How Much Does It Cost To Have An Appendectomy?

Kenneth Lin

Posted 4/24/12 on Common Sense Family Doctor

A few years ago, a good friend of mine who holds bachelor’s and law degrees from Ivy League schools lost his job and became one of the estimated 50 million medically uninsured persons in the U.S. Over the course of several days, he developed increasingly severe abdominal pain, fever, and vomiting. Though reluctant to seek medical attention, he finally was persuaded to visit his local hospital’s emergency department, where he was diagnosed with acute appendicitis. Despite his critical condition and the need for immediate surgery, he refused treatment until the hospital’s billing department gave him an estimate of how much an emergency appendectomy would cost. Then, as he was being prepared for the operating room, he somehow managed to bargain with the surgeon to reduce his customary fees.
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My Take On State Health Insurance Exchanges – Part 1

Kenneth Lin

Posted 4/12/12 on Common Sense Family Doctor

Regardless of whether or not the Supreme Court strikes down the individual mandate or the entire 2010 health reform law in June, state-based health insurance exchanges are a good idea and, if established, should benefit many working Americans who are too well-off to qualify for Medicaid but unable to otherwise afford health insurance coverage on their own. This post and two to follow over the next week are excerpts from an unpublished paper that I recently authored on this topic.

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One of the key elements of the insurance coverage expansion contained in the Affordable Care Act (ACA) is the establishment of health benefits exchanges operated by individual states, groups of states, or the federal government, by January 1, 2014. These exchanges will offer competitive and/or subsidized insurance options for individuals whose employers do not provide insurance, as well as offer plans to small businesses (up to 100 employees) at reasonable rates. Prior to the ACA, Massachusetts and Utah had both operated state insurance exchanges with varying degrees of success. By outlining only basic requirements for the functions of the exchanges, the ACA left many important questions regarding their design unanswered. Some states appear to be pursuing a “wait and see” strategy, hoping that the U.S. Supreme Court will strike down the ACA prior to the January 2013 deadline for showing sufficient progress toward establishing an exchange or ceding control to the federal government. Others are at various stages of the planning process; as of January 2012, 13 states had formally established their exchanges through legislation or executive orders. Maryland and California are at the vanguard of this group.

Continue reading “My Take On State Health Insurance Exchanges – Part 1”

Essential Readings on Health Reform

Kenneth Lin

Posted 3/22/12 on Common Sense Family Doctor

Can’t get a Supreme Court-side seat for next week’s six hours of oral arguments on the constitutionality of the Affordable Care Act? Want to understand how the United States reached the point where the fate of a mostly yet-to-be-implemented 2010 federal law that extends health insurance coverage to nearly all of its citizens may rest on the Justices’ interpretations of the Constitution’s Commerce and Taxing and Spending clauses? You would do better to spend those six hours reading two essential books that shed a great deal of light on the legislative history and contemporary health policy issues that have shaped the current debate: Paul Starr’s Remedy and Reaction and Douglas Kamerow’sDissecting American Health Care.

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The Reality Behind the “Death Panel” Rhetoric

Kenneth Lin

Posted 3/14/12 on Common Sense Family Doctor

In a moving piece recently published in the Annals of Internal Medicine, surgeon Mark Vierra describes his emergency room encounter with a man dying from colorectal cancer. Called to discuss possible surgery for a perforated bowel, Dr. Vierra sadly observes that despite the patient’s grim prognosis, he and his wife “had not discussed limits on his care, how far to carry things, what to do when the treatment stopped working, or when the end was in sight.” They had not had any of these discussions with their primary care physician or either of his oncologists. After Dr. Vierra reviews the options and the patient’s wife chooses hospice care, he reflects on the wide gulf between the reality of end-of-life decision-making and the damaging political rhetoric of “death panels”:

I should not have been called to see this patient. Decisions like the one we had to make that day should have been made among friends and family or in the company of his family physician or oncologist, at a time when he was awake and at his best, when he was not in pain, and he could remember who he was and he could explain to those he would leave behind how he wanted to be remembered. To have to make such decisions the way we did that day—counseled by a stranger in the sterile alcove of a busy emergency room—is not what any of us would want. That it turned out the way it did, I believe, was fortunate. It would have been so easy for the powerful momentum of modern medicine to have carried his broken body into the operating room and from there to the ICU, where he would be nurtured by the finest medical technology and the clinical compassion of strangers.

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Addressing Gaps in End-Of-Life Planning

Kenneth Lin

Posted 3/15/12 on Common Sense Family Doctor

A recent article by family physician Ken Murray in the Wall Street Journal, titled “Why Doctors Die Differently,” observed that doctors are more likely than other people to decline end-of-life interventions that have little likelihood of benefit:

It’s not something that we like to talk about, but doctors die, too. What’s unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently.

Doctors don’t want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken. During their last moments, they know, for instance, that they don’t want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right).

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What’s In Your Doctor’s Health Care Shopping Cart?

Kenneth Lin

Posted 3/08/12 on Common Sense Family Doctor

A few years ago, the medical journal I edit received a letter from a reader who complained that the approximate prices of drugs we provided were often quite different from the prices he found online or in his local drugstore. This letter ultimately led to a re-evaluation of our rationale and process for estimating drug costs, as editor Jay Siwek, MD explained in this editorial:

Given the difficulties of arriving at the cost of a course of therapy or a one-month prescription, and the wide range of prices possible, we wondered whether it was worth the trouble. So, we did what we regularly do when faced with questions like this—we surveyed our readers. The answer was loud and clear: you want representative prices listed, for generic and brand name drugs. You also prefer an actual dollar amount, or range, rather than using symbols such as $–$$$, as some drug formularies do. And, you found this information helpful when deciding among drugs or when counseling patients.

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Screening – Illiterate Physicians May Do More Harm Than Good

Kenneth Lin

Posted 3/05/12 on Common Sense Family Doctor

On the first day of the clinical preventive medicine course that I teach every spring, I review the concept of lead-time bias and its potential to make a screening test look more effective than it really is (or, effective when it’s not). Frugal Family Doctor recently explained how lead-time bias deceptively improves 5-year survival statistics. If you are unfamiliar with this concept, I recommend reading his post, but the basic idea is that by advancing the time in the disease course that cancer (or some other condition) is detected, screening will always increase the percentage of patients who survive for 5 years or more, even if it doesn’t do anything to reduce mortality. This concept is as basic to the appropriate use of screening tests as vital signs are to the practice of medicine. In my opinion, any physicians who don’t understand lead-time bias ought to have their test-ordering privileges suspended until they do.

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