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Hospital Pricing Mandate – A Sort of ‘Bird Box’ Reality

NOTE: This photo is not Sandra Bullock, but rather, a healthcare shopper seeking assistance online.

Over the holidays, my daughter and I watched a newly-released Netflix movie, ‘Bird Box.’ Other than having Sandra Bullock as the lead actress, I knew nothing about the film. The plot of this show, without issuing a spoiler alert, is that some unknown force mysteriously destroys the earth’s population, and the only certainty of survival is to not ‘see’ this evil. To remain alive, survivors must cover their eyes from the evil that chases them. One small peek can spell doom for those curious. In this riveting movie, having blindfold vigilance is the difference between life and death.

Recent findings in the January issue of the Health Affairs journal reveals that higher costs, not better patient care, serve as the primary explanation on why the U.S. spends much more on healthcare than other developed countries. Researchers found that U.S. healthcare spending was $9,892 per person in 2016, about 25 percent more than second-place Switzerland, which averaged $7,919 per person. Our neighbor to the north, Canada, is less than half of what we spend, $4,753.

The drivers for this enormous cost chasm, according to this article, is that the U.S. has higher drug prices, higher salaries for doctors and nurses, higher hospital administration costs and, yes, higher prices for many other medical services. Despite these costs, Americans have less access to many healthcare services than residents of other developed countries. A perfect storm, we might say. I have reported similar findings in a prior blog.

To make matters worse, the same study indicated that in 2015, there were 7.9 practicing nurses and 2.6 practicing physicians for every 1,000 Americans, compared to OECD medians of 9.9 nurses and 3.2 physicians. The long-term prospects of our numbers improving are not promising. Also in 2015, the U.S. had only 7.5 new medical school graduates per 100,000 people, considerably less than the median of 12.1 in developed countries.

Certainly, there must be some good news to share with you, right? Yes…and no.

Hospital Price Transparency Requirement

The prices we pay for hospital care, clinics, surgery centers, and prescribed medications, are usually unknown until sometime AFTER the interaction – typically following review and payment by our insurance vendor. The healthcare infrastructure gives much lip service to patient centricity, but follow through is underwhelming, to put it mildly. Transparency is extremely important these days because most Iowans and Americans are required by their health plans to pay higher deductibles and co-pays when seeking medical care.

Beginning January 1, the Centers for Medicare and Medicaid Service (CMS) is attempting to force price transparency by requiring all hospitals to post their list prices online. Under this arrangement, hospitals are required to publish a list of their standard charges online in a “machine-readable” format and to update this information at least annually. Hospitals are currently required to make this information publicly available or available upon request.

On the surface, this appears to be a hopeful beginning for all shoppers – and it is. However, when I look at hospital websites in Iowa and elsewhere, mandated compliance is far from patient centric. Using two of the largest hospital systems in Des Moines as proof – Mercy Medical Center and UnityPoint – we have a long way to go before price transparency nirvana can be reached.

Mercy Medical Center – Des Moines

The Mercy ‘Cost Estimator’ tab begins with a disclaimer that any costs published are nothing more than ‘estimates.’ The price-shopping patient must first click the “I Agree” button before being allowed to advance to the next page, which is sort of a magical mystery tour (special thanks to Lennon and McCartney). This page shows a similar disclaimer that all prices are mere ‘estimates,’ (special thanks this time to lawyers and marketing). In the left margin, we find links to a dozen ‘body systems’ that will allow price-shoppers to analyze procedures, median charges, various percentile charges, MS-DRG/CPT and Codes.

Not to be outdone, an exhausting ‘list of current standard charges’ is found subtly at the bottom of the ‘Body System’ list. Progress is now being made (tongue in cheek), as the price-shopper (hopefully not needing urgent care while searching for helpful prices) can find a treasure trove of data in an Excel spreadsheet:

  • CDM Numbers
  • Code Descriptions
  • CPT Codes
  • Revenue Codes
  • Charge

This spreadsheet shows 40,054 charge description masters (CDMs), which are incomprehensible medical procedures that are a hodgepodge of numbers and technical medical terms. One example is the 46040 4405 Abscess I&D Ischiorect, which has a charge (before discounts) of $10,936.  Huh?

In fairness to Mercy Medical Center, largely due to their repeated disclaimers, my expectations for finding value were set reasonably low. Put another way, I would not use this website as a shopper, as it is absolutely meaningless. Hospitals provide this data (and the gibberish language that comes with it) only because they are federally required to do so, not because they have a profound desire to empower patients.

Have you ever bought a non-medical product or service using ‘estimated’ prices? I didn’t think so…nor have I.

UnityPoint Health

UnityPoint’s ‘prices’ are found in the tab aptly labeled, ‘Patient Charges and Costs.’ On this page, the hospital does a reasonable job of explaining what the charges are…and are not. About halfway down this page the price-shopper can find two links that provide “Des Moines’s current charge information as of December 31, 2018,” in addition to “Des Moines’s standard Diagnosis-Related Group charge information as of December 31, 2018.” Each link will take the shopper to Excel spreadsheets that make little to no sense…even for someone like me, who makes a living using spreadsheets.

UnityPoint also provides a link to Iowa Hospital Charges Compare, a website provided by the Iowa Hospital Association. In addition to comparing ‘estimated’ hospital inpatient services by selected Iowa hospitals, it also provides ‘estimated’ prices for outpatient surgery procedures.

Trying to determine hospital prices in advance of a test, procedure or stay is daunting, frustrating and futile. This new hospital ‘transparency’ requirement is a very small step that needs a rocket boost into the 21st Century. What price-shoppers now see on hospital websites come from ‘chargemasters,’ which are massive compendiums of prices set by each hospital for every service or drug a patient receives. Historically, even hospital administrators can be flummoxed by how chargemasters are established.

But the real issue is that each published price is nothing more than a ‘list’ or ‘estimated’ cost. Currently, most procedures are still being charged separately, and are not bundled together. In most hospital encounters, it is extremely difficult to determine whether additional procedures will be required PRIOR to the patient entering the hospital. On top of this, the negotiated price of any claim is determined by the third-party payer (e.g. insurance companies, self-funded plans, Medicare, Medicaid, etc.) the shopper uses. Additionally, hospital location and the shopper’s specific health plan features (deductibles, coinsurance, etc.) will also determine the final cost.

Here’s a novel concept: Instead of pricing their services using the ‘horseshoes and hand grenades’ approach, hospitals could take the initiative and partner with ‘motivated’ insurance payers to develop a patient-friendly tool that provides legitimate ‘real-time’ prices along with patient-specific health plan out-of-pocket calculators. This sounds much too simple, doesn’t it?

Transparency WITHOUT the blindfold

To stay alive, Sandra Bullock needed to keep her blindfold close by before navigating outdoors. Healthcare shoppers, on the other hand, are trying remove their blindfolds to make appropriate decisions when seeking high-value healthcare. Unfortunately, to maintain the status quo, the current healthcare infrastructure works very hard to keep the blindfolds tight and opaque. But, to do the right thing in healthcare, we must tear down the existing silos of self-interest that dominate the care that Iowans and Americans deserve – and pay for.

Much work needs to be done to find this common good. By doing so, our blindfolds may finally be removed and clarity revealed.

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Working Remotely – It Comes at a Cost

I sometimes joke that my “international headquarters” is located in Clive, Iowa, with satellite offices peppered “throughout the globe.” Technically, there is a great deal of truth to this seemingly impressive boast. However, fact and fiction become more clear after revealing my true workplace arrangement.

My office is indeed based in Clive, but I don’t participate in daily or weekly employee meetings. I do not gossip at the water-cooler – heck, I have NO water cooler! My office consists of one person – ME. When I am not physically in the office, I can be anywhere and everywhere still transacting business – with the assistance of my laptop, iPhone and iPad (Wi-Fi is a critical ‘friend’ to me). Even though I have a physical office, I often feel that I work ‘remotely’. Much of what I do is by myself or orchestrated with a few trusted third-parties. I have come to like this ‘remote’ arrangement a great deal. But it does come at a cost.

According to a 2017 Gallup survey, 43 percent of 15,000 employed Americans said they spent at least some time working remotely – usually from their own home. This represents a four percent increase from 2012. In our 2016 Iowa Employer Benefits Study©, we found that over 34 percent of employers with more than 101 employees offer flextime, while just over 14 percent of employers with fewer than 101 employees did. Flextime allows for employees to customize their schedules within a certain range of hours and days. Unfortunately, these results do not specifically reveal how many Iowa employers allow employees to work remotely.

Flexible scheduling and working remotely are increasingly important factors for employees to take (or leave) a job. Employees argue, and many employers acknowledge, that these practices are beneficial for both – workers are more productive for their organizations (an obvious win for employers) while being able to more successfully navigate through their own personal work-life issues (a win for employees). Working remotely and having flexible hours also provide financial upsides to employees –  savings in lunches and transportation costs, along with having greater childcare flexibility.

A 2015 Employee Job Satisfaction and Engagement report by SHRM indicated that 55 percent of employees cited that flexibility to balance work and life issues was a very important aspect of their job satisfaction. This same report found that leading reasons employees would not leave their jobs within the next year was primarily due to compensation/pay (45 percent) and having the flexibility to balance work and life issues (42 percent).

But, as I have personally found, working ‘remotely’ does have some drawbacks. Here are two of the largest challenges that employers (and employees) should be cognizant of when working remotely.

Social Connectivity Can Suffer

Social connectivity drives the engine of our mental well-being. Connectedness within the workplace plays a vital role for employees to feel they are seen, heard and valued through organizational relationships. Working remotely can easily isolate one from social inter-activities that is crucial for employees who yearn to have the ‘sense of belonging.’

According to the 2018 State of Remote Work, surveyed employees who work remotely reported the two biggest advantages were having a flexible schedule (43 percent) and spending time with family (15 percent). But, if not careful, these advantages can be offset by loneliness (21 percent), reduced collaborating/communicating (21 percent), having distractions at home (16 percent), and staying motivated (14 percent).

To go one step further on social isolation and loneliness, as more people in the U.S. are living alone, some researchers are warning this could become a “greater public threat than the widely discussed problem of obesity.” That should grab our attention!

To combat the negative side-effects of loneliness, employers might encourage (or establish policies) requiring remote workers to come to the office once a week to learn and grow. Studies suggest this approach is more likely to generate happier employees compared to fully-remote employees who don’t physically reconnect with the office.

Some employees may be quite geographically remote, and perhaps it would be more realistic to have them come to the office monthly or quarterly. Speaking from experience, the most rewarding days at my office usually result from having face-to-face meetings with various individuals that I would otherwise correspond with via phone or email. Embracing the opportunities to physically meet with others should always be a priority – it is for me.

Stress or Burnout

This may sound somewhat counterintuitive to some of us, but working remotely can nudge employees to work longer hours to please their supervisors, just because they are grateful for having the opportunity to work remotely. For me, if I don’t stay on top of my self-imposed projects, they will not be completed. This responsibility causes added pressure to ALWAYS be engaged with my work, sometimes more than I really should be.

Unintentionally, employees may burnout from performing this additional work without the employer having the benefit of monitoring the employee’s well-being throughout a course of time. That is why it is so critical for organizational leaders to engage with remote employees about what is going on – not only in their work – but with their personal lives. Feeling isolated has large, emotional costs.

As workplaces continue to morph into new environments that require employees to work remotely, it is imperative for leaders to find ways to have regular ‘face-time’ to ensure the worker does not lose the social connectedness that will keep them both happy and productive. This same principle applies to entrepreneurs who are working on their own.

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Standing at Your Desk – A Healthy ‘Fad’?

Since mid-October, I have been experiencing a pinched nerve in my lower back. Anyone who has experienced this type of condition knows the pain can be excruciating, as my symptoms also include numbness or weakness of my lower back and left leg. Lumbar radiculopathy is typically caused by a compressed spinal nerve root, which results with pain in the leg rather than in the lumbar spine. Why this happened to me is unknown, but I would speculate it gradually developed from daily running when not biking. Having ‘additional’ birthdays may also be another reason!

With the help of a physical therapist, I perform various daily exercises at home (or in the office). Despite PT, however, the searing pain persisted enough to have an MRI performed, confirming the Lumbar 4 location. As I wait for the next elevated level of care – most likely an epidural steroid injection – I judiciously use Tramadol, a synthetic analgesic opioid medication that is used to treat moderate to moderately-severe pain. For me, the best relief is to simply sit down, which allows me to forgo Tramadol. Accordingly, I spend more time sitting at my desk working on projects that don’t require traveling to outside meetings. Needless to say, having these physical limitations are wreaking havoc on my daily activities…and exercise routine.

I share this ‘protected health information’ because I am intrigued by the latest craze – the stand-up desk – a desk that allows you to stand up while working at the computer. You will find ads in newspapers, magazines and the internet about these desks, often touting why it is so much healthier to be working on your feet rather than, well, your bottom.  The purported health benefits of these desks are both broad and deep. One website listed at least seven potential health benefits when using such desks:

  1. Standing Lowers Your Risk of Weight Gain and Obesity
  2. Lowers Blood Sugar Levels
  3. Lowers Risk of Heart Disease
  4. Appears to REDUCE BACK PAIN!!!
  5. Helps Improve Mood and Energy Levels
  6. May Boost Productivity
  7. May Help You Live Longer

Fantastic! I want…no…I NEED to have a stand-up desk!

Due to our sedentary office jobs and daily living habits, American workers burn around 140 fewer calories per day compared to 59 years ago (1960). In July 2016, The Lancet issued study results that indicated 60 minutes of daily physical activity (e.g. brisk walking, pleasure biking, etc.) may help offset health risks of having to sit eight hours a day at the office. This November, The Department of Health and Human Services (HHS) issued updated activity guidelines for Americans to help combat the fact that nearly 80 percent of U.S. adults and adolescents are insufficiently active. The health benefits of exercise are clearly not fake news, as there is too much scientific research to refute the naysayers.

Cautionary Note

Before buying into the aforementioned stand-up desk ‘craze,’ one might want to consider some research that at least tempers its glowing accolades.  Aaron Carroll, professor of pediatrics at Indiana University School of Medicine, writes well-researched blogs about healthcare and policy. Recently in the New York Times, Carroll wrote a compelling piece about why standing-desks are ‘overrated,’ winnowing fact from fiction.

I will not take up my sitting time by regurgitating Carroll’s article, but I would like to summarize his ‘finding’ with the following: Exercise is important for our health, but merely standing is NOT considered to be ‘exercise.’ Sitting may not be the problem on why we are unhealthy, but rather, it may be a “marker for other risk factors that would be associated with higher mortality.”

Personally, I’m intrigued about standing while working at my computer. But first, my lower back must heal before I can stand for any period of time. For now, my lofty expectations about using a stand-up desk have been adjusted at a more reasonable (and comfortable) level…that of my office chair!

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