...a leading representative of the youth organization of the conservative CDU suggested that elderly people should be excluded from certain insurance payments like artificial hips.
I'd tell this guy, "Well, Junior, the elderly are going to need artificial hips a lot more than people your age, but I see your point. The cost burden will fall on your generation, and it won't be pretty."
Here's an article from today's WSJ about what one hospital is doing to ration care. It's a difficult job but I believe it needs to be done. "Unlimited" care is a fantasy.
At One Hospital, A Stark Solution For Allocating Care
Galveston Facility Cuts Drugs, Treatments for the Uninsured
By BERNARD WYSOCKI JR.
Staff Reporter of THE WALL STREET JOURNAL
GALVESTON, Texas -- Joan Richardson, chief medical director at the hospital of the University of Texas Medical Branch, faced an agonizing decision: Should she approve a $1,500 drug for a 52-year-old woman with metastatic breast cancer?
The patient had no money, no insurance and rapidly fading hope. Three powerful cancer drugs had failed to help her. A fourth, exemestane, offered a slim chance, but strict rules at the hospital barred the drug from being given to patients who couldn't pay for it. Dr. Richardson would have to authorize the money to come from a $25,000-a-month drug fund for indigents -- meaning some other poor person who needed a costly drug might not get it.
The 59-year-old Dr. Richardson, who sports a spiky hairstyle and a west Texas twang, approved just one exemestane treatment. "Unless this patient really improves, this is the end of the road," she said. The hospital says it's too early to tell if the drug is working.
The rules restricting drugs at this 795-bed hospital are part of a bold experiment in allocating health care at a time of rising costs. In most other U.S. medical centers, decisions about who gets scarce resources such as expensive drugs and surgical procedures are often made on an ad hoc basis -- with few formal guidelines for doctors and nurses on how to help their patients while hewing to budget restrictions.
But UTMB, as this state-supported hospital is known, has developed a detailed playbook to help determine exactly who gets treated and who doesn't. Its rules require that patients undergo financial screening before they can be admitted and that virtually everybody pay a fee before seeing a doctor. For patients who are poor or uninsured, the rules restrict or proscribe the use of certain drugs and treatments. Some procedures are barred outright -- such as hyperbaric oxygen treatments, which are widely used at other hospitals to help wounds heal. The system empowers certain decision makers, such as Dr. Richardson, to make exceptions to the rules, but usually within a specific budget.
Unlike most hospitals, UTMB is also blunt about its need to limit some services on financial grounds. "We are rationing," says John Stobo, UTMB's 62-year-old president and chief executive.
The hospital's rationing system -- dubbed "DAMP" for "Demand and Access Management Program" -- has helped its bottom line. Five years ago, UTMB was headed for an $80 million budget deficit. Last year, it posted a modest budget surplus. But the rules have hit its hometown hard.
UTMB, a sprawling complex that includes a medical school and a nursing school, is the only hospital in Galveston, a port city of 55,000 that has fallen on tough times. Under the rationing rules, UTMB has cut back on admissions of uninsured patients, who are then forced to defer or forgo treatment. Before DAMP was instituted, in 1998, about 26% of UTMB's patients were uninsured. Today, that figure is 17%. In the hospital's emergency room -- which by federal law can't turn away anyone who claims to need immediate care -- the waiting time has stretched to as long as five hours or even longer.
Hospital officials say they had little choice. In the late 1990s, uninsured patients were overwhelming the institution, and many didn't pay their bills. UTMB, which was established in 1891 with a mission to care for the poor, was also swamped by waves of low-paying patients covered by Medicare, the federal program for the elderly, and Medicaid, the state-federal program for the poor and disabled. In a message to the staff posted on the hospital's Web site in 1998, Dr. Stobo warned that UTMB would have to restrict care for the indigent or become indigent itself.
At first, Dr. Stobo, newly recruited from a top job at Johns Hopkins University School of Medicine in Baltimore, reduced costs the traditional way: He fired staff and mothballed beds. When he felt he could cut no further, he took a more-radical step. He appointed a committee of administrators, doctors and midlevel staffers to codify a top-to-bottom system for distributing services -- with limits that could be consistently applied.
The committee, which came up with the acronym DAMP, set rules that start at the front door: People without insurance must pay $80 before they can see a doctor, unless they can prove they are indigent -- meaning they earn less than $2,800 a month for a family of four, which is 185% of the federal poverty level. In that case, they qualify for a discounted fee of about $30, depending on their county of residence. The discount is also given to dependents, and UTMB rules stipulate that children will never be turned away. But otherwise, anyone who shows up at UTMB without the money is sent home, unless a doctor deems them sick enough to be seen immediately.
Under the rationing scheme, the first cut is made by people such as Roslyn McCray, one of 17 financial screeners who scrutinize the income and insurance of everyone seeking treatment. One afternoon earlier this year, Ms. McCray sat in a tiny office near the entrance to the UTMB outpatient clinic and called up the computer records of John Paul Regini, a 48-year-old, unemployed welder's helper who sat across from her.
It was the second attempt by Mr. Regini, who is uninsured and doesn't qualify for Medicaid, to see a UTMB doctor. Two months earlier, he had been referred to a UTMB internal-medicine specialist by a county health clinic, which had diagnosed him with high blood pressure. He showed up without the upfront fee. The screener he saw at the time, one of Ms. McCray's colleagues, suggested that Mr. Regini try to prove he had little or no income in order to be eligible for the discount. Then she suggested a way how: Get a notarized letter from his mother stating that she supported him. Before he was sent home, a doctor reviewed his file, as UTMB rules require, and concluded his situation wasn't urgent enough for him to be seen immediately. In cases where patients don't have the upfront fee, a nurse makes a quick assessment and then presents the findings to a doctor. UTMB doesn't reveal details of these doctor-patient interactions, citing laws protecting patient confidentiality.
It was the second attempt by Mr. Regini, who is uninsured and doesn't qualify for Medicaid, to see a UTMB doctor. Two months earlier, he had been referred to a UTMB internal-medicine specialist by a county health clinic, which had diagnosed him with high blood pressure. He showed up without the upfront fee. The screener he saw at the time, one of Ms. McCray's colleagues, suggested that Mr. Regini try to prove he had little or no income in order to be eligible for the discount. Then she suggested a way how: Get a notarized letter from his mother stating that she supported him. Before he was sent home, a doctor reviewed his file, as UTMB rules require, and concluded his situation wasn't urgent enough for him to be seen immediately. In cases where patients don't have the upfront fee, a nurse makes a quick assessment and then presents the findings to a doctor. UTMB doesn't reveal details of these doctor-patient interactions, citing laws protecting patient confidentiality.
Now Mr. Regini was back with the notarized letter and $30, and it was up to Ms. McCray to determine whether the document was sufficient proof that he was a dependent. "Is this still your phone number?" Ms. McCray asked. "No, that's my mom's," replied Mr. Regini, a strapping man in blue jeans. She decided the letter looked legitimate and approved his appointment to see a doctor later that day. Mr. Regini says he was diagnosed with excess iron in his blood and is awaiting further appointments.
Ms. McCray, the 39-year-old daughter of a nurse and a machinist, has been a UTMB employee for 15 years, and says she often shows patients how to sign up for Medicaid or for another federal-state program that aids families whose incomes are above Texas's very low Medicaid ceilings. But she's also on the lookout for people who falsely claim to be indigent. "They come in with diamonds and wearing Saks Fifth," she says.
UTMB also has strict rules for patients who have failed to pay a previous bill, causing a "bad-debt flag" to pop up on the hospital computer. These patients -- currently a staggering 64,000 people, or 7% of those in the hospital's records -- are barred from making an appointment with a doctor unless they qualify as indigent under DAMP rules, or a doctor deems their case urgent.
On a recent day, Ms. McCray reviewed the bank statements of a southeast Texas couple who had mailed them in to try to prove they were indigent and remove a bad-debt flag. The wife wanted to make a follow-up appointment after a gastrointestinal endoscopy, at her doctor's recommendation, but she owed $1,300 for the procedure. This time, Ms. McCray wasn't persuaded. The bank statements alone didn't show that the couple's monthly income was under $1,800 -- DAMP's ceiling for indigent status in their case. Ms. McCray mailed back a request for more financial information.
As a result of UTMB's financial screening, some poor, sick people are deterred from seeking or getting treatment. Phyllis Kinsey Scothorn, 57, who underwent surgery at UTMB for a heart attack in August 2001, has troubling symptoms but can't make an appointment at UTMB because of an unpaid bill of $869.
"I'm losing sensation in eight of my 10 fingers," Ms. Scothorn said. "I feel burning sensations in my arms." At the time of her surgery, Ms. Scothorn's then-husband's insurance covered most of her bills, but she lost coverage after her divorce. Earlier this year she visited a Galveston County clinic that serves the indigent, where a general practitioner referred her to cardiac and neurologic specialists at UTMB, but she was barred from getting those appointments, she says.
Sitting with her new husband, retired bus driver Keith Scothorn, in their tiny living room in Santa Fe, Texas, Ms. Scothorn dialed the UTMB billing office and described her illness, adding that she had an application pending for Medicaid and Medicare. The UTMB billing staffer told her the bad-debt flag would be removed from her account if she sent in a signed letter promising payment of $50 a month.
"So that's what your life is worth -- $50 a month?" Mr. Scothorn asked. He said they couldn't afford it. The couple's sole source of income is the $600 monthly pension that Mr. Scothorn, 66, draws from his home country of Britain. He lacks U.S. health insurance and has untreated medical problems of his own. Ms. Scothorn said she hasn't gone to the UTMB emergency room because she knows she will get bills she can't pay. It's also a matter of pride. "It's very hard for me to say I need [financial] help," she said. A hospital spokesman says, "We work with patients to help them develop a payment schedule. Once we and the patient have agreed on the terms, we schedule additional visits."
Before the rationing program started, the UTMB pharmacy often gave away drugs to poor Texans, many of whom drove hundreds of miles to get them. In 1998, the pharmacy posted a loss of $12 million, and a crackdown on drugs soon followed. A committee established a "gatekeeper" list of expensive drugs, requiring doctors to get approval from high-level faculty members before they could be used.
A few drugs -- such as Xigris, Eli Lilly & Co.'s more than $6,000 medication for sepsis, a deadly syndrome associated with severe infections -- were so tightly restricted that only Dr. Richardson, the chief medical director, could approve their use. Some commonly prescribed drugs were also put off-limits, such as Detrol, an $85-a-month, long-acting incontinence medication. UTMB patients who can't afford it are prescribed a shorter-acting bladder-control medication instead.
Despite the restrictions, the UTMB pharmacy posted a loss of $2.8 million in 2001. Karen Sexton, the chief operating officer, proposed closing the pharmacy's outpatient service. After raising objections, the pharmacy director, Kim Sergeant, suggested raising the amounts patients must pay and discharging some uninsured patients with a 14-day supply of drugs instead of a 30-day supply. That rule was adopted, and the pharmacy met Dr. Sexton's goal of narrowing its losses by $1 million last year.
Dr. Stobo, the UTMB president and chief executive, briefly considered abandoning the hospital's mission to care for the poor and focusing instead on its research strengths in tropical medicine, environmental health, AIDS research and other specialties. But he quickly rejected that idea. "Taking care of vulnerable populations is what we've been doing for 110 years, and we're good at it," Dr. Stobo says. "Let's have the intestinal fortitude to stay the course."
In February, the state of Texas, facing a multibillion-dollar budget deficit, forced UTMB to reduce its state-funded budget by $12 million over the next six months, with further cuts of about $50 million likely in 2004 and beyond. UTMB gets about $289 million in annual funding from the state, out of an overall budget of $1.2 billion. UTMB is upgrading its intensive-care units, pediatric care and other programs, but with the budget cutbacks looming, Dr. Sexton began drawing up a list of possible programs for elimination.
Cochlear implants, which can restore hearing to the deaf in 60% to 80% of cases -- but cost a total of about $78,000 and are only partly reimbursed by even the most generous insurance plans -- were among the procedures she targeted. Under existing UTMB rules, only patients who paid for the implant devices themselves, which cost about $20,000, were allowed to receive them. Dr. Sexton believed doctors were being lax in enforcing DAMP rules and were giving implants to too many patients who couldn't pay for them.
In March, as Dr. Sexton weighed whether to eliminate the program, she went for a walk on the hospital grounds and struck up a conversation with a mother whose child had come to be examined for a cochlear implant. "I was crying by the time I got to the front door," she says. Meanwhile, the chairman of the otolaryngology department argued that cochlear implants offered disabled people the hope of a normal life, and he promised strict adherence to DAMP rules.
Dr. Sexton, a registered nurse with a Ph.D. focused on nursing care, struggled with her decision. But she believed that as long as UTMB carried an inventory of implants, sympathetic staff would be tempted to keep doing procedures for nonpaying patients. She halted all cochlear implants.
Wrestling with these issues is "frightening," she says. "We're talking about losing muscle, not fat."
Dr. Richardson, the chief medical director, also wrestles with the responsibilities of rationing. When the new rules were established, she arranged for a special fund to pay for drugs that were put off-limits to poor patients. To get them, doctors must request waivers from Dr. Richardson on paper or via e-mail. She also has authority to approve special "teaching waivers" for expensive procedures that might provide useful experience for medical students.
Striding to her office one recent day, she pulled several waiver requests from the pocket of her white hospital coat. One was for a 36-year-old man on the waiting-list for a heart transplant who needed a $100-a-month blood thinner. The patient's government disability payments cover many of his expenses, such as a device to help his heart pump, but not the drug. Dr. Richardson, a pediatrician who has spent most of her career at UTMB, approved the $100-a-month drug waiver. Her reasoning: UTMB had already expended so much money getting the patient ready for a transplant that it made no sense to stop treating him.
In some cases, she uses cost-benefit analysis. Among Dr. Richardson's duties are managing patient flow, and because about 100 new inpatients are admitted every day, 100 must be discharged. She quickly granted one doctor's request to prescribe a 14-day supply of an antibiotic called Levaquin, calculating that it was well worth its $125 tab because it would allow a woman with pneumonia to go home in a day or so -- and free up a hospital bed for which the hospital could charge $800 a day.
She made a different decision on a request for four cases of the nutritional supplement Ensure for a severely underweight patient who had recently undergone bowel surgery. The cost of the supplement was several hundred dollars. Shaking her head, Dr. Richardson said, "The person can get Carnation Instant Breakfast for a whole lot less." Dr. Richardson says the substitution resulted in little or no loss in nutritional value.
When she can, she compromises. Recently, a patient who underwent a kidney transplant needed a $4,500 medicine to stave off infection. The patient's operation was covered by Medicare, but the drug, called valganciclovir, wasn't. "I cut a backroom deal with the patient," Dr. Richardson says. She says she agreed to cover half the price of the drug from her special fund, provided the patient paid the other half. "I tried to help him, but I didn't want to break the bank."
Lately she has been forced to say no to some procedures involving illegal immigrants. Before the rationing regime, UTMB sometimes absorbed the cost of expensive, nonemergency care for such patients. "The issue was not, 'Can they pay?' or 'Are they a citizen of this country?' " Dr. Richardson says. Today, UTMB's policy is to stabilize such patients, but to avoid protracted treatment.
Not long ago, a 61-year-old Mexican woman arrived at the UTMB emergency room with tongue cancer. Her doctor applied for a teaching waiver for surgery, but Dr. Richardson turned it down. Her reason was that she couldn't approve a noncitizen for a teaching case. Dr. Richardson says the woman was admitted to the hospital briefly but discharged with a recommendation of places to seek treatment in Mexico. "If somebody is sick, you want to treat them," Dr. Richardson says. "When you find you can no longer uphold that credo, it's tough." |
