Category Archives: Patients

A wakeup call from the nanny state

Amber alert alert

Amber alert alert

My cellphone was off Friday night so I was lucky enough to miss the Amber Alert that was sent out at 1:45 am when a mom decided to drive home from Pennsylvania to have her son treated at Boston Children’s Hospital. I heard about it Saturday night from some friends who couldn’t believe this had occurred and were annoyed at being awoken.  From where I sit, the only good thing about it is that it’s literally a wake-up call to the whole community about how the system treats vulnerable people.

It’s hard to say exactly what happened. But from what’s been written, it goes something like this:

  • A nurse practitioner in Wilkes-Barre, PA told a mom to take her 2-month old to a nearby emergency room for treatment of severe dehydration
  • Mom felt she had gotten “the runaround” from the Pennsylvania clinic and decided to drive to Boston Children’s Hospital to have her son treated there. She is from Boston and apparently has a relationship with a doctor there
  • On the way back she dropped off her older son with a niece in Waltham so she could focus on the infant
  • Somewhere along the way, someone in PA decided to issue an Amber Alert –meant to be used when a child is abducted and “believed to be in imminent danger of death or serious bodily injury”
  • The Amber Alert went out, waking everyone up
  • Infant made it to Children’s, where he’s been admitted and is improving –but now in custody of DCF (protective services)
  • Other child was also taken by DCF
  • Mom was arrested in MA as a fugitive from justice in PA. Judge listened to her story and released her on a token $250 bail

As I mentioned I don’t know exactly what happened. But I tend to give the mom the benefit of the doubt. In particular:

  • Who knows the quality of care and clarity of instructions the woman received at the clinic in PA?
  • A general ED is no place for a 2-month old. Many are still totally unprepared for kids, never mind babies
  • Boston Children’s is rated the #1 pediatric hospital in the country and she may have relationships there already. Depending on the kid’s condition, who wouldn’t at least consider making the drive?
  • It’s hard to drag a toddler all over the place during an emergency, so why not drop them off at a relative’s house along the way?

The mom apparently has some moving violations and a charge for prostitution. I wouldn’t be too quick to judge her for those things.

It’s hard to know what to do when your kid is sick and you’re trying to navigate the healthcare system. That’s true even for a well resourced, well educated dad like me who works in healthcare. Without those privileges it appears all too easy to end up with Amber Alerts, arrested moms, and kids taken by the state when a mom tries to do what’s best.

I don’t like it.

Image courtesy of mrpuen at

By healthcare business consultant David E. Williams, president of Health Business Group.

Let’s stop calling flu vaccine for the elderly “High Dose”

How high is that dose?

How high is that dose?

From everything I’ve been reading, the higher dose flu vaccine is very effective for older people. But I’m concerned that the name, officially Fluzone High-Dose, may scare people away. I spoke to my friendly, informative Osco pharmacist when I got the flu shot a few weeks ago. She told me that she was recommending High-Dose to older people but that some were nervous because it sounded like maybe it would be too strong for them. The pharmacist lamented that she had to call it High-Dose since that’s its name.

I’m not in the habit of giving free advice to drug companies like Sanofi-Pasteur, maker of Fluzone High-Dose, but in this case I’ll do so for the public good! Here are a few ideas they could feed to their branding consultant:

  • Fluzone Senior
  • Fluzone Senior Protect
  • Fluzone Plus
  • Fluzone Silver
  • Fluzone 65+

Image courtesy of renjith krishnan at

By healthcare business consultant David E. Williams, president of Health Business Group.

Why do sick people quit their Medicare Advantage plans?

Heading back to Mama Fed

Heading back to Mama Fed

Health plans don’t like sick people. They rack up big medical expenses, drive up health plan administrative expenses, and generally knock down profitability. In the bad old days of Medicare managed care, some plans went out of their way to make sure their membership rolls were filled with healthy people. My favorite tactic from those times? Putting the enrollment office on an upper floor of a no-elevator building to keep out the frail.

Plans are supposed to have fewer incentives now to avoid the sick. The government pays Medicare Advantage plans on a risk-adjusted basis, so in theory plans are indifferent to member health status. But a new study in Health Affairs (High-Cost Patients Had Substantial Rates of Leaving Medicare Advantage and Joining Traditional Medicare) shows that when Medicare Advantage patients get sick they tend to drop out and put themselves back in the arms of the government.

What’s going on? The authors aren’t certain, but they float some ideas:

  • Plans lack incentives to spend their enhanced payments for the sick. (Maybe they just pocket some of the extra funds)
  • Plans are inexperienced managing post-acute and long-term care
  • Risk adjustment factors aren’t high enough
  • Plans impose too much cost sharing
  • Provider networks are too limited

These explanations are all reasonable and –like other findings– raise questions about the value of Medicare Advantage plans and of health plans in general. They spend a lot of money on various administrative functions and generate friction with providers and members. But at the end of the day they don’t tend to add a lot of value in cost management or quality improvement, and patients who use the system a lot would rather take their chances in a government-run program. Some plans actually realize this, which is one reason they lobbied so strongly against the “public option” in the Affordable Care Act.

Health plans, including Medicare Advantage plans, have a long way to go to prove themselves, and I have my doubts about whether they’ll make it. I’ll be interested to see what happens over the next decade or two. Will providers (in the form of accountable care organizations or similar) take over the role of health plans and will they be more effective? Will we eventually move to a single payer system that does away with health plans?

Stay tuned.

Image courtesy of Stuart Miles at

By healthcare business consultant David E. Williams, president of Health Business Group.

What can we do about overuse of emergency rooms?

Come and get it!

Come and get it!

I’d expect an emergency physician with 35 years of experience to have some solid insights on why people come to the emergency room. Sure enough, Dr. Paul Auerbach delivers the goods in his Wall Street Journal opinion piece (Why ER Visits for Non-Emergencies Aren’t Going Away). In particular:

  • Patients can’t easily distinguish between true emergencies and non-emergencies
  • You can’t teach economics lessons to people when they are sick
  • Patients have learned they can get care in an emergency department more conveniently and quicker than in a community setting
  • Ambulatory physicians are culpable, because they encourage patients to go to the ER and don’t offer convenient hours
  • Emergency room use will continue to be heavy until key deficiencies in care delivery are addressed

So it was interesting that the Journal published five letters from people with different ideas. I disagree with four (all by doctors), and note that the fifth idea (by someone who may be a dentist) is already being implemented.

  • Dr. Ainslie thinks that “if ERs were forced to post prices, patients could decide what services they wanted to use.” That might work for an elective knee replacement, but doesn’t square at all with my experience in the ER. Am I really going to pick out what emergency services I want and exclude others? Who is going to have the time to discuss the costs and tradeoffs? Am I going to try my luck at a different ER if I don’t like the pricing at the first? Ridiculous
  • Dr. Dunn complains that primary care physicians like him spend half their time filling out documentation that offers no value add for the patient. He thinks docs should be paid “for the service they provide (without having to battle for reimbursement) and eliminate the non-value-added documentation.” This would boost the capacity of primary care physicians and reduce the need for emergency room use. I’m sympathetic to the paperwork complaint but I don’t think we can replace it with no questions asked fee for service. If Dr. Dunn is ready to take on global capitation for his population of patients then his idea might work. Even then there will be some paperwork
  • Dr. Geehr blames ObamCare. “ObamaCare, like its predecessor RomneyCare, promised fewer ER visits and more primary-care access. Government always fails to account for the unintended consequences of vast, new entitlement programs.” Actually, some proponents of ObamaCare (including me) did foresee the rise in ED utilization. Opponents didn’t think of this argument ahead of time, since they were so busy blaming the uninsured for clogging up the emergency department.
  • Dr. Brotherton writes, “the best way to reduce ER visits is for insurers to pay adequately for primary care.” Somehow –he doesn’t explain how– this will cause patients to go to their primary care doctors instead of the emergency room. I’ll give him the benefit of the doubt and suggest that he means higher payments will induce more physicians to practice primary care, but that would take quite a while to play out and still doesn’t address patient behavior.
  • David Lieberman wants hospitals to put urgent care clinics alongside emergency departments to keep the non-emergencies out. Not a bad idea and some hospitals are actually doing this. It works best when hospitals have a financial incentive to hold down costs

Image courtesy of Stuart Miles at

By healthcare business consultant David E. Williams, president of Health Business Group.

Concierge medicine 90210

LUX Health Network co-founder Akiva Greenfield

LUX Health Network co-founder Akiva Greenfield

LUX Health Network bills itself as “the most exclusive, personalized, and comprehensive health care experience.” Its concierge-style primary care and specialty physicians practice in Beverly Hills. It sounded interesting, so I interviewed co-founder Akiva Greenfield to learn more.

Concierge practices are typically primary care only, and I’ve often wondered about how they handle patients who need specialist care. So I’m interested to learn about the LUX model. How did you come up with the idea?

We talked with patients and we talked with physicians about what’s important in concierge style care. Patients told us that they certainly want great care from their primary care physician but, just as important, they consistently told us that they want outstanding seamless care from specialists as well. We believe this is a reasonable request, in fact it’s their prerogative.

So, I saw that this model of interdisciplinary care would fill a critical void in the concierge medicine marketplace. LUX Health Network has become the solution because we bridge the gap by providing highly-coordinated care among internists and specialists who all offer our concierge services.

LUX has assembled an elite network of specialist physicians who work as one team to deliver highly integrated, cross-disciplinary care, quickly and conveniently. LUX patients, who we refer to as LUX clients, have around-the-clock access to their team of specialists, who work in close coordination with their primary care physician to provide patients with a complete and synchronized healthcare experience. An added highlight of the LUX network is our client care coordinators who facilitate all scheduling and oversee insurance correspondence on their behalf, eliminating the stress and lost time that often precedes and follows medical appointments and procedures. Each member’s personal care team conducts periodic interdisciplinary conferences to discuss member needs, treatment, and progress to ensure full coordination of care.

Clients, especially those who are content with their internist, can also choose to pay for an annual retainer fee to receive concierge access to the specialist of their choice, who will work closely with their primary care doctor to develop a care plan tailored to client needs, and one that adheres to their preferences.

How does LUX compare to a typical concierge model? What are the similarities and differences?

We’ve been able to review and revise the way healthcare is delivered and managed from our unique perspective. LUX was not founded by physicians but by young entrepreneurs who have worked closely with doctors and thoroughly understand the healthcare industry. Other medical concierge models focus primarily on internal medicine. LUX is the first company to include internist and specialty medicine, where each physician practices independently and is not employed by us. We value their autonomy, as do they, and make the client-doctor connection, while keeping the physicians in full control of managing care. There are no limits to the number of concierge patients and/or families accepted by our doctors, a criterion imposed by other companies operating in this space.

To help support our network and clients, LUX’s client care coordinators serve as patient advocates and are at the patient’s disposal 24/7– no request is too big or too small. We even offer to correspond with insurance companies on behalf of clients so they can focus on what matters most to them. Additionally, our membership plans are fully customizable. We work with our clients to develop a mutually beneficial health plan.

Parts of our business model including membership-based concierge level access (same or next day appointment, unhurried visits, etc.), health and wellness options, and scheduling, is similar to that of other companies.

Typically primary care concierge practices convert their entire panels to the concierge model. Is that the case here as well? 

No. We do not require our physicians to convert their entire practices to a concierge style. Instead, they offer this extra level of care and access to patients who they believe can benefit from our programs. This allows the doctor to operate a hybrid practice, accepting both concierge and non-concierge patients.

It is often believed that a doctor with a hybrid practice will provide superior care to his or her concierge patients because of the promises made to them. Naturally, this can create an array of problems within a practice and to prevent such occurrences from arising, LUX works closely with doctors’ staff to reserve ample time on the schedule for concierge patients, well in advance of scheduling other patients. This alleviates the concern for non-concierge patients, knowing that patients paying an extra fee will not cut into their appointment time, and removes the burden from the doctors and their office staff by keeping the work day organized.

Do the specialists also convert their full panels? If not, what are the implications? If so, how many patients do you need in the LUX network to make that possible?

At LUX, specialists concierge model operates just like primary care model. They may keep their traditional care patients, while adding concierge style clients to their practices. The only change we request to be made is for them to cater to our concierge clients with the breadth of LUX services, which is agreed upon prior to them joining our elite network.

What happens to a patient if their specialty isn’t represented within the LUX panel? And doesn’t the idea of having access to just a few specialists run counter to the goal of maximizing choice? It sounds like it might be just another narrow network (albeit a gold-plated one). 

Most major specialties are represented by quality physicians in our LUX network. However, if a patient needs a specialist that is not represented in our network, we do our due diligence to find a doctor who is willing to join our network, and meets our admittance criteria outlinee by our Physicians Advisory Board, to serve the client. We are expanding our network of physicians to include other specialties like pediatrics, neurology, and psychiatry. It is also pivotal to our business to have larger numbers within each specialty, which is another area we are currently developing.

What happens when a patient is hospitalized? Does LUX have concierge hospitalists?

The client’s LUX primary care and/or specialty physician(s) will visit the hospital to ensure continuation of care.

One concern I have about concierge practices is that they appeal to physicians who want an easier lifestyle. I don’t begrudge them that, but concierge patients may actually prefer that their physicians are totally dedicated to the job. What do you think?

LUX network physicians are totally dedicated to their patients. In fact, I think that practicing medicine through the concierge model allows physicians to be more dedicated because they have more time to allot to each patient. Concierge medicine compensates physicians for the time spent to build a strong physician-patient relationship, thus allowing them to be more successful at their job and the care of their patients.

All your doctors are in Beverly Hills. Can the model work elsewhere or is this setup just for the rich and famous?

Our innovative approach to concierge medicine is designed for those who put a priority on their health and wellness and value their time. We plan to expand our model to other cities in California like San Diego and San Francisco as well as nationally. Although our main target audience tends to be a more affluent population, our plans are not designed exclusively for them. Our custom pricing is contingent upon the client’s medical needs and we do our best to match that. Our prices also reflect the caliber of physicians we’ve selected to be a part of our network. Each one has a stellar reputation among patients and other clinicians.

By healthcare business consultant David E. Williams, president of Health Business Group.

Computer aided diagnosis for mental health: two important strides

Advancing the state of the art

Advancing the state of the art

Researchers are using modern technologies to develop advanced tools to assist with the assessment of mental health problems. We hear a lot about “big data” and genetic sequencing, which can be expensive and complex, but there are also promising tools that are not so pricey or complex, even if they do employ components of big data and genetics.

Two examples caught my eye this week:

The speech analysis program was tested on 34 subjects, so we’ll have to see if the results hold up. But the idea makes sense. Well trained clinicians can already assess disjointed speech patterns and reach similar conclusions. But the computer seems to do an even better job, and more importantly, could ultimately make such techniques feasible for a much broader population who don’t have ready access to psychiatric services. And all while lowering the cost of assessment dramatically.

I’ve always thought it was quite primitive and even bizarre for clinicians to assess suicide risk by asking patients if they were thinking of killing themselves. So I’m pleased that a new tool combines a series of questions about energy level, feelings and accomplishments and uncertainty with a blood biomarker test. Again, this approach could ultimately be simpler and cheaper to administer, and more consistent than existing methods.

We won’t be replacing physicians any time soon, but these new approaches are emblematic of what we can expect as developers make better use of available data, analytics approaches, and distribution methods. I’m most excited about increased diagnostic accuracy, earlier availability of information, more widespread availabilty, and lower cost.

Image courtesy of Ambro at

By healthcare business consultant David E. Williams, president of Health Business Group.

You might be covered, even if your doctor sends you a bill

Am I covered?

Am I covered?

Kaiser Health News published an informative Q&A today, posing and answering three common questions about the practical aspects of health insurance. I’ve been working in healthcare for 20 years but I still like to read these pieces. Often the answers to the simple questions are not so simple, and sometimes I learn something new.

One of the questions caught my eye:

Q: I have insurance coverage through the health law’s marketplace. When I visited a cancer clinic for a routine blood check, I asked upfront three times (first over the phone and again when I was there) if all services would be in-network. The answer was “yes” each time. Afterward I received a bill from an out-of-network lab for $570. Is there anything I could have done to avoid this charge?

The column answered that theoretically the patient should be able to find out where the blood work is being sent and check if it’s in network, but realistically that’s a lot to ask.

From where I sit I think it’s unreasonable to expect the patient to have to do so. At a minimum I would complain to the clinic and would also considering leaving feedback on a ratings site to let others know.

But I also want to draw attention to the last part of the reply:

“In the meantime, check with your insurer… It’s not unusual for providers to bill patients for services that are ultimately covered by their plan.”

That’s a very important point, and fits with my own experience. Providers will typically bill the insurance company and if they get turned down or not fully paid they send the bill to the patient. This process can take a while, and that sometimes means the provider is sending a statement, not a bill, by the time everything is settled. When I see a balance for $176.45 that’s 60 days old –as I did recently on a provider statement– what does it really mean?

Here are a couple recent examples from my experience:

  • A dentist sent a bill for my dependents, which had been rejected by the insurance due to lack of eligibility. I called the insurance company, which assured me coverage was in place. Eventually it was re-billed and went through. The same thing happened at the same office for another family member, and it was also corrected after I inquired. I never figured out who made the mistake or what exactly occurred between the office and the insurer.
  • A dependent needed frequent eye exams due to a drug treatment he was undergoing. The first visit was paid but then other visits were denied. Some time passed before I received the bills and figured out insurance wasn’t paying. I called the ophthalmologist’s office and was told the visits had been coded as routine eye exams –which have to be a year apart to be covered. When I explained it should not have been coded that way they said it was too late to change it, the insurance company wouldn’t go back and fix it, and oh by the way if I paid over the phone they’d knock 50% off what I owed! Rather than accept that deal I called my insurance company and they took care of it within a week

A friend told me she is consistently billed for co-pays that she has paid at the time of the visit, but because it’s such a hassle to document her payments and to work to get them reversed, she just drops it. Although I pay all my co-pays at the time of service and have not had this trouble, I told her about other people I know who refuse to pay any co-pays at the time of service –for fear of this exact problem– and instead wait for the bills to come in the mail.

Bottom line: Don’t let the provider be the one to tell you you’re not covered. If you think you may be covered, call your health plan. Often it works out.

Image courtesy of digitalart at

By healthcare business consultant David E. Williams, president of Health Business Group.