Suing Patients for Unpaid Hospital Medical Bills

Although published as a research letter, this study highlights a very important aspect of the business side of medicine in healthcare. Healthcare is very costly in the United States when compared to other countries. To collect revenue for the services provided, should hospitals pursue unpaid bills through all means including garnishing wages? If hospitals don’t do that then are they at risk of being in financial distress, particularly hospitals that are in poor areas? A larger question, that as a society needs an answer, is whether healthcare is a privilege or a right? Should an individuals be health responsible for healthcare expenses or society should collectively support healthcare costs of everyone? Blaming hospitals for pursuing unpaid bills is not going to fix the problem but may actually make it worse.

Anti-platelet Drugs after Coronary Intervention

The type and duration of anti-platelet therapy after cardiac catheterization and stent placement (also called percutaneous coronary intervention or PCI) is an ongoing debate.

There are two main groups of drugs. One is aspirin which is under use for over 100 years and we know a lot about it. The other group is P2Y12 blockers. P2Y12 is a receptor on the surface of platelets and these drugs block this receptor. The most well-known drug in this group is clopidogrel or Plavix.

A Japanese study examined the role of aspirin + clopidogrel for one month followed by 12-months of clopidogrel versus aspirin + clopidogrel for 12 months showed that the earlier strategy was superior. In contrast, a Korean study, also published in JAMA, found that there is no statistically significant difference between the two.

The results may appear different and the reason my be that the two studies were somewhat different. Below are some of the differences:

1. Korean study allowed the use of other P2Y12 inhibitors/blockers such as prasugrel or ticagrelor while Japanese study allowed on clopidogrel.

2. Korean study had lower adherence to drug therapy in the P2Y12 group as compared to combined group (79% vs. 95%).

3. P2Y12 inhibitors were given for 3-months in the first group in Korean study while Japanese study had for 1-month only.

Despite these somewhat difference results, the overall message is the same. Patients may have similar outcomes when given clopidogrel (or other P2Y12 inhibitors) alone after an initial period of combined therapy with aspirin. This may be a particularly good news for those patients who are at higher risk of bleeding.

Anti-platelet Therapy after Cardiac Stent Placement

The type and duration of anti-platelet therapy after cardiac catheterization and stent placement (also called percutaneous coronary intervention or PCI) is an ongoing debate. Aspirin is under use for over 100 years and we know a lot about it. Plus, it is a cheaper drug. Clopidogrel, better known by its market name Plavix, is now in marker for many years and its generic versions are available. Almost all studies have examined the use of additional anti-platelet drugs after PCI on top of aspirin use. What if we examine the use of anti-platelet drugs on top of clopidogrel use?

A study published in JAMA examined this question in a multi-center, open-label, randomized clinical trial conducted in Japan. They enrolled 3045 patients to either 1 month of aspirin + clopidogrel therapy followed by clopidogrel therapy alone versus 12 months of aspirin + clopidogrel therapy. The outcome they were looking at was a combined outcome of cardiovascular death, myocardial infarction, stroke (ischemic or hemorrhagic), stent thrombosis, or bleeding.

I am certain that authors were hoping for finding that the two treatments were similar. To their surprise, not only 1-month of aspirin + clopidogrel followed by clopidogrel alone was similar in efficacy but was superior to the 12-months of aspirin + clopidogrel (2.35% vs. 3.70%; P<0.001). In other words, a shorter duration of combined therapy followed by clopidogrel therapy is as effective, if not better, than 12-months of combined therapy. These findings are important especially for patients who are at high risk of bleeding.

Patient Satisfaction and Patient Psychological Well-being

Patient satisfaction with physician communication is part of the HCAHPS patient satisfaction survey. HCAHPS is a mandated survey of a sample of patients discharged from hospitals to assess their satsifaction with hospital, physicians, nurses, and discharge process. While CMS has advised not to use the individual domains of the survey as those individual domains are not tested (as compared to the whole survey which is tested), hospital administrators continue to use individuals domains to reward/punish physicians.

This recently published study shows that patient satisfaction strongly depends on patient’s psychological well-being. It is unlikely that a physician has any strong influence on a patient’s psychological well-being and hence on the patient satisfaction. Interesting study! We need more such studies to tease out what factors (patient level or healthcare level) that affect patient satisfaction so that we can adjust healthcare delivery accordingly.

Academic Center–Too Big to Fail?

A very interesting article published online in JAMA with a provacative title “Academic Medical Centers: Too Large for Their Own Health?”. The following few sentences are very telling “…. many of today’s AMCs are similar to huge tankers loaded with health care services, and research and education are merely passengers ……. the margins on clinical revenues are often used to cover deficits in budgets for research and education and from providing subsidized care ………. any changes threatening the margins from clinical care will affect the entire mission of an AMC. The AMC missions are not self-funded; the margins on clinical care are required at most AMCs …” (emphasis added).

Something for leaders in healthcare to think about and consider when planning for the future.