Part two of this series, which focuses on healthcare costs, can be found here.
In 2017, over 880 million outpatient visits to hospitals were made by Americans for their healthcare needs. An estimated five million people work in hospitals throughout the country.
With such a vast array of moving parts, specific needs, and services available, behemoth hospitals have increasingly utilized data analytics to try and maximize efficiency.
Like Sabermetrics in baseball, statistics and data drive decision-making.
Hospitals ostensibly employ data to help drive down administrative costs; informing clinical decisions; limit fraud and abuse; coordinate care more efficiently; and remind patients to better take care of themselves.
But like in baseball, too much focus on data cuts out the inherently personal aspect of the industry — the absence of which, some say, hampers the quality of decision-making and the purpose of healthcare in the first place: helping others.
A 2016 study published by Johns Hopkins suggests the third-leading cause of death that year was medical error.
Hospitals grade their success by various marks, two of which are survival and readmission rates.
A 2018 study indicated that even hospitals with low mortality rates struggled with high readmission rates, a fact complicated by the difficulty of following up with millions of patients running through the overall hospital system.
And while all doctors and medical professionals–whether employed at a hospital or not–use data in some way, some doctors see the current setup handcuffing them from helping their patients — the negative consequences of which are very real and have begun to change patient and provider behavior.
A growing number of prospective patients are looking for medical services operating outside of the typical insurance-centered environment that is so data-heavy.
A pioneer in this field is Dr. Keith Smith of the Surgery Center of Oklahoma.
Smith opened his center in 1997 and doesn’t accept insurance payments for his services. Prices for procedures are listed on his website and are dwarfed by the estimates of the average hospital.
Due to his business model, Smith says he is forced to provide transparency and high-quality service to his patients otherwise he’d have no business.
Because of the way hospitals are set up, with all the bureaucracy and red tape, Smith says “Unless you are in control of the institution, you are really powerless to make the changes necessary to provide quality and transparency.”
Since embarking out on his own, his business has grown quite the reputation and client base.
Where hospitals have insurance companies shepherding patients their way because of the pre-negotiated service contracts, Smith must rely on customer satisfaction to keep patients coming back. That accountability is key, Smith stressed.
According to Smith, even some hospitals are experimenting with the cash-pricing model but are wary of advertising it. They’re afraid that if big insurers, such as Blue Cross/Blue Shield, found out, their existing contracts would be jeopardized.
One common criticism of the direct care model employed by Smith is that it’s not applicable to the entire base of healthcare needs. To this, Smith says, “There are fewer and fewer components of medicine which have not already been touched by this free-market movement.”
One example is the fact that something as serious and specialized as open-heart surgery is no longer something only hospitals provide to patients.
Smith points to the elimination of the insurance or government intermediary from the doctor-patient relationship as a drastic and necessary condition for improving the quality of care his patients receive.
In the insurance-focused system, Smith says, “The most disenfranchised participant in the industry is the patient.”
His patients receive much more personalized, attentive care, according to Smith. If they didn’t, he believes they would no longer use his service.
Another common criticism of Smith’s model is whether those with low income can access his services. To that, he pointed to financing plans, cost-sharing ministries, and charity as valuable options if a patient needs help defraying costs.
Nevertheless, if one opts not to purchase insurance and needs a procedure, going to an outfit such as Smith’s routinely saves significant amounts of money.
Patients will save by A) not having a monthly premium which in the Obamacare exchange averages nearly $600 for individuals B) avoiding annual deductibles and C) paying drastically less for the actual procedure.
Compared with Medicaid, the means-tested welfare program used by many low-income households as an analog for health insurance, Smith pointed to a 2008 Oregon study that found “no statistically significant effects on physical health or labor market outcomes” from the public expansion to the private alternative.
Importantly, that study’s findings were focused on patients still operating within the insurance-centered model, which may or may not carry over with Smith’s approach to medicine.
Avik Roy, president of The Foundation for Research on Equal Opportunity (FREOPP), pointed to Medicaid’s low reimbursement rates which make it more difficult for patients to access care since many doctors choose not to accept Medicaid patients.
Since Smith launched his operations in 1997, the popularity of a free-market approach to medicine has grown.
Dr. Kris Held is an ophthalmologist in San Antonio who has been operating her practice outside of the insurance-centered realm since 2015.
She is a staunch advocate for direct patient care.
Held is also a breast cancer survivor and almost died, not from it, but from hospital malfeasance. While she was being treated, Held told The Texan her state began declining. Thankfully, being a physician herself, she was able to figure out the hospital had given her the wrong medication.
The hospital had mixed up her data with that of a much larger man and she was thus receiving doses of medicine not fit for her. Held said her experience is representative of a much larger problem in the hospital system.
“Patients have been reduced to a bar code,” Held says.
Dr. Sheila Page, president of the Texas Chapter of the Association of American Physicians and Surgeons (AAPS), sees a decline in healthcare quality illustrated in the declining life expectancy rate.
Since 2014, the life expectancy in America has dropped for the first multi-year period since 1961-1963.
“Most caregivers have drastically reduced the amount of time they spend in direct contact with the patient,” Page stipulated. “They spend more time looking at a computer screen looking at prompts than addressing the patient” — a process which Page calls “checked-box medicine.”
Page, like others, is frustrated with what she sees as a lack of attentiveness by the doctor to the patient. She also mentioned friends of hers have received poor care and misdiagnosis in hospitals.
While human error will never go away, Page says it’s exacerbated by the data-focused approach large hospitals now take.
Another aspect Page alluded to — and Held specifically mentioned — was the physician rating system known as the Merit-based Incentive Payment System (MIPS).
This score determines the Medicare reimbursement rate for participating physicians.
In Senate hearing testimony this year, the president of the American Academy of Family Physicians said MIPS “detracts from physicians’ ability to focus on patients.”
Dr. Barbara McAneny, president of the American Medical Association, told the Senate she lost $100,000 to score a perfect 100 on the MIPS scale — a casualty of having to keep up with all the government-mandated reporting requirements.
McAneny recommended precluding smaller outfits from MIPS so they “can continue to use their resources on patient care.”
Held told The Texan that physicians who spend the least time and money on their patients receive a higher grade and those who spend the most time with their patients receive a lower one. It has also incorrectly scored its physicians, causing costly confusion.
According to Held, “A quality doctor by the government’s definition is one who supplies more data and spends the least on their patient — saving money for the government.”
MIPS is just one part of the broader focus on data over personal touch.
About the bureaucratic trend, Page lamented, “The patient has really become a source of data for the hospital corporation and other companies. It’s less about meeting their needs and more about reporting that data which is being used to score patients’ risk.”
“MIPS, and things like it, is just another way for middlemen to get between doctors and their patients,” Held underscored. These middlemen, she says, create barriers between patients and the care they need.
Held mentioned during the call that one patient of hers had a nine-step flow sheet illustrating the process for them to receive medication.
Barriers to medication, Held notes, only exacerbates the medical problem the patient is experiencing — and the onus to navigate the regulations is placed on the patients and their doctors.
Page was blunt in her assessment of the government-insurer data bureaucracy.
“Through the software, they determine the value of the person’s life and how much an insurance company ought to spend on their care. The money that is coming out of the government for healthcare is not being spent on care for individual patients, it’s being spent on IT and software,” Page stated.
Christen Linke Young with the Brookings Institution has a different view and emphasizes the fact that there is satisfaction among some consumers and patients with the current system.
Young pointed to a Harvard study in which Medicaid recipients reported being content with their coverage. “It’s wrong to suggest that the only coverage out there is ‘crap’ that’s not useful to people,” Young states.
Amidst the political debate, largely from progressive candidates, over moving even further beyond Obamacare, the focus on the impact such proposals would have on the quality of care has grown. Presidential candidates like Sens. Elizabeth Warren (D-MA) and Bernie Sanders (I-VT) are proposing to vastly expand government bureaucracy in the healthcare industry under their proposed “Medicare for All” plan.
America’s friends across the pond and neighbors to the north are showing some indisputable problems from similar approaches.
A new report shows that Britain’s National Health Service has a waiting list of 4.42 million people. Meanwhile, in 2017, over one million Canadians languished on a waiting list to receive some form of treatment.
These examples harken back to something Smith, Held, and Page all stressed: “Coverage does not equal care.”
Simply because one nominally has “coverage” does not mean they are receiving, as Held puts it, “the highest quality of care at the lowest possible price.”
Held talked about a patient she had who was diabetic and could not open her eyes. The patient was unable to get attention in typical outfits but was able to get into Held’s the next day.
Held also stated her waiting lines since she has gone cash-only dropped from four to six months to the next day.
Hospitals and insurance companies naturally maintain that the existing system is the only option for the average person. Yet more and more patients are taking their business to providers like Smith and Held.
This includes our very own editor this past spring, who was denied approval for a necessary procedure by an insurance company and instead sought out Smith in Oklahoma City.
The overall bill for him was thousands of dollars cheaper and the quality of care, in his experience, was a step above what he has normally experienced.
Healthcare has become a costly and complex system. The direct patient care model being implemented by some providers in Texas and neighboring states is looking to inject doses of simplicity and transparency in the hopes of ultimately improving the quality of care that a patient receives.
It’s bold medicine with so much of today’s emphasis on insurance and coverage and a system so inherently infused with analytics and paperwork.
But as costs continue to rise, choices diminish, and frustration mounts for millions of Americans at an increasingly bureaucratic system, these free-market physicians could be just what the doctor ordered.
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Brad Johnson
Brad Johnson is a senior reporter for The Texan and an Ohio native who graduated from the University of Cincinnati in 2017. He is an avid sports fan who most enjoys watching his favorite teams continue their title drought throughout his cognizant lifetime. In his free time, you may find Brad quoting Monty Python productions and trying to calculate the airspeed velocity of an unladen swallow.
