So Much Health Care Data, So Little Actionable Information

Palliative care grades by state. Source: released 2019 “State-by-State Report Card on Access to Palliative Care in our Nation’s Hospitals”

by James A. Bacon

There are many ways to gauge the quality and cost-effectiveness of Virginia’s hospitals. One is to measure cost and efficiency. Another is to track mortality rates and re-admissions. Yet another is to rate patient satisfaction. You can find these metrics on the Virginia Health Information website.

But health care is a phenomenally complex business, and many other aspects of hospital care are measurable. In a recent press release, the Virginia Hospital & Healthcare Association (VHHA) pointed out, for instance, that Virginia is one of 20 states (and Washington, D.C.) to earn an “A” for palliative care, based on a study by the Center to Advance Palliative Care and the National Palliative Care Research Center.

What is palliative care? It is, according to the report, “specialized medical care for people living with a serious illness. It is focused on providing relief from the symptoms and stress of the illness. The goal is to improve quality of life for both the patient and the family. Palliative care is based on the needs of the patient, not on the patient’s prognosis. It is appropriate at any age and at any stage in a serious illness.”

Having witnessed the lingering deaths of a step mother and father-in-law in recent years, I get it. The goal should not be to prolong life at any cost but to improve the quality of life that remains.

The VHHA also points to a study, the 2019 Leapfrog hospital safety grades to show that Virginia ranks second in the nation for “patient safety.” By safety, Leapfrog means protecting patients from errors, injuries, accidents, and infections in the hospital. I have to say, if I go into a hospital for treatment of an illness, I don’t want to acquire additional maladies while I’m there. As the Hippocratic oath says, “First, do no harm.” Pretty basic, but keeping hospitals safe is easier said than done. (See Virginia hospital scores here.)

Obviously, the VHHA brought these reports to the public’s attention because they make Virginia hospitals look good. Fair enough. They deserve credit where credit is due.

Hospitals are the core institutions of Virginia’s health care system around which all other components revolve. They deserve a lot more attention and analysis — the good along with the bad — than Virginia’s shriveled newsrooms can give them. The problem isn’t just the declining number of journalists, however. Newsrooms still cover health care. They just treat health care mainly as an issue of access and victimhood, so Virginians get mostly articles about Medicaid expansion, hospital closures, hospital lawsuits against patients who can’t pay, and the like.

But healthcare affects everyone, not just the poor and dispossessed. The average employer-provided health care policy now costs a typical American family $20,000 a year — not counting deductibles and co-pays. The cost of healthcare is a huge burden to middle-class families. Why? What is driving costs so high? What is being done in the realm of public policy to boost productivity and improve outcomes to the benefit of all? Is anyone even asking those questions?

Virginians celebrate the successes of the big health care systems — VCU, UVa, Inova, Sentara, Carilion — in increasing the volume of R&D grants as a sign of economic vitality, which, from one perspective, it is. But no one is asking where the money that funds those successes come from. How much (if any) comes from over-charging students enrolled in schools teaching the medical professions? How much comes from over-charging patients? How much of the cost of private health policies represents hidden transfer payments to Medicare and Medicaid patients?

Finally, there is the political economy angle. How powerful and influential is the hospital industry in Virginia? Health care entities have given $9.5 million in campaign contributions so far this electoral cycle, according to the Virginia Public Access Project, ranking it behind only the real estate/construction and retail industries. What legislation do health care entities want, and who benefits? Are they advancing socially beneficial reform or obstructing it?

There is so much that we, as members of the public, do not know. A wealth of data is available to anyone who wants to look at it, but few have the inclination or time to do it. The blind are leading the blind.

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16 responses to “So Much Health Care Data, So Little Actionable Information

  1. As one screwed over by Sentara more than once, and the problems they caused, if the laws on the books were actually enforced, you’d see this problem fixed (or at least massively improved) quickly. Same for if journalists actually covered real stories like this blog does.

  2. I think the biggest, somewhat uncovered, story in Virginia healthcare is consolidation. I still see a doctor in the neighborhood where I grew up. It’s along Rt 1 in southern Fairfax County and has more than the usual level of poverty and working class families in Fairfax County. My doctor’s father was my doctor growing up. So, I feel like I get the straight story – from a business perspective, from my doctor. Fifteen years ago primary care was almost always single physicians or small groups of physicians owning their own practices. As insurance companies began practicing “medicine over the phone” by telling the doctor what they would and wouldn’t cover the doctors began to lose ground economically. Some went to concierge practice models where a relatively limited number of patients pay an annual fee of $2,000 or so (out of their own pockets apparently) and they get “Cadillac” service from the doctor. Patients who can’t afford the concierge fee have to find their medical service elsewhere. Obviously, if a doctor can sign up 500 patients at $2,000 per year that $1m. Any recoveries from insurance, etc are added to that fee. Then came the hospital acquisitions of primary care physicians’ practices. Hospital conglomerates like MedStar started buying out primary care providers. I assume they felt that they could run the practices more effectively and that they wanted to achieve vertical integration of the patient population. Meanwhile, the bigger hospitals were buying the smaller hospitals and forming health care behemoths.

    All of this came home when a relative suffered a stroke. My relative was taken to Reston Hospital so I went there to see what was going on. They told me that they wanted to airlift my relative to Washington Hospital Center. I said that I thought Fairfax Inova was closer and a better choice. They explained to me that Reston was “contracted with” Washington Hospital Center (now MedStar) so that’s where my relative would be taken. All ended up fine but I’ve come to realize that health care choices are being limited by consolidation. I also have to believe, from a purely classical economics perspective, that continued consolidation will result in less competition and worse price / performance.

    Is health care consolidation in the public interest? The candidates for General Assembly seem fascinated by the hot button issue of gun control. Fine. Are they ignoring issues with less public attention like health care consolidation?

  3. Great questions. I helped my mom through the last six years if her life after my Dad died. We did it with social security, medicare, military tri care and investment income. We were lucky in the extreme.

  4. Consolidation is a huge issue, and it has happened here in Virginia in spades. Each region — Nova, Hampton Roads, Roanoke/western Va, Richmond — is controlled by a monopoly, duopoly or tri-opoly. I can’t think of another industry that has a higher level of concentration.

    Hospitals contend that health care is not like other industries (they’re right about that) and that consolidated health care systems eliminate redundancy and overhead. I’d like to see the evidence for that. I’d also like to see the evidence that the cost savings (if any) were passed on to patients.

  5. What if health care providers and pharmacists were required to clearly post prices (including the discounts negotiated with each and every insurer) in a uniform fashion? Imagine if a Hotels.com of healthcare crawled all these menus, and helped consumers compare ratings, base prices, estimate out of pocket costs after insurance, and book appointments in one place? The transparancy might give consumers greater influence on market pricing.

    I would also like to see the end of inflated “street-rates” that are neither market-based nor useful. Countless resources are consumed in the process of negotiating down street rates that virtually no-one pays. I don’t have a policy suggestion here, but believe it’s worth exploring as a policy issue.

    • Price transparency is part of the solution — at least for non-emergency treatments. (When I got my hip-replacement surgery, I searched online for comparable prices among Virginia providers but found nothing.) I think your idea is a good one, but there is one added complication. What hospitals and docs charge depends upon your insurance company. Each insurance company negotiates different discounts off that insane sticker price. Therefore, you’d need a search engine that could give you different results for different insurance plans. Still, we need to start somewhere.

  6. Jim. After the Navy and some other gigs, my Dad bought out a urology practice in a small North Carolina town. It had a pretty decent Hill Burton funded community hospital. They did all types of surgery but for really tough stuff you’d go to Duke or Chapel Hill. Dad thrived for years and brought in two more docs. Their market was huge geographically. Then he got sick,retired and died. His partners sold the practice to some slickly named entity called Verdant or something. It also bought up most if the independent med practices and the hospital where my children were born.

  7. I had an interesting experience on health care yesterday.

    I saw where Mary Washington Hospital in Fredericksburg was setting up a Medicare Advantage Insurance program.

    Yep – the same hospital that was dinged for taking people to court over their hospital debt!

    The guy who gave the seminar says this is where healthcare is going which is essentially community-based “coordinated care” where the primary care and the specialists are all on the same system which is the hospital.

    He saids MWH is in the “forefront”of this evolution and that they can actually make MORE money at it because Medicare is now paying for coordinated care and outcomes more than fee-for-service codes that industry insurance will pay for reimbursement.

    to be honest, it walks and talks like managed care but on the other hand if your primary care and your other providers were all working off the same medical record……the practices will be using nurse practicioners and physician assistants and they all see your record, they all see your lab tests and prescriptions…

    what would be the downsides?

  8. I have never seen healthcare discussed more in a statewide legislative campaign, but the real issues (such as the problems from this consolidation) are largely ignored. Instead politicians are making promises they cannot keep, at least not with state legislation, or attacking each other for votes that didn’t actually happen (and some that did.) Political messages are crude clubs. (The Democrats are doing their best to defeat the only two doctors in the GA – a third just didn’t run — the kind of expertise that makes the concept of “citizen legislature” valuable. One of them has gotten called a quack. THAT will get more docs to run in the future.)

    It another area ripe for campaign finance reform, because as Jim notes the big dollars are flowing and almost all are coming from the various providers. The consumer side is badly represented.

    Gee, I wish the concierge practice I just joined was only $2,000…my first real visit next week and I expect a massage and a swag bag with my test results. It is so out-of-pocket I can’t even use HSA dollars. Such a different health care system if you’ve got some dough…..

  9. Great discussion; I hope there’s more to come.

    My beef is that we’ve spent all these recent years of political energy and turmoil on coverage and payment mechanisms — i.e. the ACA and Medicare and Medicaid eligibility — giving far too little attention to the costs of the health care and prescription drugs being paid for.

    Pricing transparency to the consumer (the absence of) is certainly a contributing factor. And all the changes in the industry being driven by the ways those costs are fixed (obviously not through “rack” rates but through private insurance negotiations and opaque government reimbursement formulae and changing definitions of “best practices” and massive cross subsidies within hospitals and between them and their “affiliated” doctors).

    Where can the average Joe, even well informed generally, get a handle on where we ought to be headed with this? Leave “Medicare for all” out of it; ain’t gonna happen anytime soon. But what are the trends that need to be encouraged, or suppressed? And by whom — market forces redirected by better incentives, or good old command-and-control? And how can any of this happen without the transparency you’ve been talking about for years now? Which apparently won’t come until mandated — so who at the State level can mandate it today, or is legislation needed?

    While we lucky ones shake our heads at this impenetrable mess and buy our way around the hassles with concierge GPs — that does nothing to reduce the effects on the State budget of these uncontrolled costs and the frustrations of voters left behind (with no coverage at all or hidden clawbacks like that Medicaid claim on owned real estate that’s been in the press), — with all that, we’ve got the makings of social unrest that could generate a very unfortunate voter reaction.

    Why can’t we talk constructively about how to fix these real, immediate health care concerns? Maybe it doesn’t make for a zippy stump speech, but I think there’s a widespread awareness out there that the current health system needs a major overhaul and those candidates who do talk about it will strike a nerve.

  10. Health care is even more complicated than the electric utility industry!

    To a certain extent – it’s the result of what the free market does when the govt regulates pieces and parts of it in ways that it conflicts itself.

    But before we go blaming govt (again), consider (again) that every single developed country in the world has heavy govt influence and in their case that govt influence results in lower costs and longer life expectancy.

    Price “transparency” by the way is NOT a free-market concept but a govt dictate concept. We don’t expect the govt to do that with cars or airlines or cereal or many other products and services right?

    I have zero problems with Medicaid wanting the home in exchange for nursing home care by the way. If you have a home – you have an asset that you should be using for your own needs and not expecting others to pay for you.

  11. There is a simple reason why our legislators are not tackling these legitimate questions. They are complicated and would take a lot of time and effort to understand all their nuances and ramifications. To address them would take more time and concentration than is available in a jam-packed General Assembly session. Today’s legislators do not put in that kind of time between sessions. Twenty or so years ago, that was not the case; legislators worked between sessions on knotty problems. (Steve knows what I am talking about.) There are some legitimate reasons why they don’t do it now, but the result is a loss in the development of public policy in the Commonwealth.

    There is a permanent legislative body designated to study health care issues–the Joint Commission on Health Care. It has an executive director, three professional staff members, and one administrative staff member. The topics it takes up are worthwhile, but hardly earth shattering. This year’s study agenda:
    1. Dispensing of Drugs and Devices Pursuant to Pharmacy Collaborative Practice Agreements, Standing Orders, and Statewide Protocols
    2. Prescription Drug Price Gouging
    3. Language Development for Children who are Deaf or Hard of Hearing and Assessment Resources for Parents and Educators

    The American health care system is a Rube Goldberg system that no one would consciously design from scratch. I agree with the comments expressed above relating to hospital consolidation, physicians joining practices affiliated with hospitals, etc. But, in truth, what would/could the legislature do about it? Is it going to prohibit such business consolidations? Should it? Could it? In some cases, e.g. Bon Secours Health System, a system stretching over several states is involved and interstate commerce issues would present an obstacle.

    One of my favorite TV shows is “Doc Martin”. I don’t know how realistic is its portrayal of the English health care system, but what is depicted seems wonderful: you go in to see the doctor; he/she examines you, perhaps gives you a prescription; you take the prescription to the local chemist and fill it. No worry about insurance coverage and whether the doctor or medication is in your policy’s network. No co-pays. Sort of like Steve’s concierge GP, except the annual fee is paid to the government through taxes.

  12. Thanks, Dick. You reassure me that maybe, someday, this will get the attention it deserves at the Virginia level. There is so much that could be done to improve health care delivery if we just got past the “Obamacare is evil” ideological posturing and simply tried to improve on what we have. As you point out there is a State level GA committee on this — if the Dems get the majority in both Houses what do you think that would that do to spur the committee and Health Dept on to ask for the federal options and waivers that might be asked for? Or is this sort of reform going to require federal legislation?

    • re: ” if the Dems get the majority in both Houses what do you think that would that do to spur the committee and Health Dept on to ask for the federal options and waivers that might be asked for? Or is this sort of reform going to require federal legislation?”

      short answer – probably yes… at least they’d be willing to TRY to go forward and we’d know where they could not and needed Federal changes which they would then be asking our Gov, Senators and Congressmen to pursue at their level INSTEAD of essentially agreeing with the idea of “low-cost” insurance which is totally bogus – it’s fooling people who think it’s a solution… it’s just shunting off the less informed to a future of bankruptcy if they do get sick or injured.

      I’d say that’s a pretty irresponsible legislative idea myself – to not only not respond to the need but to pave a path to disaster for some who are desperate with few options – the idea apparently that “it’s better than nothing”… That’s some the Va GOP seems to support, no?

  13. Re: what could Virginia do?

    well, I’m quite sure that ALSO falls into “healthcare is complicated especially what the Feds only can do and what Virginia can do”

    however, all this talk about price transparency, is that not something Virginia could not do?

    I personally don’t think it will change much because price alone is not what most smart folks do – the quality and reputation of the provider is also equally important … and even then, that pretty much has little important on emergency and urgent issues where time is of the essence.

    BUT – it COULD be CLAIMED by the GOP in Va as something they did to reduce health care costs – better than just known for their opposition to MedicAid!

    Dick mentioned Great Britain. German and Switzerland are two countries that have PRIVATE health care systems BUT mandated universal coverage… It’s HARD for me to BELIEVE that out of about 40 other countries on the planet that NONE of them are a reasonable model for health care and that in the US we have this really ignorant BINARY choice between “socialsim” and our current system.

    Dick mentions the knotty problem issue and it’s true but the GA does have staff and they can hire consultants if they really want to have experts bring back to them some options to pursue.

    Look at some of their successes in this like VDOT’s Smart Scale program which DID take General Assembly approval to go forward.

    So perhaps it’s time to change the way our General Assembly “works” if all they can do is not much as the legislative level other than neuter the SCC and other shennigans and they have “no time and no expertise” for knotty problems.

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