Bryan R. Fine, MD, MPH

Beginning with the 2012 academic year, Eastern Virginia Medical School - where I have a faculty appointment - was awarded a federal grant to incorporate public health training into the classic categorically pediatric residency training.

This validation - that public health training can be an important part of an allopathic, clinical program - may seem intuitive to some. But the actual implementation remains quite challenging.

Foremost, there are logistics that must be negotiated. These days, everyone reading this blog will likely be familiar with the increasingly strict work-hours limitations, which currently mandate a maximum 80-hour workweek (likely to be shortened even further in the future) and limit interns to 16-hour shifts.

How, then, does a public health curriculum get prioritized? The intention is that by the end of a three-year residency program, graduates have obtained the near equivalent of 12 credit hours that could be transferred, if desired, to some public health programs. Can a lecture on health equality be as vital as a mock code, a talk on anemia, or a lecture on toxic ingestions?

I recently taught the course on Public Health Policy and Economics, which was sandwiched between the Introduction to Public Health and Health Disparities courses. I was given an hour a week to speak directly to residents at lunchtime.

In comparison, when discussing this with a colleague at another institution, he marveled at the commitment. He explained the difficulty at giving any one division a guaranteed lecture per month, even on clinical issues, let alone a once-a-week public health commitment. His incredulity was palpable.

Some of the strategy I use, then, is to make the talks as pertinent - and clinically relevant - as possible. It meant revamping some of my canned talks and designing them specifically for my audience du jour. It also meant working with my public health-trained colleagues and offering them guidance on how to talk to tired, busy, often disinterested residents, because passions on the importance of global health metrics or the broad implications of socioeconomic disparities do not easily translate.

1. Try to limit talks to 35-40 minutes. It's doable, no matter how broad the topic.
2. Use very specific titles to draw in listeners. Such as: “Clinical Application of Medicaid for the Virginia Pediatrician.”
3. Incorporate vignettes with a clinical slant, best stated as, “A three-year old patient with a managed care Medicaid product presented with cellulitis…”
4. Multimedia -good.
5. PowerPoint - bad. A 35-40 minute talk can be delivered with a maximum of 10 slides, easy.

It is important to remember that administrative and economic issues are not high priority to residents, not because they don’t consider them important but more likely because they are so insulated from the practical value. Just as someone might be tough to engage on a highly technical talk on endoscopic supraglottoplasty if she is never going to do an edoscopic supraglottoplasty, so too may the implications of EPSDT, or the nuance of federally-funded community health centers, or the challenges with Head Start, seem foreign.

In fact, these challenges are similar with all physicians, not just residents. And why I write this blog, and speak at Grand Rounds, and try to engage my pediatric hospitalist colleagues on listservs and national conferences.

In this changing landscape, you have to know this information. We have to work to seamlessly integrate such knowledge into training. That's part of my goal here.

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Articles

Public health as an important part of an allopathic, clinical program may be intuitive to some, but implementing it is still a challenge.

Making Public Health Policy and Economics a Priority

My father, a plastic surgeon, often makes the following point when we discuss the economics of medical practice:

"My cosmetic practice is rarely covered by health insurance, and as such 100 percent of people ask me how much things cost. My reconstructive practice is generally covered by insurance, and zero percent of people ask how much it costs, because they expect - and will accept nothing less - than nothing out-of-pocket."

I’ve paraphrased his sentiment, and unfortunately for the reader I can’t accurately recreate the gesticulations and strategically placed emphases that my father employs. For example, he often says "100 percent" several times to ensure the listener understands he means every-single-one. And he will pinch his thumb and index finger into a circle and hold it up to demonstrate what he means by "zero."

This exchange, a variation of which we have fairly often, represents both his impression of what is wrong with the healthcare system - the disconnect between patient care and cost - and how passionate physicians can be about the topic. While not everyone will enthusiastically embrace his proposed solutions (which generally revolve around free-market tenets), almost everyone will agree that the distance between consumer and commodity has become too far for most people to navigate intelligently.

Yes, I’ve used "consumer" to mean "patient" and "commodity" to mean "healthcare services." I recognize some people cringe at this analogy, and over the years I have read well-written humanities essays and letters to the editor decrying the "industrialization" of medicine.

"I am a doctor, not a healthcare provider. I see patients, not customers," some physicians have eloquently declared.

But I believe that the words are synonymous when you consider that physicians generally expect to get paid for their work. I’m not saying that healthcare services are a commodity in the classic widget sense, but I have grown to concede that the service we as doctors provide is a commodity. Thus, when we are discussing the economics of medicine, it is fair - and in fact appropriate - to categorize the conversation in economic terms.

These terms can be mutually exclusive. The child / family in front of us can be both patient and consumer, and can still receive honest, compassionate, quality services even if we’re sub-acutely aware of the fiscal machinations that influence every patient encounter we have. I would argue that this awareness - irrespective of the semantics - ultimately benefits the patient, both during the bedside encounter and in a broader, public health sense.

Patients and doctors have indubitably been drawn further and further away from the financial implications of the decisions we make in the course of a doctor-patient relationship. It is a fun exercise to imagine how decisions we make on a daily basis might change if even a hint of economics were incorporated into the decision-making process.

For even the noblest doctors, would risk assessments "change" if there were dollars more closely involved? In the pediatric world, this might be represented by the classic case of a young infant with fever. We hold steadfast to the notion that even the most well-appearing infant should be admitted to the hospital for 48 hours if she present with a low-grade fever, citing loose evidence of one-in-a-thousand chance of meningitis. We stick catheters in urethras, and needles in veins and lumbar spaces, and implore families that this is the standard of care.

But what of the family without insurance, who would have to bear the brunt of an $8,000 hospital bill for a short stay? Might the standard of care not shift a little, should the baby be particularly well appearing, the fever spuriously documented and since resolved, and the initial lab work reassuring?

So few people, when seeking acute care, ask about costs. In the pediatric hospital, it darn well approaches zero percent. Which is probably a good thing for now …because so few doctors would know even where to begin with an answer.

I’m not saying that healthcare services are a commodity in the classic widget sense, but I have grown to concede that the service we as doctors provide is a commodity.

Identifying the Distance between Healthcare Cost and Patient Care

"Whether we like it or not, we must admit that we are living and working in a period of basic changes in the economic aspects of the practice of medicine."

I, of course, could have come up with the words above, as they certainly hold true today. In a couple months, the Supreme Court will decide on President Obama’s signature piece of legislation, the Affordable Care Act, a rendering that may undo the basic changes that have already taken place and return us to a situation where basic changes are still necessary.

But, these words were in fact written in 1948, 

This is a fascinating read, with insight into the transition from pristine doctor-patient relationships (and conspicuous masculine-centric pronoun choices) to the employer and government-based systems that we have today.

"There was a day when the physician could make his visits on a completely individual basis …His bills were entirely between himself and his patients."

The articles reads, in parts, as a libertarian manifesto, and it is hard to conceive the passionate perspective of a physician in the 1940s facing the prospect of monumental change in the system.

"…it is not necessary to remind you that we are confronted with a plan for national health insurance administered by the Federal Government."

The title of the piece is "Pediatrics and Economics." More than 60 years ago - and probably in every year since - this has been an issue of considerable importance, and yet still there remains an incredible shroud over the topic. Some might argue that the placing of these terms next to each other with the collaborative conjunction "and" is heretical. Pediatrics, they might say, by definition falls outside the bounds of typical economic considerations because of the public health (and public relations) considerations.

Are we at a stage where someone can utter the word "profit" while still maintaining a credible outward attitude toward holistic, accessible pediatric patient care? We generally substitute euphemisms, such as "private" or "non-academic." We shield young physicians from the gory details of the dollar(s), often burying them in academic models that rarely disclose physician charges, let alone openly reveal true collections or the disbursement percentage of each collected dollar to the fingers in the till.

Further insights still, from 1948, suggest that the core challenges to the healthcare system have remained inert over 60 years even while the reimbursement model has shifted almost completely.

"Children in isolated areas are handicapped particularly in specialist care, clinic care, and the highly skilled diagnostic and treatment services… deficiencies exist in the distribution of physicians and medical care in some areas of the country in comparison with others…"

What remains the most challenging is to define the goals. We all would likely agree that things need to get "better," yet we are far from offering opinion that is widely embraced. Some of this falls in our own inability to answer the most basic of questions: What is equality? What is considered access?

Perhaps the answers reside in the whispers that tickle the walls in our living rooms, when taking into account the lengths we would go to for the health of our own children.

Economics and pediatrics will always be a complex topic. There will always be passionate debate. This is no better illustrated than in the very core premises of Medicaid financing, whereby children are entitled - by law - to any reasonable and necessary diagnostic or treatment modalities, yet obtaining these services are generally difficult because providers often describe that they aren’t remunerated adequately and thus limit their exposure to the Medicaid population.

It carries a wonderful irony that, in this age, a paper from more than 60 years ago could be published again - cleaning up the older-style English and reworking a few basic facts - and remain almost entirely current. There is a lesson here. What lesson? Well, that I’ll leave up to your interpretation, through the prism that shines light to your eyes.

 Sisson, Warren S. “Pediatrics and Economics.” Pediatrics. 2,1,89-96. 1948.



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As the Supreme Court considers the fate of the Affordable Care Act, some guidance on the heart of the matter can be found from more than 60 years ago, from physician Warren Sisson.

Debate over Healthcare Economics Nothing New

There is as lingering discomfort in the "down there" area. But I’m optimistic that will continue to improve, and I’ve even starting jogging - with doctor’s clearance, of course.

The scars are healing nicely, so my summer beach aspirations aren’t destroyed.

Probably, I could roll this story on for quite a while.

I still haven’t received a bill from the anesthesia team. I suppose it’s possible it’s rolled into the hospital bill for services, but since the EOB wasn’t truly itemized I can’t say for certain. I doubt it, though. It is rare that physicians and hospital bill together. Even physicians employed by hospitals often live in separate physician practice group that bills - and advocates - as a distinct entity.

So, as of this moment, I have received the surgeon’s professional fees explanation of benefits and the hospital explanation of benefits, the former of which arrived at approximately $7,000 in charges (I was asked to pay about $1,000), and the latter - hospital "fees" - came in at nearly $20,000.

Immediately after my last post, nearly three weeks ago, I had my follow-up visit. Upon arrival and check-in, the woman at the desk asked me how I would like to settle my bill (for physician’s fees). I politely explained to her that the one bill I had received - $297 for the initial assessment, of which I was asked to pay $294 - I had promptly paid. The remainder of charges, which she had on a paper in front of her, I hadn’t even been billed for yet. I explained that I’d received the EOB from the insurance company - but I understand that "This Is Not a Bill." She assured me she’d get on it.

My hospital EOB also arrived. Conveniently, it is impossible for me to recognize what I have been charged for. The itemized list of services and widgets, which together add up to a total bill of $19,285 for my two-hour visit to an outpatient center in Virginia Beach, is in fact a simple repeated "Medical_Care." Yes, I apparently received 24 units of "Medical_Care," which varied in price from $0.15 to $8,433. You would think distinguishing these units would be important to a consumer who is trying to make educated choices, yes?

As well, I haven’t received an actual bill from the hospital. My insurance company got to me first.

I did receive a customer satisfaction survey rather promptly, which I filled out and have returned. My grading was across the board quite good, as I have been happy with the outcome, I felt the nurses and physicians were quite knowledgeable, and the hospital itself was clean and bright.

There were no questions on the survey about costs of care. I’m assuming that is because patient’s don’t usually worry about those sort of things, and if ever there was an indictment that costs aren’t being equate or tied into patient satisfaction, the absence of appropriate questions on the patient satisfaction survey - the Holy Grail to hospital administrators - is profound.

I continue to be amazed by the complexity and layering of the medical bills associated with my short, elective, outpatient procedure.

Multiplying this by a chronic condition, with a less knowledgeable consumer and an unexpected occurrence, for someone who may be in a lesser position to afford the bills - you can easily see how out-of-control the processing becomes.

As of now, I have eaten up the entirety of my deductible in my high-deductible health care plan. I’m glad this has happened by April, as I’m now - in theory - rather incentivized to get my health check-ups, and pursue the needed labs and preventive care, all of which will be covered 100 percent. One moral is that elective surgeries for people in high-deductible plans should always be done in January.

I’ve been through this before, written about this before. I’m interested to see how it plays out, where the responsibility is expected to lay for teasing through all the information. In the past, this has gotten me phone calls from hospital financial offices and collections agencies. Not because I am unwilling or unable to pay, but rather because I’m holding "the system" accountable to provide accurate information, closely reviewing the services rendered in my care, and expecting exceptional customer service.

Hernias and High-Deductibles: Byzantine Bills Prove Hard to Decipher

Today, as I write this, I am post-operative day number 21.

An unusual challenge came upon the artificial mesh in my gut, as I’ve come down with something that strikes me as the flu. Or rather, "The Flu." Not the simple cough, cough, runny nose, move-on-with-your-day flu. But the all over aches, immobility, and deep-angry-frequent-cough flu.

I can’t feel the bulges in my groin that were there pre-operatively, so I think things are holding up. I go to the surgeon tomorrow for a routine post-op check-up. I expect that my visit tomorrow will be "free," as part of the global fee for laparoscopic hernia repairs. 

I have received my bill from the surgeon. And, from someone else (to be explained). What is strange is the hesitation I feel in writing about it on a public forum. I wonder if there is some sort of ethical, or even legal, issue. We’re told on our hospitalist listserv that we are not, under any circumstance, to discuss pricing or reimbursement, for fear of being in violation of the Sherman Act.

It is this hesitation that represents the challenges we are trying to overcome, as a society, to stifle the issue of transparency in pricing.

In this situation, I am a patient. I have read through all the paperwork - though not with a magnifying glass - and I don’t think there’s anything that prevents me from explaining what I was charged, and what I ultimately paid.

Let me start this process by noting that I have not yet received a bill from the hospital. Maybe by the next blog?

I first received a bill from the surgeon, charging the amount of $297. With my high-deductible plan in place, contractually I pay the amount that my insurance company has negotiated with the provider / surgeon. In this case, that amount was $294. Yes, folks, I received a 1 percent discount.

What arrived in the mailbox next, that I have in my possession, are two claim recaps from the insurance company. As I expected, they are not straightforward. Nor are they actually considered "bills" but rather the Explanation of Benefits (EOBs).

The first is the surgeon’s fee. In this case, the surgeon’s name is listed - not conspicuously, but quietly on the side - as the "Provider." The charge listed is for "Surgery-Abdominal" and there is nothing that hints that this was a hernia repair. Nowhere on the EOB. Just a generic term for abdominal surgery. And, this charge is listed twice, I’m assuming because I had a bilateral hernia repair.

The charge is for $1,717, per "Surgery-Abdominal" - a total of $3,434 - and the negotiated discount brings this down to a $740.63. An 80 percent discount, and a seemingly fair price. Probably even too fair, for a person with the fine motor skills and intense training to do laparoscopic surgery?

The second claim recap, or EOB, has me more confused. Initially, I thought it was from the anesthesia team, but the amounts seem too low and the coded procedure is the same. The listed "Provider" is a name I’ve never seen or heard (I don’t think).

The codes are there again, twice, for "Surgery-Abdominal." Also, the charges are the same - a total of $3,434. But in this case, on this EOB, the amount due to a different provider whose name I’ve never seen or heard is only $118.

Perhaps a surgical assistant? I think he used one.

Mine was a very straight-forward, elective surgery. These things that I’m pointing out to you now are things I had seen before and that I expected: unclear EOB with overly generic terms; unclear provider; unclear cost sharing. The idea that the insurance company can’t provide more consumer-friendly information on these forms is odd. Should be an easy fix.

I suppose the next step is that I wait for the bills from the actual offices, as EOBs do very plainly state "This Is Not a Bill." My job then will be to match the EOBs up with the office bills, a step that seems innocuous but could wind up a huge annoyance in someone with multiple bills, from multiple providers, for complex or unexpected issues.



Three weeks after surgery, the costs are clearer with two "bills": one from my surgeon, the other from a provider I've never heard of or even seen before.

Hernias and High-Deductibles: Unclear EOBs and Unknown Providers

Today, as I write this, I am post-operative day number three.

The laparoscopic incisions are healing, though the purple hues persist. Especially around my umbilicus, where the inferior bruising is quite significant and residual glue - from closing the wound - has lasted through several showers and my scratching at the area. While I remain a bit bloated, I have decreased my pain med usage. Though I still can’t sit in one place for more than 10 or 15 minutes.

The surgeon said the hernias were quite large, especially the one on the right. He thinks my proceeding with the elective surgery was the right call. He said everything went "perfect." He didn’t comment on my anesthesia anxieties, which I’m sure gave the folks in the pre-op area a good chuckle.

My most passionate appreciation I’ve saved for Lady Luck, who decided not to make me one of the 10 percent with urinary retention, and thus I did not need to go home with a catheter in place.

As of this moment, I have no idea what my procedure costs. To be precise, I have no idea what the surgeon will charge me; no idea what the hospital charges will be; and no idea how much I’ll be asked to pay out of pocket. I have yet to spend a penny.

I did ask. In the hospital, with my father sitting next to me in registration, I asked how much the procedure would cost me.

“Oh, I have no idea,” the lady said through an honest-to-goodness laugh. Very clearly she had never been asked the question before. She did manage to include this statement, however: “A whole lot, I bet.”

Over the course of the immediate 48 hours post-operatively, my father was around to help with little things. As payment for emptying the dishwasher, walking Gibson, and bringing nourishment to the couch, he simply asked that I keep the television on Fox News. We got to talk a lot about healthcare costs.

“I essentially have two practices,” he said at one point. “One is my cosmetic surgery practice, all elective. Every single patient asks me how much the procedure costs.”

My father continued: “My other practice - reconstruction - is insulated by insurance coverage. And people never ask how much anything costs. Never.”

Where does the answer lie?

If, in the registration area, rather than laughing, the woman had told me that my hernia surgery would cost $10,000, would I have had the option to up and leave, and walk to the hospital next door for a second opinion? Should that have been available to her, a big book with all the charges and line items to denote how much it would cost for a person with my insurance coverage?

At on point, in the pre-operative area, an anesthesiologist who I’d just met pitched me the newest latest-and-greatest, a local nerve block injected directly into my abdomen. It helps with post-operative pain control, I was told, and while it wasn’t yet standard of care or routinely being done, it had blossomed out of the academic "research" phase.

All I had to do was sign a consent form. No costs were discussed. I didn’t ask, mostly because I had a splitting anorexia headache from not having eaten in over 12 hours, and because general anesthesia scares me like clowns scare the average 5-year old. I didn’t care to investigate the costs at that moment. Forgive my journalistic faux pas. 

I have yet to receive a single bill. Not for the original surgical consultation over a month ago, nor for any of the cutting and pasting that took place three days ago. I anticipate they will soon start to fill the mailbox, first as innocuous EOBs (“This is not a bill”) then with direct requests for money. 

I’m wondering how I will prioritize. Because I have a high-deductible health plan, I am responsible for the first few thousand out of pocket and then I am covered 100 percent thereafter. Which bills do I pay first? Do I send money to the hospital for the procedure and have insurance pay the physician professional fees? Vice versa? I’m intrigued to see how this will play out.

Strange, yes, that a physician with a passion for healthcare policy and economics stares at his own medical financial situation with intrigue and uncertainty?



My surgery is complete, I'm resting at home, and still, I have no idea what my procedure costs and what I owe as a patient with a high-deductible health plan.