Aug 12, 2019

Axios Vitals

Good morning. Forget TV news. If you, like me, have found better drama to watch on national television, respond to this email to a) affirm that "Bachelor in Paradise" is the best show on television and b) tell me whether you're Team Caelynn or Team Blake.

Today's word count is 896, or about 3.5 minutes.

1 big thing: How the health care system fails dying patients

Illustration: Sarah Grillo/Axios

My colleague Bob Herman raises a good point about an overlooked failure of the U.S. health care system: It’s pretty bad at dealing with patients who are about to die.

The big picture: Medical culture has often framed death as a binary decision: preserve a patient's life at all costs or give up and accept what happens. 

  • From medical education all the way through to payments, our system generally does not encourage doctors to listen to dying patients' needs or priorities.
  • That does a disservice to the fear, uncertainty and philosophical questions about life and death that patients and their families experience.

The health care system isn't helping patients wrestle with these difficult questions, while advances in medicine are making them even harder to answer.

  • "I would like to believe that I will be very clear-eyed and rational, that I will know when it's time to stop treatment," Diane Meier, a leading expert on palliative care, said when asked how she would like to die. "But I am not so arrogant as to think that I might not choose [more treatment] out of fear."

Where it stands: Experts say we have designed a system that fails to support both the chronically ill who are the costliest to treat and those who are closer to death.

  • Medicare's hospice benefit is restrictive. And despite some recent changes in policy, physicians don't have a strong financial incentive to spend their time listening to patients' concerns.

Yes, but: It’s getting better. The hospice and palliative care movement has expanded rapidly. And more people are dying at home, where they'd rather be, instead of in a hospital.

Go deeper: Bob’s story is part of Axios’ deep dive on death. If you missed it this weekend, it’s worth your time.

2. A new twist on medical tourism

American hospital care is so expensive that some employers are paying patients to receive care in other countries, and they're sending an American doctor with them to provide the care, the New York Times reports with Kaiser Health News.

  • One patient received a $5,000 payment from her husband's employer in addition to a total knee replacement free of cost-sharing in exchange for having the procedure done in Mexico. The company also covered the travel expenses.
  • The cost to the employer was still less than half of what it would have been in the U.S.
  • The doctor, who flew from Milwaukee to Cancun, was paid 3 times the Medicare rate for performing the surgery.

The big picture: Medical tourism is old news, but a Denver company has seen an opportunity and is organizing treatments abroad.

  • The company, North American Specialty Hospital, has a network of doctors — including the one in the anecdote above — who travel to Cancun on their days off to provide care for American patients.
  • NASH believes that having American doctors will help persuade self-insured employers that the care is high quality, and to offer the option to their workers.

Why it matters: Hospital care costs are so high in America that it makes financial sense for employers to pay their employees to receive care from an American doctor in another country. Think of what that means for the vast majority of Americans who don't have this opportunity.

3. Hospital care is getting more expensive
Expand chart
Data: United Health Group; Chart: Axios Visuals

Speaking of expensive hospital care, hospital prices for inpatient services increased more than the prices paid to doctors providing these services between 2013 and 2017, according to a new data brief by United Health Group.

  • Hospital prices for inpatient services increased by 19% over this time period, or by 4.5% per year.
  • Physician prices for inpatient services increased by 10%, or 2.5% per year.

Yes, but: Part of insurers' job is to negotiate good rates for their enrollees, raising the question of how hospitals are able to cut such lucrative deals year after year.

  • Insurers say their hands are tied by hospitals with ever-increasing market share, a result of consolidation. This also gives hospitals power over the physicians working in them.

By the numbers: Privately insured patients paid more than $200 billion for hospital inpatient services in 2018, according to the brief.

  • This number is expected to rise to more than $350 billion in 2029.
4. Inside a drug shortage

A shortage of a medicine used to treat immune disorders has led to providers rationing the drug, leaving patients more susceptible to infections and in more pain, the Wall Street Journal reports.

  • The medicine, immune globulin, is derived from blood plasma. It's versatile, and can be used to treat people with compromised immune systems or some muscle and nerve disorders.

Hospitals and infusion clinics have been providing it to those who need it most, leaving some patients without.

  • Manufacturers say increased demand for the medicine has contributed to the shortages.

The big picture: There were 282 active drug shortages in the U.S. as of the end of June, an increase from 224 last year, according to the University of Utah Drug Information Service.

5. While you were weekending ...
  • Moderate presidential candidates say Medicare for All would be anti-labor, but not all labor unions agree, Politico reports.
  • The NYT details medical workers' heroic efforts inside the University Medical Center of El Paso to save victims of last weekend's shooting.
  • Hospitals notched a major victory against North Carolina, as the state announced that employees on its health plan will have in-network access to major hospital systems that hadn't agreed to state-set prices, the Charlotte Observer reports.
  • An elderly couple who died in an apparent murder-suicide left notes about their struggles to afford their medical bills, NBC reports.