphoretic..."

ER doctor: "Code cor activated. Cath lab ready. Proceed as soon as possible."

Pt arrives. Looks poorly. A 12-lead EKG is obtained in the ER and confirms an evolving acute anterior myocardial infarction. There is no contraindication to proceeding directly to cath lab. Given loading dose of Plavix, integrelin. Shuttled to lab. Angio performed. 95% LAD stenosis and significant 3-vessel disease is noted. Ventriculogram not performed due the patient's condition. His BP drops, intraaortic balloon pump placed. Due to his age and lack of comorbidities, it is decided to place a drug-eluting stent in LAD artery. Aside from some VT during case and one episode of ventricular fibrillation during his procedure requiring countershock, but patient tolerates remarkably well. Patient is transfered to ICU.

After the dust settles, hospital administration comes to take patient's valuables and to register Mr. Powell. They inquire about his insurance: he produces a platinum policy card from Blue Cross Blue Shield of Illinois which Mr. Powell chose amongst several insurance policies offered by his employer. He could cover his entire family for approximately $400 per month ($200 per paycheck): total annual outlay $4800. Employer also picks up a more significant portion of the cost (approximately $14,000 per year) but can deduct this amount from their profit for tax purposes. Mr. Powell cannot deduct the price of his insurance from his income amount and has a $5000 annual family deductible. Also, Mr. Thurgood's income falls into the 33% federal tax bracket ($67,643 per year). Still, all is good - he's covered.

Mr. Powell is started on Toprol XL 25 mg daily, Altace, aspirin, Plavix, and Crestor - all at the doctor's discretion (He is young, after all). Patient has development of congestive heart failure on day two, requires ongoing balloon pump support. Some atrial fibrillation occurs, requiring titration of medications to control. Echocardiogram performed to assess LV function. Balloon pump but eventually is weaned on Day #3. He leaves the ICU on Day 4. His room outside the ICU is private (due to infection control efforts, they say) and equipped with a flat screen TV from which he orders his food (it is, after all, a brand new heart hospital that has been tastefully appointed.) He spends two more days on the ward and then is discharged to follow-up in Clinic in one month.

Pt returns home and later receives a bill for his hospital stay. On his Explanation of Benefits, he notices a total bill for $180,000. Insurance has agreed to pay about $150,000 due to a pre-negotiated arrangement of the insurer with the hospital. The insurer has likewise negotiated with the employer to offer a price point with a comfortable profit "spread." Mr. Powell is not responsible for understanding the difference - he just has to pay his annual deductable of $5000.

Despite his care, Mr. Powell continues to have ongoing angina. Because of his recurrent pain, he is admitted and another angiogram performed which was unchanged. It is decided that because of his young age and pain refractory to medical therapy, he is referred to bypass. He is seen by the surgeon the same day, and elective surgery scheduled for the following day.

His post operative stay is uncomplicated and he returns home in 4 days. Cost for surgery and hospital stay: About $100,000.

Approximately 6 weeks later, Mr. Powell notes palpitations and lightheadedness. He returns to ER where his is found to be in sustained monomorphic ventricular tachycardia. Another angiogram performed. All bypass vessels are open and his native disease unchanged. A dual chamber ICD is scheduled for next day of manufacturer of the electrophysiologist's choice* (patient had atrial fibrillation in the past, after all) and implanted uneventfully. Mr. Powell later returns home.

Again a bill is sent to his home: cost of hospitalization with ICD implant $160,000. Insurance has prenegotiated a lower price with hospital - $110,000 - but has agreed to pay the full negotiated amount with the remainder "forgiven" as far as Mr. Powell is concerned. Mr. Powell is amazed by the state-of-the art technology installed in his chest.

Mr. Powell follows up in two weeks after his surgery with his electrophysiologist, two weeks after that with his cardiologist, and about a month later, his internist. He is followed for his ICD every three months thereafter. Home monitoring of his ICD is instituted on his first follow-up visit. The device company sends the monitor to his home, free of charge.

* In reality, hospital has asked doctor which company's devices he's willing to work with and hospital negotiates bare bones pricing on ICD and up charges device approximately two to three times cost to provide margin for hospital operations.


CASE #2: The U.S. Case of Mortimer T. Schnerd

The ER radio sounds: (*bleeeeee, deeeeeeeeeppppp*) "Rampart, we have a 43 year old white male en route with a 45 minute history of substernal chest pain and diaphoresis. Initial single-lead EKG discloses ST segment elevation. One ASA given, nitro given, BP 96/47, pulse 110, respirations 22, pt diaphoretic..."

ER doctor: "Code cor activated. Cath lab ready. Proceed as soon as possible."

Pt arrives. He looks poorly. A 12-lead EKG is obtained in the ER and confirms an evolving acute anterior myocardial infarction. There is no contraindication to proceeding direct to cath lab. Given loading dose of Plavix, integrelin. Shuttled to lab. Angio performed. 95% LAD stenosis and severe underlying 3-vessel disease is noted. Ventriculogram not performed. His BP drops, intraaortic balloon pump placed. Due to his age and lack of comorbidities, it is decided to place a drug-eluting stent in LAD artery. Aside from some VT during case and one episode of ventricular fibrillation, Mr. Schnerd tolerates his procedure remarkably well. He is transferred to ICU.

After the dust settles, hospital administration comes to take patient's valuables and to register Mr. Schnerd. They inquire about his insurance: he has none. Hospital clerk notes situation (annual income $17,400, 15% tax bracket (Taxes $2,193 per year) - knows patient has little means to pay his bill and gets on the horn to social work. A social worker arrives and tries to apply on his behalf for Public Aide to pay for the cost of his hospitalization. The patient is responsible for a "spend down" of approximately $500-$1000. Unfortunately, because he is male, employed part time, and has no dependents, he does not qualify for Public Aide. The hospital then submits its bill for his care to the Medicaid program. He will be enrolled in the public clinic at the hospital to receive his follow-up care after discharge.

Mr. Schnerd is started on Toprol XL 25 mg daily, lisinopril, aspirin, Plavix, and simvastatin (to limit his out-of-pocket expense) - all at the doctor's discretion. Mr. Schnerd develops congestive heart failure on day two, requires ongoing balloon pump support. Echocardiogram performed to assess LV function. Balloon pump eventually is weaned on Day #3. He leaves ICU on Day 4. Mr. Schnerd's room outside the ICU is private (due to infection control efforts, they say) and equipped with a flat screen TV from which he orders his food (it is, after all, a brand new heart hospital that has been tastefully appointed.) He spends two more days on the ward and then is discharged to follow-up in Clinic in one month.

Pt returns home and does not receive a bill for his hospital stay and and receives follow-up care via the public clinic at the hospital. He is still somewhat short of breath.

Despite his care, Mr. Schnerd continues to have ongoing angina. Because of his recurrent pain, he is admitted and another angiogram performed which was unchanged. It is decided that because of his young age and pain refractory to medical therapy, he is referred to bypass. He is seen by the surgeon the same day, and elective surgery scheduled for the next day.

His post operative stay is uncomplicated and he returns home in 4 days. Again the cost of his inpatient stay and surgery is submitted to Medicaid and his follow-up care arranged via the public clinic.

Approximately 6 weeks later, Mr. Schnerd notes palpitations and lightheadedness. He returns to ER where his is found to be in sustained monomorphic ventricular tachycardia. He is cardioverted. Another angiogram performed and his bypass vessels are patent and his native vessels unchanged. An dual-chamber ICD is scheduled for next day (he had atruial fibrillation before) of the doctor's choice*. Again, Mr. Schnerd is seen by the social worker and arrangements made for this hospitalization to be paid by Medicaid as well. If it is determined that he signficantly disabled as a result of his current illness, Mr. Schnerd could be eventially be enrolled in Medicare. The device is implanted uneventfully and he returns home.

Mr. Schnerd follows up in two weeks after his surgery with his electrophysiologist and every three months thereafter. Home monitoring of his ICD is instituted on his first follow-up visit and the device company sends the monitor to his home, free of charge.

* In reality, hospital has asked doctor which company's devices he's willing to work with and hospital negotiates bare bones pricing on ICD and up charges device approximately two to three times cost to provide margin for hospital operations.


Now, head on over to Sarah Clarke's blog from the UK and read these same patient's care as rendered by the British health care system.

Disclaimer: The dollar amounts entered here are only very gross estimates of costs incurred. Both patients and their scenarios are COMPLETELY fictitious, but rather used to illustrate important clinical care differences between the two health care systems today.

Finally, I would be remiss to not thank Dr. Clarke for her hard work in getting this done after many hours of overseas travel and a full day of megaclinic.

-Wes

9 comments:

Keith said...

Wes,

I don;t see any differnce in the two senarios except it probably costs a whole lot more in the US than in Great Britain, which is why we are prcing middle income people out of the market. Sarah has not offered any cost estimates on her end, and all we know is that the patient there does not seemingly have to worry about any bill, which seems much better than what I imagine happens over here. Must be great to have your MI and then watch the outragously inflated usual and customary charges arrive in your mailbox. Probably why the patient ends up back in the hospital in V-tach!

DrWes said...

Keith-

Sarah is looking into costs, but due to her need to return to the UK, time difference, etc., was not able to provide on the first pass. I suspect she'll look into that issue, but like most things, it would not suprise me to find these are closely held corporate secrets.

Anonymous said...

My dad had something along same lines and he got first class treatment in England 5 years ago. No stress, no out of pocket,no issues and doing very well now. He might have gotten same treatment in U.S but I don't that to comment

Anonymous said...

Well, I guess all is settled. You suffer a heart attack with no insurance you'll get wonderful care - as good as the guy with platium insurance. I don't wish to complicate things but suppose the K-Mart guy has been a diabetic for ten years. He hasn't seen a doctor for the last five years and is often without insulin. You get the picture. Would he perhaps have avoided the heart attack and thus the $200K and counting cost if he lived in the UK? I suspect it's the chronic and not yet life threating care that better illustrates the differences between the two systems. Do these comments go to Dr. Clarke automatically?

Anonymous said...

Mea culpa. I did some googling and somewhere having to do with David Brooks, I learned that CBO does not think health care costs will be reduced by providing regular health care for the chronically ill. So I'll just have to rely on my old knee jerk liberalism - current system bad. Health reform now!

Adam Thompson, EMT-P said...

There just isn't that many people that have a sustained lack of medical insurance to reform the whole system. The numbers thrown out by our over-ambitious president are just false. There are not that many dead bodies in the streets. In fact, I haven't seen one. We already have a socialized healthcare system in place that is adding to our bankrupt state. Medicaid and Medicare both suck and drain our healthcare systems, what makes anyone think that Obamacare will be any better? Let us spend another trillion dollars that we don't have.

heidiup1 said...

Mmmmmm, I wonder if we are living in the same USA. Dr Wes, where did you get your information on the Mortimer Snerd scenario? Your information seems a bit pollyannaish. I have certainly heard many different people's stories about this over my 30 years as a hospital RN (general Med-Surg, Transplant, SICU--and many of them differ markedly from yours.

I hope that Wes and Sarah will do some more scenarios with actual social worker assistance, at least for the US piece.

Your Mortimer Snerd information may be technically correct as far as it goes. He may be totally covered for this catastrophic happening IF he is accepted for Medicaid and IF he is accepted for Medicare. However, those are BIG IFs. And perhaps he is just poor enough for your scenario to work.

However, people who make a bit more money and who are also uninsured fall through the cracks frequently. And you know what, they get a bill for the WHOLE non-discounted rate (unlike the insured). I have known many who were bankrupted by their medical needs. And currently there are two people where I work whose families/friends are conducting fund raisers to help the patient cope with the bills.

Let me also tell you that after a couple days in the hospital, the bills FROM the hospital start rolling in--sometimes the bill comes right to the sick ICU patient, while is is hospitalized.

Additionally, for Mortimer Snerd, it's possible that he is covered for the hospitalization, but quite likely that he won't be able to pay for post-op visits to the surgeon and cardiologist, or for his meds.

Rationing is happening now in the US, for all the wrong reasons. We keep dying people alive on machines for days and weeks while people like Mortimer Snerd can't get good preventive or follow-up care. (Moral distress about keeping the dying alive is a known huge dissatisfier for ICU nurses.)

I doubt that the health care reform legislation will cure much of anything in our sick, bloated system; but I hope it will help out a few more needy people.

DrWes said...

Heidiup1-

I consulted our Social Work department before publishing "Mr. Schnerd's" scenario. While we could have chosen many different scenarios and people with various income levels and circumstances, for brevity sake, we chose opposite ends of the spectrum. While I understand your political bent, the point here was to compare our two systems. To my knowledge, I am unaware of any other such direct comparison.

heidiup1 said...

I appreciate the theme of your blog and was initially hoping for a good discussion on the topic, (but with all due respect, it seems as if it may have been an excuse for posting only your political bent.)(Yes, it’s your blog.)

I’m still nagged by what you’ve left out.

What about the UNDERinsured? They are frequently employed in low-paying jobs with high deductible and high copay insurance. I don’t know what you think $17,000 buys you in the USA, but it’s not much in terms of food and shelter, let alone meds. My husband works for a large national company making about $15.00/hr; the health insurance premiums are relatively expensive and the insurance is horrible, especially for catastrophic events. Should we lose our house, which is small (but paid for) just because he has an ACS event like the one in your blog?

I just spent $198 for a 15 minute yearly Med Check visit (for 1 simple med) with my Family Practice Nurse Practitioner. She is worth every cent of the money. However, I make ~$45.00/hr (pretax, pre-health insurance, etc) and it took me about 7 working hours to pay for that one little visit.

Recently two large hospital systems in my large Midwestern city were disciplined for having used abusive bill collecting techniques. If everyone is well-insured (privately or publicly), then who are the patients who are being pursued vigorously by bill collectors?

I wonder if you see mostly well-to-do and well-insured patients in your practice (aside from those emergency MIs)? Has your practice stopped accepting Medicare and Medicaid patients, like many? Will your practice accept new uninsured people who can’t pay up front? If a current patient can’t pay for a follow-up visit, does your practice make any accommodations? Does your practice send overdue accounts to bill collectors?

I’m a bleeding heart liberal who is fiscally responsible and who believes in no debt. I also agree with David Goldhill’s idea in The Atlantic (Sept 2009) (http://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/7617/) that health insurance should be like car or homeowner/renter's insurance, and that it should only be used for larger problems, rather than for everyday sniffles. Presumably, the market would even costs out somewhat so that the routine/preventive visits would be more affordable, as well as eliminating unnecessary screening, etc.

Until that unlikely day, I hope that you will do your utmost to expand your interesting theme—so that your audience understands more of the issue.