Category: Patients

Cracking down on abusive medical debt collection practices

published date
December 18th, 2006 by

Thank goodness for the Boston Globe. The four-part series on Debtors’ Hell that ran over the summer highlighted the abusive nature of the debt collection business. Now, at least some Massachusetts counties are responding.

The headlines from the summer series more or less tell you what you need to know:

  • Part 1: Preying on Red-Ink America. No mercy for consumers
  • Part 2: A Court System Compromised. Dignity faces a steamroller
  • Part 3: Enforcers’ might goes unchecked
  • Part 4: National Crisis, Official Silence. Regulators, policy makers seldom intervene

One of the articles in part four, For some, a bitter remedy for overdue medical dental bills, described the following, all-too-common situation:

When Marcy Armington objected to her obstetrician’s bill, believing her health insurance should cover the $300 balance due for the birth of her daughter, she had no idea that such a common dispute would leave her vulnerable to the ”The Hubbard Law Office Experience.”

That would be attorney Richard R. Hubbard of Uxbridge. Hubbard sued Armington on behalf of Dr. Thomas A. Spina of Hopedale – though the suit listed the wrong address, so she knew nothing about it. Last March, two Worcester County sheriff’s deputies came to her Milford home to take her car. To keep it, Armington had to pay $983, to cover the $383 court judgment and the $600 sheriff’s fee.

Debt collection is a very sleazy business to begin with as the series describes—

Constables…carry badges and have arrest powers — yet are untrained and unmonitored. [M]any do the dirty work of property seizure for some of the most aggressive debt collectors in the state… In Boston, 88 of the 186 constables have criminal arrest records of one kind or another…

–so I’m not surprised that debt collectors would try these tactics. But what’s appalling to me is that unpaid, contested medical bills are considered legitimate debt and that sheriffs so willingly participate. Anyone in the medical field knows bills are often just plain wrong and almost always hard to understand.

There’s still nothing like front-page exposure in a big city newspaper to effect change. The Globe reported today that sheriffs in three large counties are no longer seizing cars to repay medical and dental expenses, nor when the amounts owed are less than $1500. Those changes have been enough to drop seizures by half, which tells you something about how common these cases are.

As previously reported, medical bills are a major contributor to bankruptcy filings. Even people with health insurance can end up in BK if they encounter a serious, prolonged illness. One reason is that medical care is expensive. Another is that administrative errors, bureaucratic indifference, and aggressive “debt” collection are enough to drive people over the edge.

Putting the Informed into Informed Consent

published date
December 8th, 2006 by

Putting the Informed into Informed Consent

Physicians and clinical trial coordinators often view “informed consent” as just a form that needs to be filled out or a procedure that needs to be undertaken. A common consequence is that those who have consented have not necessarily been well informed. Informed consent should really be treated as an ongoing process, with a chance for patients to absorb and discuss information over time.

A new study of informed consent for clinical trials conducted in the ICU comes to the not very surprising finding that most patients who consented to participation in a trial don’t really know what’s going on. I would have been shocked if the data showed anything else.

A more useful study, in my view, would examine how many patients undergoing elective procedures or enrolling in clinical trials outside of the hospital understand what is happening.

In health care, the rich and powerful really aren’t insulated

published date
December 7th, 2006 by

In health care, the rich and powerful really aren’t insulated

Princeton economist Uwe Reinhardt wrote a letter to the Wall St. Journal last week, tweaking the Journal for espousing market forces in health care in the form of high-deductible plans. After all, writes Reinhardt, corporate executives often receive generous, lifetime health insurance and are even reimbursed for out-of-pocket expenses. Shouldn’t they have “skin in the game,” too?

Today the Journal published a thought-provoking response by Matthew Huggins:

Perhaps the… isolation from the market… makes [corporate executives] ill-suited to oversee the wholesale purchase of health-care services for others. [I]nstead of stripping executives of their… coverage, as Prof. Reinhardt wryly suggests, in furtherance of sounder markets, why not strip them of their predominant role in purchasing health-care services? Reassign such purchasing decisions to individual patients by dismantling the regulations and tax incentives that tend greatly to enhance the relative purchasing power of large employers and governmental bodies.

Another letter by Brian Acker pointed out that we don’t advocate equality in other sectors, so we shouldn’t worry about inequality in health care benefits either.

Actually, there is more equality in access to health care services than there is for most other things. For example, think about disparities in transportation from Boston to Washington:

  • Lots of people don’t have enough money to go. They stay home.
  • Others take the bus
  • Some drive –in cars of various levels of comfort
  • Some fly coach
  • Others fly first class
  • Some (like the executives we talked about earlier) go by private jet

Now think about what happens to someone who needs to go to the hospital in Boston

  • Anyone can go to a top hospital like the Brigham and Women’s or Mass General and be treated pretty much the same. You might get hassled by accounting if you don’t have insurance, but the doctors and nurses don’t tend to give you a hard time based on your economic status
  • If you’re someone special (e.g., a big donor) you might find yourself on a VIP floor at Mass General (though it’s unlikely elsewhere). The room’s not that much better, though, and you probably won’t receive better care. And I’ll go out on a limb and say your chance of having something go wrong due to medical “error” is not much affected by being up there. Maybe you can get access to better or more prominent physicians, but not necessarily. And anyway, do you really know how good or bad they are?

Overall, the rich and powerful are highly constrained in their ability to get exceptional service and quality in health care compared to other spheres in their lives. That’s one reason that corporate executives are interested in improving the quality quality and service levels of the US health care system. They are not insulated from commoners in health care the way they are everywhere else. Unlike Huggins, I wouldn’t take health care purchasing out of their hands just yet.

A novel idea for measuring quality: focus on the patient!

published date
December 6th, 2006 by

A novel idea for measuring quality: focus on the patient!

It’s kind of pathetic that this is just being recognized.

Speakers at a forum hosted by the Alliance for Health Reform and the Commonwealth Fund… said that “patient-centered care” is important in efforts to measure health care quality.. [S]peakers said that patient-centered care measures can include the level of patient involvement in their health care, the effectiveness of coordination of care among different providers, routine feedback to hospitals, clinical information systems that support high-quality care and publicly available information on patient-centered care… [T]he Joint Commission Journal on Quality Improvement found that patients who received patient-centered care were less likely to experience complications and death than other patients…

Anything that makes “experiencing death” less likely is probably good.

In case having prostate cancer wasn’t bad enough

published date
December 1st, 2006 by

In case having prostate cancer wasn’t bad enough

If you’re unlucky enough to get prostate cancer, you’d at least expect your doctor to help arrange the best possible treatment plan for you. However, some urologists may be a little more interested in boosting reimbursement for themselves than in making life easier and better for their patients. They’re using I.M.R.T., a radiation therapy that can result in payments of up to $47,000, which is far higher than for other methods. According to the New York Times:

Helping drive the trend is a Texas company, Urorad Healthcare, which sells complete packages of I.M.R.T. technology and services, and hopes to persuade even more urologists to buy them.
“Join the Urorad team and let us show your group how Urorad clients double their practice’s revenue,” the company says in a marketing pitch to doctors on its Web site.
Urologists who have purchased the new multiple beam systems say they are embracing a superior way to treat prostate cancer. But because there is little research directly comparing I.M.R.T. with the other treatments, there is little consensus among urologists about which approach is best…

Compared with seed implants, for example, I.M.R.T. involves a large time commitment, requiring patients to visit a radiation center 45 times over the course of nine weeks.

One thing that particularly concerns me is those patients who will be pushed into IMRT when they might be better off with no treatment at all.