Emory Case Study

The main reasons why Emory decided to implement CPOE systems were to reduce the number of medication errors, as before CPOE went live, physicians at Emory would place orders by writing them on an order sheet attached to the patient chart, and in some cases, they would call a nurse to write the orders on the order sheets. When this happens, it was not uncommon for the physicians to sign off orders that weren’t verified correctly by the nurses. There’s also the concern of lost paperwork, or illegible orders. Therefore CPOE systems are mainly designed to reduce, or eliminate handwritten orders.

These are all good reasons, but CPOE did not exactly eliminate all medical errors as some physicians, who are not as familiar with technology, would often put in the order for the wrong patient. However, it is definitely more efficient, as the doctors have the responsibility to enter in the order themselves, and they are entering it into the computer so it improved legibility.

Before adapting to CPOE systems, physicians would communicate verbally to the nurses to place the work order, but now with CPOE, every work order is now computerized. Physicians can enter in the information themselves digitally, and medication and other orders can be placed correctly.

Workaround, is when you use other methods than what the system is originally designed for, to get the work done. An example of this would be the physicians letting nurses place orders, without entirely verifying it, instead of writing it down themselves. I personally did not have much of an experience in working around the technologies that I use.

Some suggestions that I have for creating a culture where people are willing to adapt to unforeseen problems while using complex system like EHRs and CPOE, would be to just take it slowly step by step, and to train physicians to use technology. The systems should also be more user-friendly. Developers should work with physicians and nurses to develop one that would help them understand how to use the software better. I don’t exactly remember any major system changes while using computers, but while I was in my java programming class, I was first introduced Dr. Java, and then later introduced to Eclipse, which checks the java code more efficiently, but there’s more shortcut buttons that you need to familiarize yourself with to make use of the software.

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Emory Case Study

• What are main reasons why Emory decided to implement CPOE systems? Were these good reasons? 

Emory decided to implement CPOE because they are more reliable and easier to access than the previous system. After implementing CPOE, doctors can initiate orders online instead of signing papers. It reduces the probability of losing the paper. In addition, doctors can send the patients' exam online instead of through faxing.

They were good reasons because they free doctors and hospital workers papers, which are burdensome and hard to manage. CPOE allow both doctors and patients to view the details online.

• Why won’t CPOE’s eliminate all medical errors? 

CPOE cannot eliminate all medical errors due to man-made mistakes. According to a ground nurse's experience, CPOE is extremely difficult to use. Though CPOE has benefitted many emergency physicians in a significant way, it also brings trouble for those less technology savvy physicians. They would click on the wrong patient names.

The overall feedbacks from physicians are positive.

• What are the some differences between how Emory placed orders before CPOE and then after CPOE? 

After CPOE, nurses no longer need to take notes from the doctor and let the doctor sign the order. Doctors will type in the orders himself. Doctors can also view the information through the sheets with a remote access. It improves efficiency and minimizes the mistakes.

• What is workaround, and how does a change in workflow make workarounds more noticeable? 

Workaround means that hospital workers work in a different way to achieve the goal instead of the normal way. They perceive that some problems are very hard to solve.

A disintermediation in Emory CPOE shifts the workload of nurses to physicians. Physicians complain about that because they have to do more. Nurses have problems reviewing the order because they no longer receive verbal orders from doctors. Pharmacists love this change because they are freed up from writing orders all day to walking around on the floor.

• Have you ever experienced anything like this in your work or school systems? 

U of A Campus Recreation Center has just renovated its locker room and introduces a new towel tracker. This move causes disintermediation between the towel renters and workers at rental area. Additionally, renters would no longer need to get into line and return the towels due to the micro trackers on the towel. While it saves trouble for most of us, people who are not so acceptable to the change needs to register their finger prints.






I suggest that people should be informed of the benefits change bring in a long run so that more people are welcoming the changes.

Emory CPOE Study

•What are main reasons why Emory decided to implement CPOE systems? Were these good reasons? 
 The reasons the Emory implemented CPOE was due to the number of unintentional medical errors that had been occurring, generally, in health care and as a delineation, the Emory hospital system.  Almost 900,000 injuries occurred, in 1984, due to errors in patient management in the U.S. - where more people died versus car accidents, breast cancer or AIDS.  Some examples of such type of errors occur through multiple transcriptions of an order or orders of medications.  Any attempt to mitigate the number of preventable errors, that does not worsen the problem, would seem reasonable to implement.  Though, as discovered in the article, there were consequences that resulted from implementing CPOE and hard evidence was not provided as to whether or not the incidents of errors decreased.

Why won’t CPOE’s eliminate all medical errors?
Initially, CPOE's will not eliminate all medical errors because of the learning curve involved in the adapting to the new system.  Changing such a process involves coming up against a great deal of rigidity by the involved agents, as described in the article, and they have to unlearn habits.  In the long-run, such incidents may decrease as knowledge and familiarity with the CPOE system increase by those in health care.  However, it is still dependent on human involvement which always opens the potential for error.

•What are the some differences between how Emory placed orders before CPOE and then after CPOE?
Before CPOE's more of the order handling was in the hands of the unit clerks and nurses who were entering everything by hand which could result in greater human error.  After CPOE was implemented, the doctors had greater responsibility in the placed orders and they were writing the orders through computers and not by hand.  There were some issues with the new system as not all the physicians were as proficient with correct entry and some confusion ensued on the proper form for entry.  There was also no gatekeepers keeping a "check" on the proper transmission of orders.  Some animosity resulted for both the physician increased workload and nurses who felt the system was too complex and cumbersome.

What is workaround, and how does a change in workflow make workarounds more noticeable?
A workaround was a way that an order would eventually make it to its desired result though not going through the normal process, but working around it.  These workarounds are generally inefficient and knowledge of how to do it was in a limited amount of persons' hands.  These workarounds were exposed when the CPOE system was in place as they could no longer "successfully" function like they could before CPOE.

Have you ever experienced anything like this in your work or school systems?
Yes, I experience such an occurrence of some new implementation every semester that involves an "de-training" of an old process and training of a new process.  The people who are no on board with the change do seem to create a bottleneck.  Many times such a new process is not effectively communicated to all the possible people involved and it is not unusual to find this and have to explain how a process has changed to another person.  There is definitely a domino effect that takes places and with pushback or poor communication the positive effects that could have resulted can be stunted.  Then an individual might feel entitled to say "see the process isn't working, lets go back to the old process".

Are there any suggestion you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE? Have you had to go through any major system changes in other parts of your life?
I think the best way to create a culture where everyone becomes more accepting to change is to be very clear of the consequences that the current system is having and then show clarity about how instituting specific changes will help to overcome such consequences.  And that every person's role in accepting this change is pivotal.  If there is any rigidity from people, then the consequences may end up worse than the consequences of the original system.  Also, sympathizing and empathizing that adapting to such changes are not going to be easy, that there may be headaches, but in the long-term it will be of greater benefit.

Emory Case: A Study By Ben Ampel

What are main reasons why Emory decided to implement CPOE systems? Were these good reasons?

There were errors in the system due to manual order sheets. These paper sheets had to be verified, but sometimes were not before an order had already been carried out. Handwriting, lost paperwork, and a high number of changing hands for the paperwork created a high amount of errors.

CPOE allows medical institutions to move away from these handwritten papers, and removes the need for the nurse to potentially make mistakes when taking notes from the physician. Physicians now also have remote access to these sheets, allowing them information away from the hospital, which is reason itself for me to think that this was a good plan. The plan to improve patient care also seemed to be a success, although there was a mixed response from the physicians.

Why Won't CPOE's eliminate all medical errors? 

No system that has human input will ever eliminate errors. Many doctors are older and very hesitant to learn to operate the new system. They may accidentally select the wrong patient in the system, or enter information in an incorrect field. I'm an MIS major and I still make mistakes in the systems I use, of course doctors are going to make mistakes in their personal system.

But, overall, Dr. Matthews in the study states that errors were drastically reduced. So even though errors still exist, CPOE's have reduced overall error, and created a net benefit.

What are the some differences between how Emory placed orders before CPOE and then after CPOE? 

It used to be that physicians would give a verbal order to their nurse. The nurse would then write the information down on an order sheet. The nurse would then verify the order by reading it back, and then the physician would sign off on it.

Now, the nurse has been taken out of the equation. The physician takes down all information on a computer, and saves the information right there. The sheets can be looked at through remote access, and medication can be ordered immediately from the system.

What is a workaround?  How does a change in workflow make workarounds more noticeable?  

A workaround is a way of completing a task in a way that the system was not intentionally designed for, or avoiding an problem part of the process. Workarounds can potentially be time saving. If workflow is changed, workarounds may become unusable as the system no longer allows the task to be completed without following all steps, which could exaserbate issues if the previous problem in the system was not fixed or updated.

Have you ever experienced anything like this in your work or school systems?

At the Rec Center, we've added new electronic waiver forms for patrons to sign when they purchase a membership. The way the system works is you're supposed to click through the entire assumption of risk form on a tiny touch pad and then sign, however the pad times out after 20 seconds. But if you click through one page and then tap where the "sign" button appears later, you can get into the signing part of the program, saving about 30 seconds of tapping through waiver, plus the potential problem of the pad timing out and needing to restart.

What about other workarounds you do for software you use now?

Other than what is done at the Rec Center, I try to use hot keys to automate processes in my software, but I'm not sure I use any actual workarounds in my day to day life to avoid issues or bugs in the software.

Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?   

I believe training and information is the most important part of the process. If doctors know from the get-go that these systems will save them time and energy, they will be much more willing to deal with problems as they come. If physicians can't see the benefit of a system, then any unforeseen problem will just anger them further, leading to a much less productive day. Also keeping someone on staff who is always available to help with problems can help with productivity and positivity.

Have you had to go through any major system changes in other parts of your life using computers?

Again, the Rec Center likes updating their horrible system all the time, which only creates new and interesting problems to deal with. The people who actually use the system on a day to day are never consulted about changes that should be made, and this is obvious with every new update. Integral parts of the system break regularly, while areas of the system that are used maybe once a week for special cases work flawlessly.

Emory Case Study

What are main reasons why Emory decided to implement CPOE systems? Were these good reasons?

Emory chose to implement a CPOE system to modernize their previous process that involved manually filling out order sheets. Some physicians would do this themselves, or even have a nurse do it for them. There were frequent errors occurring with orders, as things could be lost in the process, handwriting could be misinterpreted etc. I think the fact that too many errors were occurring is a good enough reason to choose to implement the CPOE. While it was an expensive change to make and a big one process wise, overall it led to a reduction in the number of errors occurring. 

Why won’t CPOE’s eliminate all medical errors?

Unfortunately, even in a computerized environment there is still the possibility for users and their input to create issues. An example of this is the physicians or whoever is doing the entries accidently placing an order for the incorrect patient. Additionally, ownership of placing orders was transitioned fully onto the physicians, when they did not complete them all previously, so that can cause errors as well.

What are the some differences between how Emory placed orders before CPOE and then after CPOE?

Now, all orders are placed by the physician directly, whereas it previously was often completed by nurses. They place all orders through the computerized system, and can place multiple orders for a patient simultaneously. The physicians can now also place the orders from anywhere they access the internet, not just in the hospital. This is all much different from previously writing orders or needing someone else from the hospital staff to do so.

What is workaround, and how does a change in workflow make workarounds more noticeable?
A workaround is a way that a process is circumvented, often without realizing you are explicitly doing so. For example, actions in a process that were considered unspoken rules, like not formally disclosing old orders, when that was supposedly part of the old process, issues can occur.

Have you ever experienced anything like this in your work or school systems?

Yes, I had experience creating a new electronic system to standardize a business process previously conducted over email. It quickly became clear that business users can be excited for a new system or way of doing things, but there can still be a lot of animosity towards change and doing things a better way unless they truly had a strong dislike for the old system.

Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?

My largest suggestion for those for those implementing large systems such as EHRs and CPOEs is to make stakeholder communication the foundation of the implementation. From gathering requirements through a go-live, the more opinions you can gather and education you can give, the better off you will be. Even though it can be a pain as the developer or implementer of the system, your subject matter experts will be more than happy to offer their insight and tips, and they’ll likely be very valuable and encourage adaptable culture.

Emory Case

Change of any sort can be difficult but more so for an industry that has been doing something the same way for about a century. Emory Healthcare was founded in 1905 and, although they made some small IT advances in the 90s, used the same way of order processing until around 2005. When President Obama and congress made it a focus to enhance health information technology by enacting a stimulus package that invested $19 billion in the area. This change was met with resistance but Computerized Provider Order Entry Systems (CPOEs) were made with the goal of reducing adverse drug events and making the process more efficient as a whole.

Emory Healthcare is the largest health care system in Georgia so the overhaul that they experienced was on a large scale. They have 4 hospitals with 1,184 licensed patient beds along with 9,000 employees. Whenever you implement a change that will affect people on this big of a scale there will definitely be some hurdles. In the past, physicians would write patient orders on order sheets or have nurses do it for them. Nurses were supposed to read back the order and physicians would sign off if it was correct but there were some instances where the physician would sign off on it after the order was filled. This could create some errors because of miscommunication and was not an efficient way of filling orders but was what they were used to for so long.

CPOEs changed this process and put the responsibility mostly on the physician. This may have caused some unwanted work for the physician but was a much needed advancement. The physician or another provider with the correct privileges would enter the orders on the hospital computers. The physician could put in orders from anywhere with internet access which made things more efficient. The implementation of this was met with mixed reactions. Some liked the customization but other less technologically savvy physicians saw it as a hindrance to their work.

The value of CPOEs is still debated but most healthcare employees would agree that it is a needed and important step for our healthcare system. Adapting to the digital world will be easier and easier as the years go on because almost everyone has some sort of understanding about technology. Studies have shown that they do reduce adverse drug events but they are not conclusive. They can also cause different kinds of errors not seen in written orders. The investment in health information technology should be continued as more advances arise making it easier for patients to get quality care.

Emory Case

• What are main reasons why Emory decided to implement CPOE systems? Were these good reasons? 
• Emory's Healthcare was one of the largest health care systems in Georgia. With over 1100 licensed patient beds, 9000 employees, and 1000 community physicians, keeping track of the patients record was a very complex system. Prior to CPOE going live, Emory placed all of their orders hand written through an order sheet. Communication wise, verbal orders we're allowed and all orders for medications were faxe or scanned then sent to the pharmacy.

• Why won’t CPOE’s eliminate all medical errors? 
• Although CPOE's dramatically improved their system and was overall very satisfying for physicians and employees at Emory. With that being said, not all of medical errors can be eliminated. Regardless if it is paper or electronic, there always is a possibility that one can enter in the order incorrectly. Whether it is for the wrong patient because the mouse was a little off and physically typing in the incorrect part, CPOE's are not capable of eliminating ALL of the medical errors because of the human mistakes.  

• Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?   Have you had to go through any major system changes in other parts of your life.
• I believe a potential issue with things such as this are the users of the systems. Regardless of the industry, there is always a big range in terms of age of the users of the systems. A young physician who just got out of medical school is obviously going to be much more adaptable to a electronic system change such as CPOE compared to an older generation. It is necessarily the actual system that causes this chaos, but I believe it is more of the concept of change.  

Emory CPOE Case Study

What are main reasons why Emory decided to implement CPOE systems? Were these good reasons?

Prior to the CPOE implementation at Emory, physicians were writing out order sheets by hand and submitting a verbal request with a nurse. Everything from placing stat orders to sending medication forms to the pharmacy all went by the unit clerk. After implementing the CPOE system, the entire ordering process changed by holding the physicians accountable. The CPOE system enabled physicians to: place orders with a computer (instead of writing it down), place orders as long as they were connected to the internet, and enabled physicians to place their own lab / radiology orders rather than having the unit clerk place them (3, 4). I believe the implementation of the CPOE system was positive overall. The positive effects include; the new order entry system is very customizable which allows the CPOE team to continuously improve the system, the system put more work on the physicians which let other healthcare workers perform other tasks, and the electronic ordering eliminates and reduces errors.

Why won’t CPOE’s eliminate all medical errors?

The CPOE will not eliminate all medical errors due to human error. As Dr. Matthews said, “The most common mistake that you see is orders entered on the wrong patient, because the mouse was off by a few millimeters when you selected an order” (4). On top of this, there are less computer-savvy physicians who reject using CPOE since it is a hindrance to medicine. While neglecting to use the CPOE system isn’t directly linked to causing errors, I believe that there will be more errors for the physicians who choose to write orders. Lastly, I think there will still be medical errors that arise with software and hardware problems. All software, including Emory’s new CPOE system, will need continuous improvements to keep the system up and running smoothly.  

Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?

Personally, I have encountered a situation where people are opposed to adapting to a new system that they do not see the benefits too. This summer I interned at a commercial real estate company. The company was looking into using Salesforce in order to better manage there 20+ accounts. Each account contained several agents, neighborhoods, clients, financials, contracts, and so much more. In the first few meetings we spoke about using Salesforce, half of our team was split thinking that, “it wouldn’t be a good option”. However, after further instructional videos and demonstrations from salesforce, our team was able to grasp the benefits from the new system. I would recommend this similar process when implementing a new system like EHRs or CPOE. Make sure you let your team (or company) understand the benefits of the new system and how the new system improves upon the past systems faults.

Emory Case Study Questions

As you read the case, "Computerized Provider Order Entry at Emory Healthcare" consider the following questions: (You can write it as a paragraph and include any issues that stood out for you as you read the case.) These questions are mostly to serve as prompts for thinking. Feel free to reply to others' posts, and add your own view.

• What are main reasons why Emory decided to implement CPOE systems? Were these good reasons? 

• Why won’t CPOE’s eliminate all medical errors? 

• What are the some differences between how Emory placed orders before CPOE and then after CPOE? 

• What is workaround, and how does a change in workflow make workarounds more noticeable? 

• Have you ever experienced anything like this in your work or school systems? 

Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?   Have you had to go through any major system changes in other parts of your life?

Eller Healthcare Career Panel, October 12

The Eller Healthcare Career Panel will be held October 12, 4-6pm, in Berger 201.

RSVP for Healthcare Panel on eSMS

Panelists include:

• Sam Burns, COO, Agape Hospice and Palliative Care
• Matthew Hawkins, President, Sunquest Information Systems
• Judy Rich, CEO, Tucson Medical Center
• Jenna Lefkowits, Sr. International Product Manager, Advanced Staining, Ventana Medical Systems
• John Flores, Speciality Regional Sales Manager, Astellas Pharma
• Joshua Compton, Associate, Mercer

Others are pending, so once I learn more, I will add it.

Colonoscopy anyone?

The article focuses on one patient’s (Ms. Yapalater) financial experience with her colonoscopy and zooms out to explain that such an experience is not an anomaly, but instead the norm with an average colonoscopy costing close to $3,000 on average. With more than 10 million people getting them every year, the final tab is a profitable one for healthcare. Mentioning the size of the health care industry, $2.7 trillion, and examples of other severe price-inflated medical procedures.

The most expensive screening test routinely undergone, colonoscopies are a perfect example of what is wrong with the healthcare system. The procedure done in the U.S. does not provide any additional benefit vs. same procedure done in another country, but with the amounts that are able to be charged for them, they are increasing in popularity with an industry which has “business plans seeking to maximize revenue”.

Colonoscopies are no longer done in a physician’s office but in a surgical center, which were designed to reduce costs. However, it has actually increased the costs as additional services, costs are tacked on. The healthcare industry has propagated colonoscopies vs. other less-expensive, less-invasive screening procedures even though research shows colonoscopies do not provide prevent colon cancer any better. With the demand for the procedure increasing over 50% between 2003 to 2009, prices have inexplicably gone up, not down. Part of the reason for this is the use of anesthesiologists had doubled for the procedures over this time period.

The most interesting part of the article mentions that the insurer negotiated down each final bill in the colonoscopy cost data that it surveyed. Just the idea that it is common for a hospital or doctor bill to allow for negotiation of their bills should cast some suspicion on its pricing policies. It is also mentioned that there is a different pricing structure for those who have Medicare, as Medicare has more leverage in negotiations and able to ask for a lower price. It is fascinating to know that price discrimination laws don’t apply to the health care industry.

Paying Till It Hurts: The Continuing Debate Over Health Costs

The Continuing Debate Over Health Costs

http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html

The start of the article talks about how there are new tools for that consumers "patients" can look up relevant medical costs near them. The company UnitedHealthcare has both online and mobile tools that people can use. An interesting statistic in the article was by Truven Health Analytics reported, "$36 BILLION could be saved each year if the median prices for the 300 most common procedures", at first I thought it was in the millions but when I reread it and saw the B, I was truly shocked and then the UnitedHealthcare website and mobile app seems to be even more useful.

The article then shares letters to the editors by healthcare companies, doctor agencies, and specialists talking about the "new" article "The $2.7 Trillion Medical Bill" and their opinions about it. The 3 authors of the letter to editors all had in their letters that they believe that the patients deserve the best care. The Sedative agency believed that they costs were deemed worthy due to the complications and difficulties. The doctor was the one that talked about the healthcare system being a mess and their needs to be more than one way to solve it.

NYT Paying Till It Hurts: Vaccines

In the article, "The Price of Prevention: Vaccine Costs Are Soaring" Elisabeth Rosenthal goes into detail about how vaccines' costs have been increasing to a point where doctors are debating whether to offer shots. Vaccines have been a surprisingly hotly debated topic but they are still one of the most important things that benefits our public health safety. This article dives into all of the different influences that go into pricing, demand, and availability of vaccinations and how they all tie in together. Rosenthal strategically highlights stakeholders from each party effected by this conundrum to demonstrate how this is happening and what the long term effects could be. She points out pharmaceutical manufacturer Pfizer and their popular vaccination Prevnar 13, pediatrician Dr. Lindsay Irvin, San Antonio mother Breanna Farris, and government agencies like the Center for Disease Control and Prevention and Advisory Committee on Immunization Practices. All of these stakeholders play a roll in how vaccines are priced and give you insight to another part of the healthcare system that is not working correctly.

When the polio vaccination was invented it was a joint investment of funds between the federal government and different foundations. Pharmaceutical manufacturing companies have changed the way vaccines are made, patented, and sold through the privatization. Rosenthal points out that since 1986 the cost to vaccinate a child up to age 18 under private insurance has rose from $100 to $2192. Now, it should be pointed out that these costs may be explainable because of the added regulations and hurdles these companies have to go through to get vaccinations produced. There were measures to change the number of subjects mandatory for a vaccine trial from thousands to tens or even hundreds of thousands subjects. Added to the fact that making vaccines is a risky market to get into, these factors may explain some o the rising costs but definitely not all of it. Manufacturers have historically experienced small losses on vaccines because of the public health benefits forcing the companies to make them easily available but now are turning profits. The article points out how the cost for Prevnar 13 has been rising about 6% ever year since 2002 although the vaccine has not changed much. These rising costs should definitely be looked into by the government to decide whether there needs to be a correction to the market.

Government agencies play a large roll in the way demand for vaccines has caused some of the price increases. Rosenthal outlines how most pharma companies look at the FDA approval to be the most important thing for their drugs success but it is different for vaccines. The Advisory Committee on Immunization Practices is the most important government entity for vaccines because they give out mandates or strong recommendations to parents to get a certain vaccine. If the committee decides a vaccination should be mandatory for schools then the parent has no choice but to get their child vaccinated. These decisions may have direct influence on the price of the vaccine as pointed out by this article. In Singapore, Prevnar 7 was being evaluated for school mandate use. Before the committee made it mandatory it was selling at about $80 per shot but after it shot up to $120. These mandates, although beneficial to public health, can cause unforeseen price increases as well.

Finally, it is all tied together through the pediatrician Dr. Lindsay Irvin and San Antonio mother Breanna Farris. Due to the increasing price, Dr. Irvin tells us that she loses money on every shot she gives. The article states that insurance companies are supposed to cover all out of pocket cost because of the Affordable Care Act but in reality they cover on average about 40-100% of the cost. They rarely cover all 100% when overhead is taken into account so family doctor offices must make the terrible choice whether or not to offer immunizations. All of these decisions and factors come down to the direct stakeholder, Breanna Farris a mother from San Antonio. When her and her two kids moved to Texas, they were told when they entered school that Farris's daughter needed extra vaccinations because of the school mandate. She called 10 different pediatricians to find someone that was offering immunizations and was covered by her insurance but no luck. Her daughter missed a week of school trying to find the vaccine. They ended up being forced to go to a public health facility and lie that they didn't have insurance so they could get the vaccine.

When it comes to children's lives and the public health safety for all, making profits should be the last goal of these pharmaceutical manufacturing companies. This article really opened my eyes to all of the various factors that go into the pricing of these crucial vaccines and how it is a similar problem for many parts of healthcare. Rosenthal does a great job pointing out all of the different roles and how they tie in and can cause some horrible consequences.

NYT Pay Till It Hurts Case Write up

Article Title: “The Odd Math of Medical Tests: One Scan, Two Prices, Both High”

In the 2014 article “The Odd Math of Medical Tests: One Scan, Two Prices, Both High”, the article starts off by talking about Len Charlap, a retired math professor, who has had two outpatient echocardiograms in the past three years that scanned the valves of his heart. The first, performed by a technician at a community hospital that lasted less than 30 minutes. The next, was at a premier academic medical center in Boston, that took three times as long and involved a cardiologist. However, the charges seems to be backwards. The community hospital had charged about $5,500, while the Harvard teaching hospital had billed $1,400 for the much more elaborate test. The drastic price difference confused poor Mr. Charlap.

The article further analyzes the Medicare payments between the teaching hospitals in Boston and other hospitals within cities like Philadelphia. It is just as Dr. Naoki Ikegami, a health systems expert at Keio University School of Medicine in Tokyo, and affiliated with the University of Pennsylvania's business school said, "One of the things about U.S. health care system is that it defies the laws of economics, and of gravity. Once the price is high, it just stays there.”

Using Mr. Charlap’s case as an example, two major takeaways from the article are: 

1. The more machines, the higher the bills.

Testing has become "what liquor is to the hospitality industry: a profit center with large and often arbitrary markups" in the United States' medical system. Like the recent Iphone 8 and Iphone X phenomenon, where the systems are similar, the phone with newer bells and whistles is the one that’s being charged at a higher price. “Someone might feel, ‘I bought the expensive new machine and this patient is insured, so I might as well use it,’ ” said Dr. Barry S. Lindenberg, a cardiologist in Schenectady, N.Y. “We have to be honest, there are abuses.”

2. Stubborn model of payment.

The article also mentioned that despite Japan’s fondness for testing, its health spending is about $4,000 a year a person, or 9.6 percent of gross domestic product. By contrast, the United States spends more than $9,000 per person annually, more than 17 percent of G.D.P., although some studies indicate that health care spending is leveling off. The difference is in part because Japan decides the value of each test and medicine, sets a price and then demands that it decrease over time. However in United States, it’s a totally different case. New Jersey had the second-highest charges for echocardiograms in the nation in 2012, 8.4 times Medicare’s approved rate. Despite having machines that are newer, more cost-efficient, and provide clear snapshots of the heart, it is not used as often in the United States as in other countries. For example, the newest miniature echocardiogram machines can fit into a doctor’s white-coat pocket and, placed on the chest during an office exam, provides a snapshot of the heart. Even primary care doctors in training can use the devices, which sell for well under $10,000, to detect basic heart problems with a few hours of instruction, according to studies. Because there's no profit involved, the doctors in the United States do not use it as it does not fit the United States' model of payment. It is still an ongoing issue that needs to be changed.

NYT Paying TIll It Hurts Ben Ampel

Article Title: In Need of a New Hip, but Priced Out of the U.S.

Michael Shopenn needed a hip replacement. His options were pay $65,000 out of pocket for all expenses at a U.S. hospital, or $13,660 in Brussels. His insurance wouldn't cover the cost, due to a pre-existing sports injury. Even though prosthetics for his condition only cost $350, the markup is incredible for everything else. The fact is, nothing stops companies and hospitals from these insane markups, and people will pay the cost due to necessity. 

With the rise of people needing or wanting joint replacements, these companies are only going to be able to gouge prices more and more, especially since none of them are willing to undercut the other. 

This article really opened my eyes to how bad things have gotten in the United States. You always hear how bad things are, but being able to put actual numbers to the inflated prices (10,000% markups) really opens your eyes. And these companies don't feel any remorse. An executive for one of these companies argued that "the best way to reduce the cost of joint replacement surgery was to rescind the tax and decrease government interference" (Rosenthal). Except the tax was only 2%, and government interference is already minimal. The cost in Brussels is significantly less, and they use government regulation for healthcare. 

This article was published in 2013, and as recently as 2015, these prices have not changed for the better (Japsen). I think without regulations, these prices will only continue to get worse, as these companies are aiming for double digit growth every year, which isn't sustainable with lower prices. Worse, the companies still aren't putting their gross profits into R&D, which only accounts for 5% of their overall spending. These replacements aren't improving, and haven't had any breakthroughs in decades, yet keep getting more expensive (female specific replacements were actually more expensive, even though they use less material).

With an aging population, we are going to start seeing a mass exodus in either personal bankruptcies due to necessary joint surgeries, or vacations to other countries for more affordable care.  

NYT Pay Till It Hurts Case Write up

Article Tittle: American Way of Birth, Costliest in the World

The most wonderful event can happen in a hospital is giving life to newborn baby, you or the couple has finally become a father or mother. Hurray and congratulation! However, this excitement is not something you will see in this article, rather is the reversed of that slice of happiness. Ms. Martin before her pregnancy delivery, she started inquiring the expected pregnancy cost at her local hospital. The financial office was not very clear on how much it would charge her, but only gave her an estimate cost from 4,000 to 45,000$. Ms. Martin was upset on how they wouldn’t know her delivery cost, they are the hospital, and they should know. Meanwhile when she was trying to figure it out her estimated delivery cost, she received a couple bills for other visits. The bill consists of ultrasound scan and was asking for a discount when she already paid for a radiologist to read her test. Uninformed on how the bill is generated, she was charged for 935$ for the ultra sound test regardless if the machine was there for many years. Ms. Martin was outrageous and cheated by the system, she was confused on how “we” live in a first world country still receive an expensive bill for only giving birth to a new life? This bill (maternity cost) compare to other first world countries like Germany, United Kingdom, Switzerland, and France are not that expensive, even in third world countries, they received a better care and lower price for a healthy delivery. But the question for her is why in the U.S? It’s like everything has been label, everything has a specialist and are charging for absurd things that they shouldn’t.

From my own perspective view, I also feel that it’s very absurd and very disturbing on how the health care system and hospital bill works in the U.S. It’s like there is no one in charge of it to begin with, the price and bill are created based on what they wanted. This is insane and ridiculous with the system and set up, it’s like every specific thing is being charged in the hospital like what we have been discussing during the class. In my opinion, I think pregnancy to begin with they should not charge it excessively or none at all, after all the mother is giving birth to a new life and that new life is what keeps humanity alive. Human should be prioritized more important than money, however, for hospital, they value capital over humans’ lives. Then, where do humans belong to?

Rising Diabetes Costs

Even Small Medical Advances Can Mean Big Jumps in Bills (Link)

In this segment of Pay Till It Hurts, the major issues surrounding ballooning costs regarding Type I and Type II Diabetes is discussed. I’ll preface this by saying that the diabetes market is severely broken and in disarray, and at best the most encouraging thing that remains is that Type I diabetics still have opportunities to receive insulin and live encouraging lives in contrast to the former status of Type I diagnosis as a terminal illness.

There are a number of concerns and strain points to illustrate about the state of the industry, and I will dive into a couple key takeaways also. The first main point outlined in the article is the consistent iteration of diabetes equipment and infusions that has led to soaring prices over the years with marginal increase in improved patient outcome. Since the development of insulin therapy in the 1920’s or synthetic insulin in the 1970’s, diabetics began having options to control their health issues with a minimum viable product of sorts. None of the technology was revolutionary by modern day standards, but the medical concepts were fully established and scalable to save and improve millions of lives. While there have certainly been large improvements, the past decade has led to more aesthetic and non-critical improvements that have pushed device and infusion maintenance costs soaring market-wide.

Patients worldwide also face is the increased rate of obsolescence in pumps and meters as well as monitoring and maintenance strategies. The more tech integrated into diabetes management, the more diabetes management companies behave like tech companies. There are ever increasing interoperability issues and software issues as the latest and greatest is rolled out, and legacy treatment methods and platforms begin to lose service support and become ever harder to purchase. The captive market of Type I diabetics specifically is becoming more and more susceptible to being treated as hostages at the will of prices the market will bear.

Given these two issues, I’ve identified key takeaways and opportunities for the dire tide to shift that is looming over the diabetes sector of healthcare.

1.     Bargaining Power Needs to be Unleashed

In the discussion of why costs are so high, I found this factoid to be especially shocking: “Medicare is not allowed to bargain for insulin prices.” I found it shocking that a federal program with such clout was unwilling to drive down costs for patients. It is important to note however that most Medicare patients pay insulin costs out of pocket, and it is not covered. Even so, given the fact that there are likely a quarter million Type I diabetics under Medicare (based on rough calculation), any ability to make industry behemoths uncomfortable about pricing could reap massive benefits to consumers. Especially when there are only three nationwide producers of synthetic insulin, and one manufacturer, Medtronic, gripping over 60% of insulin pump market share.

2.      Dire Need for Competitive Disruption

Off that pervious point, the competition for key components and drugs within diabetes care is quite scarce. There are often very few large players that run the table, and solid, strategic, and fast-moving market disruption centered on affordability and reliability may be the only true way for competition to drive prices down. Please see this supplementary blog post by a diabetes industry advocate of what would truly need to happen to disrupt the market and reverse market trends, it’s a great read.

All things said, the challenges facing improvements in this healthcare space run the gamut, from unchecked market factors to questionably beneficial product improvements increasing cost. Serious change will need to be made through the concentrated advocacy of diabetics nationwide, government and private industry players, and maybe a little well-timed luck.

Pay Till It Hurts Assignment

Some of you are posting your case discussion, but I thought it might be helpful to remind some of you what you signed up to do for the case (sorry it is only first names):

Nathan:   Debate over the costs

Avaneesh:  Vaccines

Spencer:  Diabetes

Ken:  Cost of ER

Ben:  Hip Replacement

Jakob:  Surprise Bills

Alice:  Tests and Scans

Mozamil: Asthma

Fernando:  Increasing problems of pregnancy

Brent:  Colonoscopy

Ninja:  Doctor's Salaries

Also, for an update on more recent articles by Elisabeth Rosenthal, you may find these interesting as well.  This article about a patient shot in a hospital room was also covered by This American Life.  It's about letting police guard hospitals with guns but no medical practice.  She wrote the cover story.

NYT Pay Till it Hurts Case Write Up

Article Title: As Hospital Prices Soar, a Stitch Tops $500 (Link)

The article starts off by talking about a young patient who came into the ER for stitches. The family overall had a great experience and was really pleased with their experience. They then received a bill for 3 stitches at a cost of $2229. This is a very common price for something such as this. In the US, the average cost for a persons expense at a hospital for one day is $4,000, where hospital cost charges are 1/3 of the United States 2.7 trillion dollar annual health care cost.

Hospitals do have a reason for the increase in prices on a yearly basis. They must help maintain the hospitals with the most up to date equipment as well as keeping the maintenance of the hospital as modern as possible. Majority of them are shown as non profit, but find a way. At the end of the day, hospitals costs millions to operate and continue its services; with that being said, the prices will continue to rise as technology increases.

“Hospitals see where they’re making money and try to do more of that,” said Dr. David Gifford

1. First major thing that I took away from this article was the few constraints at hospitals when it comes to pricing. For any item or product, the pricing of the item is determined by the hospital on a yearly basis. So there could be a massive different in terms of pricing for things such as an ER visit between hospitals. If any urgency that is needed to be solved in a ER, a patient doesn't really have time to look at the prices of the charges that are going to be determined after the ER visit. This is where the concept of geographical prices comes in.

2. The second major concept that I took out from this article was the Net Income of Hospitals. In SF, after Wells Fargo, the next most employed company is California Pacific Medical Center. There Net Income was also $200 million which is absolutely absurd for a "non profit" company. The CEO for this hospital makes over $5 million and have broken ground on their new campus that will cost $2.6 billion dollars with upgraded facilities. At the end of the day, business for these hospitals are very good because of high demand. Hospitals understand that they are able to increase prices and there will still be demand of the product. They can help control their own market.