The Physician and Impact of Patient Expenses

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Doctor Smiling PoseFamily practitioner Mark Ebell was 28 when he moved from a prosperous part of Michigan to practice family medicine at a community health center in the tiny Georgia town of Colbert. 

Although many of the conditions he treated were much the same in the two states, his patients in rural Georgia lived vastly different lives from those he cared for at the University of Michigan Medical Center.

“All of a sudden I went from a mostly insured population to a mostly uninsured or Medicaid population,” recalls Ebell, “so it was a real learning experience for me to have to think, ‘OK, I can’t use those expensive drugs anymore.’ ”

Ebell’s medical education had emphasized the scientific aspects of medicine: the electrophysiology of the heart, the biochemistry of elevated cholesterol, the battle between virus and host cells in HIV/AIDS.

When it came to clinical training, he and his classmates had learned how to take histories and perform physical exams. The economic realities of patients’ lives rarely came up, and medical students did not focus on how much their patients would be charged for diagnostic tests, surgical procedures or medicines.

In Georgia, he was suddenly dealing with a lot of poor patients, and their economic circumstances had to be taken into account. It was a kind of culture shock.

That was 30 years ago.

Today, most medical schools and residency programs say they are training future doctors to think about costs as well as medical indications when they consider what to recommend to patients.

According to a 2015 survey conducted by the Association of American Medical Colleges, 144 out of 145 U.S. medical schools now require students to study the health care system and health care financing in order to graduate.

At the Augusta University/University of Georgia Medical Partnership, Ebell teaches two such courses. First-year med students study community health, and second-year students focus on health at the population level. Both modules draw on Ebell’s experience as a physician and his expertise in epidemiology, which is what he now teaches at UGA’s College of Public Health.

Doctors’ bad mental habits

The classroom lectures, on how patients’ finances affect their care options, may not be sinking in as hoped.

Ruth Lewit is a fourth-year student at the AU/UGA medical campus in Athens. She studied cost and insurance issues two years ago, but says those topics did not really hit home with her until she did a clinical rotation in a local private practice last year.

“They can teach us as much as they want the second year,” said Lewit, “but until you actually see it in action, so much of that doesn’t even make sense to you.”

She says the lessons about health care costs and insurance might be more effective if they were moved to the third or fourth year of med school, when students spend more of their time dealing with actual patients. “It’s easier to conceptualize it once you’re in the clinical setting,” Lewit said.

Unfortunately, many of the clinicians that medical students work with during their rotations may not be setting the best example when it comes to prescribing affordable treatments or medications.

The conventional wisdom is that many doctors are clueless about how much a test, a treatment or a procedure will cost. That’s largely true, Ebell says, because many doctors never see the bills and reimbursement transactions that are processed by their office staffs.

“A big problem is that physicians don’t know the cost of what they’re prescribing,” Ebell said. “They are often shocked when they hear that many of the new drugs for diabetes are $300 to $600 per month.”

There’s another, psychological reason why doctors aren’t attuned to cost, says internist James Pippim, co-director of a new internal medicine residency program at Piedmont Athens Regional.

All medical students spend some of their early clinical training in an emergency room, where the law requires that all patients receive the treatment needed to stabilize them, regardless of their ability to pay. Future doctors develop what Pippim calls a “treat first” mentality.

That well-meaning mindset often carries over into non-emergency, routine care settings, where it is often not practical. “Most places offer services first and then figure out the way to get paid,” Pippim said.

Just as physicians cannot assume an insurer will pay, they cannot assume that the prescription they wrote will actually be filled.

Pippim and the residents he supervises see this reality all the time:

“It’s only on repeat visits that patients say to us, ‘Oh, I never filled that prescription.’


‘Because I couldn’t afford it, because I had to choose between feeding my children and buying my medication.’ 

With large companies seeking to merge and benefits changing all the time, the field of insurance can be bewildering. It’s hard for anyone to know all the intricacies of coverage and what they mean for an individual’s treatment. Pippim admits that he and his experienced colleagues are learning alongside their residents.

Unless there is a way to guarantee affordable, high-quality care for all patients, training medical students and residents to talk with patients about money as well as their health is a necessary piece of the puzzle.

“I think that with more emphasis placed on primary care needs and primary care physicians,” said Pippim, “the more people we’re likely to reach, and the less expensive health care will become overall.”


Senior Dental Insurance: A Rare Commodity

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couple-on-bridgeAging can take a toll on teeth, and for many seniors paying for dental care services is a serious concern because they cannot rely on their Medicare coverage. 

 Lower income seniors, in particular, are struggling. More than a third with incomes below 200 percent of the federal poverty level (about $23,000 annually) had untreated tooth decay between 2011 and 2014, according to an analysis of federal data by the American Dental Association.

“What ends up happening is that almost everybody, when aging into 65, is basically on their own and obligated to pay for dental care out of pocket,” said Dr. Michael Helgeson, chief executive officer of Apple Tree Dental. Apple Tree is a Minneapolis-based nonprofit organization operating eight clinics in Minnesota and California that target underserved seniors, as well as mobile units that provide on-site dental care at nursing homes and other facilities.

Traditional Medicare does not usually cover dental care unless it is related to services received in a hospital. Medicare Advantage Part C managed care plans generally provide some dental care, but the coverage can vary, and is often minimal, dental advocates say. The plans often are “a loss leader,” said Dr. Judith Jones, a professor of dentistry at Boston University. “The plans are meant to attract people, but the coverage is really limited.”

In a way, seniors are victims of dentistry’s success. Regular visits to the dentist, along with daily tooth brushing and water fluoridation, have all contributed to improvements in oral health. In the first half of the 20th century, by the time people reached their 30s or 40s many had already lost all their teeth, Helgeson said, while today more than 60 percent of people in nursing homes still have at least some natural teeth.

But teeth need tending. Without regular dental care, tooth problems can cause pain and limit how much and what type of food people are able to eat. Similarly, gum disease can loosen teeth and allow bacteria to enter the body. A growing body of research has linked treating periodontal disease with lower medical costs for diabetes and heart disease, among other conditions.

People’s lives are affected in other ways by their oral health. “You use your mouth to eat and kiss and smile and interact socially,” said Jones. “It’s a source of great embarrassment and suffering for many adults without access to care.”

With limited income and/or no insurance, seniors may skip visiting the dentist regularly, even though many report that their mouths are dry and painful, and they have difficulty biting and chewing, not to mention avoiding smiling and social interaction if they have missing or damaged teeth.

Medicaid, the state-federal program for lower income people, covers dental care for children in every state, but coverage for adults is limited. Most states cover emergency dental care, but eight states offer no adult dental benefits at all, according to a study by Oral Health America, an advocacy group.

Even trying to purchase private dental insurance, which typically covers a few thousand dollars worth of dental care, may not provide a good value, said Marko Vujicic, vice president of the American Dental Association’s Health Policy Institute. “When you add up the premiums and copays it is not worthwhile for the vast majority of adults to have dental insurance,” he said.

Seniors with traditional Medicare spent $737 on average out-of-pocket on dental care in 2012, said Tricia Neuman, director of the Program on Medicare Policy at the Kaiser Family Foundation. 

But the figures may be much higher for people who need major restorative work.

“I know people who are spending sometimes more than $10,000 on what they consider essential dental care, like implants, none of which is covered,” Neuman said.

Seniors with limited means have few options for help affording dental care. Federally qualified health centers may provide geriatric dental services on a sliding-fee scale, and clinics like Apple Tree help a limited number of seniors who live in their service area. But they’re a band-aid, said Jones.

She and other advocates want Medicare to add a dental benefit to Medicare Part B. Their proposal would provide a basic bundle of diagnostic and preventive services through a premium increase, and seniors would only be responsible for copayments if they need pricey restorative work like crowns and bridges.

“Over the years, there has been some interest in expanding Medicare to include dental coverage,” Neuman said. But a dental benefit has faced stiff competition from other priorities, including adding a prescription drug benefit in 2006 and preventive coverage under the health law in 2010.

But some people think this time might be different. “There are 250,000 people every month who are turning 65, and 30 percent of dentists say they could use more business,” said Beth Truett, president and CEO of Oral Health America, which supports the proposal. “It’s a perfect storm.”


Alone and Aging: A Safety Net For Seniors

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lady-sitting-in-loungerElizabeth knows what she should do, but like many of her peers, the 71-year-old does not exactly know how to approach a casual acquaintance and ask who will take care of her when she needs it most. 

Living in Austin, Texas, Elizabeth is among a growing number of seniors who find themselves alone just when aging and end-of-life care becomes real.

Unmarried, with no children, her younger sister, by seven years, passed away in 2014. Elizabeth’s social network is limited to a handful of work colleagues and a few acquaintances.

“I’m very fearful of reaching that place in my life when I really need help and possibly cannot take care of myself,” she said. “I may have no one to be there for me.”

Elizabeth represents a universe that has come to be known among geriatric specialists as “elder orphans” — seniors with no relatives to help them deal with physical and mental health challenges. Their rising numbers prompted the American Geriatrics Society in November 2016  to unveil guidelines for a segment of these older adults who can no longer make their own medical decisions and have no designated surrogates. The nonprofit dubbed them “unbefriended” and called for a national effort to help prevent a surge among incapacitated seniors who face a health crisis and do not have a decision maker.

Single seniors have always existed, but demographic and social changes have slowly transformed aging America. In 1900, average life expectancy was 47. Now, the combination of increased longevity, the large and graying baby boom generation, the decline in marriage, the rise in divorce, increased childlessness and family mobility has upended the traditional caregiving support system.

Among the indicators:

— A Centers for Disease Control and Prevention report this year shows the number of Americans older than 100 years old increased almost 44 percent between 2000 to 2014.

— Twenty-two percent of people over age 65 are — or risk becoming — elder orphans, according to a 2015 study by New York geriatrician Maria Torroella Carney.

— A U.S. Census report from 2014 projected by 2050 the 65 and older population to be 83.7 million — almost double the 2012 estimate of 43.1 million.

— The nonprofit Population Reference Bureau in Washington, D.C., reported earlier this year that family members provide more than 95 percent of informal care for older adults who are not in nursing homes.

“Americans are spending less time than ever in the married state,” said Susan Brown  of the National Center for Family & Marriage Research at Bowling Green State University in Ohio, which “raises questions about who is going to care for these people as they age and experience health declines.”

Reference Bureau demographer Mark Mather said the combination of aging boomers and family dislocation is creating “a potential caregiving crisis or at least major challenges down the road.”

The oldest boomers are now 70. With more on the horizon, the impact of smaller family size will become more pronounced: Baby boomers generally had fewer children than previous generations and significant numbers are childless, said demographer Jonathan Vespa, of the United States Census Bureau.

“As people have fewer children, there are naturally fewer people in that next generation to help take care of the older generation,” he said.

New 2015 U.S. Census data also reflects more elders who live alone — 42.8 percent of those 65 and older. Yet new twists have emerged, such as cohousing, in which people live independently in housing clusters with a common building for meals and socializing. Such thinking, said gerontologist Jan Mutchler, of the University of Massachusetts Gerontology Institute in Boston, suggests a “shift [in] the way people are thinking about who can I rely on and who is going to be there for me.”

Katie, 77, spent much of her working life in San Antonio or New York, finally retiring to California five years ago. Katie and her friends daydream about “having these little houses around the spoke of a wheel and at the center have a nurse and a good chef.”

Mary, 85, is an unmarried only child with no children. She has lived on St. Thomas in the Virgin Islands for 51 years, where she developed a close group of “extremely supportive friends.” Most, she said, are five to fifteen years younger, which proved important in January 2016 when she had open heart surgery.

“That was it,” she said, noting she never again talked about future care. “Now that I am feeling so much better, I try to keep away from discussing that kind of stuff.”

It’s a mindset of aging boomers that Mutchler [gerontologist] knows well. “People in general avoid planning for unpleasant things,” she said. “Many people do not have wills or think about longer term recovery and custodial care needs.”

Timothy Farrell,  a physician and associate professor at the University of Utah School of Medicine in Salt Lake City who worked on the new policies, said he would “regularly encounter patients with no clear surrogate decision maker.”

The guidelines include “identifying ‘non-traditional’ surrogates — such as close friends, neighbors, or others who know a person well.”

Boosting social ties among elders is part of a national campaign launched in November 2016 by the the National Association of Area Agencies on Aging, a nonprofit. The aim is to combat loneliness.