Dr. Dennis Rosen is a pediatric pulmonologist and sleep specialist at Children's Hospital Boston and Assistant Professor of Pediatrics at Harvard Medical School. He is a frequent contributor to the New York Times, Boston Globe, Boston Herald and JAMA, and posts regularly on his blog Sleeping Angels. He is married and has three children.
LAST month, the Obama administration announced that the Centers for Medicare and Medicaid Services would make much greater use of competitive bidding to buy medical equipment for Medicare patients. Because of Medicare’s size and position in the health care market, it is likely that this policy will be quickly adopted by Medicaid and private insurers.
On the face of it, competitive bidding sounds like a very good idea. If one supplier can provide power wheelchairs or oxygen masks for 30 percent less than another, it’s hard to argue for contracting with the more expensive supplier, especially at a time when everyone is looking for ways to save money. A one-year experiment with expanded competitive bidding that was recently conducted by Medicare yielded cost savings of 42 percent, without reducing the quality of care, and was hailed as a great success.
But as a doctor working with patients on the ground, I have doubts about that quality-of-care measure, and I worry that those savings obscure a potentially serious problem.
I care for many children with obstructive sleep apnea, a condition that causes the throat to collapse during sleep, preventing air from getting into the lungs. It is associated with cognitive impairment, as well as hypertension and heart disease. Some of these children need to be treated with continuous positive airway pressure, or CPAP, a machine that blows air through a mask at a fixed pressure, which props the throat open and prevents the child from choking.
Using CPAP, or any medical device, is complicated, and the machines work only if you know how to use them properly. If the CPAP mask doesn’t fit snugly, it can be uncomfortable and cause skin abrasion or even scarring. If moisture condenses in the tubing and splashes into the mask while the child is asleep, it can be very frightening and unpleasant. And there are many important adjustable features, for instance for the humidifier and the rate at which the air pressure increases. If used incorrectly, CPAP will not do what it is supposed to. The obstructive sleep apnea will remain untreated, and if a child’s blood oxygen levels drop too low, or if heart disease develops or worsens, the child could even land in the hospital.
The same is true for other devices. Patients who aren’t properly taught how to operate home IV pumps can wind up staying in the hospital instead of being treated as outpatients. Patients on home oxygen can stop breathing if they’re accidentally given too high a concentration of oxygen.
To make sure this sort of thing doesn’t happen, medical-equipment suppliers send a technician to the patients’ homes to explain what can go wrong and to show them and their families how to use the device properly. But I know from experience that some suppliers are better at this than others. Some CPAP suppliers’ technicians will spend an hour making sure the families understand everything. Others (whom I no longer use) spend no more than 15 minutes. I found this out after patients showed up in my clinic, days after their machines had been delivered, still unable to use them.
This extra care takes time, and time costs money. But sicker patients and unnecessary hospital visits cost far more. And competitive bidding doesn’t take these subsequent costs into account.
If competitive bidding is predicated on supplying equipment at the lowest possible price, something has to give. And more likely than not, that something will be patient care. Medical-equipment providers will have no incentive to do a better job of making sure the equipment is being used properly. And that, in turn, will lead to poorer outcomes.
Only by comparing these outcomes can one supplier be demonstrated to be truly more effective than another. And as someone working with real patients and their families, I know that without ensuring that patients who are prescribed medical devices know how to use them, the total cost to our society will only rise.
* Article in the New York Times 4/26/2011 about two children our team from Children's Hospital Boston cared for in Haiti last November: http://bit.ly/g7vXeO
* Original (unabridged) version of op-ed published in the Boston Globe 2/24 2011 about the unintended (yet predictable) consequences of Governor Patrick's 2012 budget proposal which includes cost shifting of medication co-payments as a way of saving costs, but will likely result in increased expense for taxpayers.
The steady rise in health care costs poses a major threat to the economic well being of our society. Medical inflation outpaced the general inflation rate by more than 2.2 fold in 2010, according to the Bureau of Labor Statistics. Health care expenditures as a percentage of the gross domestic product (GDP) went from 4.7% in 1960 to 17.3% in 2009, and are predicted to rise to 31% of GDP by 2035, barring significant changes in policy (and without considering the effects of the Affordable Health Care Act), according to a report published by the Congressional Budget Office in 2009.
Allowing health care expenses to consume such a large proportion of what we produce leaves less for everything else: education; the maintenance and replacement of our crumbling infrastructure; and job creation, to name a few.
At all levels, efforts are being made to contain and roll back health care costs. The Affordable Health Care Act is one such attempt made by the federal government, albeit one which has come under a lot of criticism both for what it does and does not do. State governments are also trying to do their part, faced with declining tax revenues and mounting expenses.
Governor Patrick recently unveiled the 2012 state budget proposal, which increases funding for Mass Health by only $100 million, or less than 1% above 2011 projected spending ($10.507 billion). This, despite the fact that the projected case load handled by Mass Health is expected to increase in the coming year by 4.6%.
In order to cover the $800 million gap between what is being budgeted for Mass Health and the predicted costs at the current levels of service, a variety of cuts in services has been proposed. Among these is the shifting of costs to low income families by increasing medication co-payments and by charging a $2 co-payment for the use of non-emergency transportation. These measures are expected to save the state $5 million, less than 1% of the expected shortfall.
However, these measures may very well wind up causing the opposite of what they are intended to do. Many patients require multiple medications, and the cost of their co-payments can quickly add up. When faced with having to choose between medicine and food, many simply stop taking their medicines and assume that because they did not notice an abrupt worsening, they didn’t really need the medicines in the first place. Likewise, if the cost of getting to a doctor’s appointment becomes an issue, many may choose not to go.
An estimated two thirds of medication-related hospital admissions in the United States are the direct result of patients not taking their medications as prescribed. The cost of this to our society is $100 billion dollars annually.
Encouraging the judicious use of expensive medications is laudable. However, if this is done by making them more expensive for those who can afford them least, it may well result in an increase in the number of hospitalizations, something which will cost much more than it will save. This short-sightedness is a classic example of being penny wise but pound foolish.
The Patrick administration would be well advised to reconsider this section of its 2012 budget proposal. Its risks, both to the health of those who rely on Mass Health and to the finances of the state, far outweigh the modest savings hoped to be achieved.