Health Business Blog

Health care business consultant and policy expert David E. Williams share his views

Drug resistant HIV scare

Last month the New York City health department issued a press release entitled “New York City Resident Diagnosed with Rare Strain of Multi-Drug Resistant HIV that Rapidly Progresses to AIDS.”Major media picked up on the announcement as a watershed event that could mark a turn for the worse in combating the HIV/AIDS pandemic.

I asked Veronica Miller, PhD, Director of the Forum for Collaborative HIV Research for her view. Here’s what she had to say:

The case of the “new strain” of HIV has generated much interest and concern. Numerous previous studies have documented the transmission of resistant HIV, including resistance to one, two or three drug classes. While the findings reported recently are not “new”, the publicity has highlighted the need to pay attention to the spread of drug resistant HIV. It also highlights the need for a surveillance program to monitor drug resistance. We lack a true picture of resistant HIV in North America. Most of the information we have comes from small, specialized studies of non-representative populations. Surveillance of HIV drug resistance will provide crucial local, state, provincial and national data concerning the prevalence of drug resistance over time. It will enable public health officials, policymakers, and clinicians to recommend the appropriate use of drug resistance testing and the most efficient initial treatment combinations.

Air ambulances: costly, dangerous, slow?

According to today’s Wall St. Journal, not only are air ambulances liable to crash (a crew member who worked 20 hours/week for 20 years would have a 40% chance of being killed), they are often slower than ground ambulances, and are used to transport patients who aren’t that sick.

The conventional wisdom is that air ambulances save the lives of patients who are too critically ill to withstand a slower ride in a ground ambulance. Yet some observers of the industry say medical air transports actually save very few lives — while costing as much as 10 times more than ground ambulances. A number of published studies including research at Stanford University and the University of Texas, show that the flights often transport minimally injured patients when ground transport frequently could get them to a hospital faster, and with less risk to others.

“In 20 years of experience in urban critical-care helicopter transport, I can count on the fingers of one hand the number of times I thought flying a patient to the hospital made a significant difference in outcome compared to lights and siren,” says David Crippen, an associate professor of critical care and emergency medicine at University of Pittsburgh Medical Center.

Of course, there are situations where air ambulances make sense, such as in rural areas. On the other hand, even speedy air ambulances can’t do much about the 10-20 hours waits I mentioned in yesterday’s post on Mass General.

After 9-year-old Tyler Herman fell and broke his jaw in the wilds of Arizona, doctors at a community hospital decided the boy should fly to Phoenix to undergo plastic surgery for a gash on his face. During the flight he was well enough to sit up and remark on the scenery. Upon arriving in Phoenix, he waited nearly 20 hours to undergo surgery. “We could have driven him there in four hours,” says Sharon Herman, the boy’s mother. Her insurance didn’t cover air transport, leaving the Hermans with a bill for $25,000.

New health insurance option for the employed but uninsured

This morning the Boston Globe reported on a new health insurance plan to cover the employees and contractors of Fortune 500 companies who currently have no access to employer-based health insurance.

According to a press release on the topic from UnitedHealth Group,

Mirroring the advantages of a traditional group policy, National Health Access provides individuals with lower costs and more flexibility in health insurance coverage than most people can obtain on their own through the individual insurance market. The program includes a choice of up to six levels at different prices that can be tailored to fit individual needs. For example, participants have options to choose major medical coverage, inpatient and outpatient benefits, wellness benefits, and discounts for in-network medical care. Wellness benefits and dental and vision preventive benefits have also been incorporated into the program. Uniprise is offering options at each of the levels. Pending state-by-state regulatory approval, open enrollment is scheduled to begin September 1, 2005.

The main advantages appear to be that employees get more choices of plan design than they would have on their own, and get access to discounts negotiated by National Health Access. That way they aren’t forced into the absurdity of paying the unreasonable “charges” that providers foist on the uninsured.

Since members of this plan are going to pay out-of-pocket for much of their care, it seems like a good opportunity to apply electronic communications between doctors and patients as described yesterday.

Electronic communication between doctors and patients

An article in this morning’s New York Times describes the move toward structured, electronic messaging between doctors and patients. (My client, RelayHealth of Emeryville, CA is featured prominently.)

For doctors, the convenience of online exchanges can be considerable. They say they can offer advice about postsurgical care, diet, changing a medication and other topics that can be handled safely and promptly without an office visit or a frustrating round of telephone tag. And surveys have shown that e-mail, by reducing the number of daily office visits, gives physicians more time to spend with patients who need to be seen face to face.

For patients, e-mail allows them to send their medical questions from home in the evening, without missing work and spending time in a doctor’s waiting room. In fact, many say exchanges in the more relaxed, conversational realm of e-mail make them feel closer to their doctors.

Some health plans are reimbursing physicians for these online webVisits. However they don’t quite get it because in many cases they still charge the patient the same co-pay as for an office visit, which discourages patients from trying the service.

“Patients love this stuff; I love this stuff; the staff loves this stuff,” said Dr. Barbara Walters, a senior medical director at Dartmouth-Hitchcock Medical Center in New Hampshire… “The intelligence of our patients never ceases to amaze me,” Dr. Walters said. “Patients can describe what’s going on with them, if given the chance and given the time.”

10 (or 20) hour wait for a bed at Mass General

The front page of today’s Boston Globe has a picture of stretchers lined up in the hallway because the ER is overcrowded. It’s what we might expect after a natural disaster, but apparently this is business as usual at Mass General Hospital:

Typical is the situation recently at Massachusetts General Hospital… It was 1:30 pm on Thursday, and 20 patients in Mass. General’s emergency department needed to be admitted to the hospital for more extensive care. But the hospital had beds for only eight new patients. The electronic chart listed how long patients had been waiting for beds on a medical floor. The longest: two patients for 21 hours and one patient for 22 hours. A half-dozen recent arrivals were parked temporarily in hallways.

In classic fashion, hospital administrators say they’re doing all they can and need more capacity. Some hospitals in Boston are adding beds. Deep in the article there is a reference to Eugene Litvak, professor of healthcare and operations management at Boston University. He believes the problem is poor planning and I think he’s mostly right.

We wouldn’t expect factories to simply add new, expensive capacity as a first resort every time demand increases, and we shouldn’t expect it of hospitals either.