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Measures of Physician Quality Don’t Measure Up

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Physician reimbursement increasingly depends upon measures of healthcare quality. Physicians who fall short on quality measures now face financial penalties. But it might be quality measures, themselves, that are falling short, according to a study conducted by the American College Physicians.

The study involved a panel of people with expertise in evidence-based medicine. Panelists were asked to evaluate the validity of quality measures being used by either Medicare, the National Committee for Quality Assurance, or the National Quality Forum. It is typically measures from these three groups that are used to determine physician quality report cards, and Medicare plans to use its measures to influence reimbursement for individual clinicians.

The panel evaluated the validity of these measures using a modified version of a RAND/UCLA method that has been widely accepted as the best way to assess the strength of evidence for healthcare interventions. That method, developed in the 1980s, combines literature review and synthesis, multiple rounds of expert panel ratings, and retrospective comparison of evidence with clinical records, when feasible. The method isn’t perfect. But its the best we’ve got by a long shot.

(To read the rest of the article, please visit Forbes.)

Posted in Health Policy

Is Your Boss Discriminating Against You Because You Smoke?

(Getty Royalty Free)

Obamacare gave employers permission to charge smokers up to 50% more for health insurance, as a way to incentivize healthier behavior. But to make sure smokers had a fair chance to avoid these penalties, the law required employers to provide tobacco cessation programs to anyone facing such a surcharge.

Almost half of the companies who charge smokers more for health insurance are breaking the law.

That’s a conclusion reached by a team of researchers who studied the health benefits employers offered to their employees in 2016. The team evaluated almost 2,000 randomly selected companies. They honed in on small employers, those with less than about 50 or 100 employees (the number varied between 50 and 100 across states, depending on the specifics of how those states regulate insurance companies.)

What did they find?

(To read the rest of this article, please visit Forbes.)

Posted in Ethics

Medical Bankruptcy Is Much Less Common Than Elizabeth Warren Tells You

U.S. Senator Elizabeth Warren speaks at the 2018 Massachusetts Democratic Party Convention, Friday, June 1, 2018, in Worcester, Mass. (AP Photo/Elise Amendola)

Elizabeth Warren describes medical bills as “the leading cause of personal bankruptcy” in the United States. She bases that opinion in part on her own research, in which she and her collaborators surveyed people who had experienced personal bankruptcy, asked them whether they’d experienced health-related financial distress, and concluded that 60% of all bankruptcies in the U.S. result from illness or injury.

An article in the New England Journal of Medicine this spring convincingly argued that Warren’s estimates were seriously exaggerated due to faulty research methods. I’ll briefly summarize that critique. But more importantly, I’ll explain why even revised bankruptcy estimates still overstate the contribution of healthcare costs to American bankruptcy rates.

Here is a quick review of the issue.

(To read the rest of this article, please visit Forbes.)

Posted in Uncategorized

Five Warning Signs Your Doctor Was Too Quick To Diagnose You With High Blood Pressure

High blood pressure is the silent killer. It puts people at risk for heart attacks, strokes, vascular disease, kidney failure…it is basically really bad to have longstanding, undertreated high blood pressure.

But it is also harmful to be told you have high blood pressure when you don’t, and to be treated for high blood pressure when that treatment won’t benefit you. So when your doctor diagnoses you with high blood pressure, it is good to make sure you have earned the diagnosis. Let me lay out a few facts about high blood pressure and then suggest several questions to ask your doctor, so you get the treatment that is best for you.

The background: high blood pressure, also known as hypertension, is a chronic condition, characterized by regularly elevated blood pressure readings. If you have occasional blood pressure readings above normal, that doesn’t mean you necessarily have hypertension. But if your blood pressure runs too high, too often, all that pressure on the walls of your arteries can do serious damage.

Blood pressure is a measure of the force that blood exerts on your arteries as it is propelled through them by your heart. Think of a balloon with a small amount of air in it: there is not much air pressing out on the balloon. Blow it up more, and the balloon becomes more taut. That is what happens to your arteries with each beat of your heart.  Your heart ventricles contract, forcing blood into your arteries, stretching them under all that forward-flowing pressure. The heart now relaxes and refills with blood, and the pressure inside your arteries goes down. That is why blood pressure is made up of two numbers: the bigger one that follows after heart contraction, and the smaller one that coincides with heart relaxation.

So what blood pressure readings are too high to have for too long?

(To read the rest of this article, please visit Forbes.)

Posted in Health & Well-being, Medical Decision Making

Sleepless in the Hospital 

Credit: Rahav Segev for The New York Times

Here’s a great New York Times article, highlighting some of the ways people like me think hospitals should help their patients sleep:

If part of a hospital stay is to recover from a procedure or illness, why is it so hard to get any rest?

There is more noise and light than is conducive for sleep. And nurses and others visit frequently to give medications, take vitals, draw blood or perform tests and checkups — in many cases waking patients to do so.

Some monitoring is necessary, of course. Medication must be given; some vital signs do need to be checked. And frequent monitoring is warranted for some patients — such as those in intensive care units. But others are best left mostly alone. Yet many hospitals don’t distinguish between the two, disrupting everyone on a predefined schedule.

Peter Ubel understands the problem as both a physician and patient. When he spent a night in the hospital recovering from surgery in 2013, he was interrupted multiple times by blood draws, vital sign checks, other lab tests, as well as by the beeping of machines. “Not an hour went by without some kind of disruption,” said Dr. Ubel, a physician with Duke University. “It’s a terrible way to start recovery.”

To read the rest of this piece, please visit the The New York Times.

Posted in Health & Well-being

A Patient Complained about the Cost of Her Medical Care. Here’s How Her Doctor Responded.

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The oncologist had prescribed Xgeva hoping it would strengthen her bones while also delaying the progression of Angela Kahn’s breast cancer. But Kahn (a pseudonym) couldn’t get over the price of the drug. Before the oncologist had a chance to ask how she was feeling, she blurted out that the medication cost “$15,000 a shot.” “That’s crazy,” the oncologist replied, continuing by saying the price “fits right in with the rest of the insanity” of U.S. healthcare pricing. At that price, Kahn concluded, “I don’t think I should get it.”

The oncologist assured her “You’re getting it,” and they both laughed.

Not that either thought Xgeva’s price was a laughing matter. In fact, like many medications, Xgeva costs much more in the U.S. than in any other developed countries, with a single injection costing more than $2,000.

There’s too many reasons for these high prices to delve into them in the space of a short essay. Instead, I want to show how the insanity of American healthcare prices played out in this one, real oncology appointment. (Note: The appointment was recorded by a marketing company, Verilogue Inc., with the permission of the doctor and patient. I gained access to an anonymized transcript of the appointment for a research project approved by the Duke University IRB.)

After assuring Kahn that she’d remain on the Xgeva, her oncologist explained how he believes healthcare pricing plays out in the U.S. “It’s totally outrageous. What usually happens is the hospital or the clinic will charge 300 times what they think they can get, and the insurance company pays 1/20th of the original.”

“Oh, okay,” Kahn replied, with a touch of confusion.

“So it’s just a game, it’s a total horrible game,” the oncologist continued. “That’s crazy,” Kahn reiterated.

(To read the rest of this article, please visit Forbes.)

Posted in Uncategorized | Tagged , ,

How Doctors Turn Patients into Lobbyists

Some cancer patients and family members weighed in unknowingly during a public comment period last year on the Trump administration’s plan to cut a drug discount program for hospitals. (Matt Rourke/AP)

I recently spoke with a Washington Post reporter about a troubling practice. Physicians convince their patients to sign letters to influence public policies the patients often don’t understand. Here is the beginning of that piece. Check it out:

A proposal to sharply cut a drug discount program that many hospitals rely on drew some 1,400 comments when the Trump administration announced its plan last year. Hundreds appeared to come from patients across the country — pleas from average Americans whose treatments for diseases such as cancer depend on costly medicines.

But a review of the responses found that some individuals were not aware they apparently had become part of an organized campaign to oppose what’s known as the “340B” program. Some had no memory of signing anything, much less sending their opinions about it.

Of the 1,406 comments that specifically mentioned 340B — part of several thousand comments submitted on a broad proposal to revise medical payment systems — about half included the same or similar wording and were submitted anonymously, an analysis by Kaiser Health News found. Those comments lamented “abuse” of the drug discounts, faulted hospitals for being “greedy” and used phrasing such as “quality, affordable, and accessible.”

Two that were duplicated hundreds of times made the very same grammatical mistake.

They “are clearly related,” said Robert Leonard, a forensic linguistic expert at Hofstra University whose team analyzed the submissions for KHN.

In fact, the wording in the duplicate comments tracks language in a formal letter submitted to regulators by a nonprofit trade group, the Community Oncology Alliance, which receives funding from pharmaceutical companies. Seema Verma, administrator of the Centers for Medicare and Medicaid Services, said public comments played into the final decision on the 340B drug program. (Julio Cortez/AP)

Cancer survivor Janice Choiniere’s name is on a public comment saying reform of the 340B program will help “those suffering from this insidious disease.” But when reached by phone, the 69-year-old Florida resident said she had “no idea” what the program is and didn’t recall signing a petition.

“My first thought is, I don’t fill out and send in responses casually,” Choiniere said. “I’m hoping nobody lifted my information.”

To read the rest of this story, please visit The Washington Post.

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Nudging Docs with Threatening Letters

Seroquel tablets. Credit: AstraZeneca, via Associated Press

I recently spoke with Margot Sanger-Katz at the New York Times. She’s an awesome healthcare reporter. She wrote a nice piece on some recent nudging research. Here’s the beginning of the article to whet your appetite:

The letters doctors received from the county medical examiner included a shocking fact: A patient you once prescribed an opioid medication has died in the last year from a drug overdose.

Faced with this statistic and others on annual county prescription drug deaths from the medical examiner, doctors reduced their prescribing of opioids by just under 10 percent, compared with doctors who didn’t get a letter.

Another letter warned primary care doctors that the federal government had flagged them for prescribing too many antipsychotic medications to patients who could be harmed by the drugs. Among those doctors, prescriptions fell by more than 15 percent over two years.

Both letters represented a new experiment in how to use low-cost, behavioral cues to shift medical practices. Instead of offering new training, or taking away insurance coverage, or doing one of the many expensive, complicated things that might change medical practice, researchers have been exploring the power of subtler nudges.

Check out the whole piece!

Posted in Uncategorized | Tagged

Making Money by Getting an MRI?

MRI technologists move a patient from a MRI scanner at Wake Medical Center. Under a new program introduced by Blue Cross and Blue Shield, patients could receive cash rebates for choosing cheaper MRI facilities. N&O File photo.

Usually it costs money to get an MRI. But sometimes, in order to save money, insurance companies pay patients to seek less expensive medical care providers. Here is an excellent news report on the topic from The News & Observer:

North Carolina’s largest health insurer is proposing a solution to control runaway health care costs: paying people to use cheaper doctors and procedures.

Blue Cross and Blue Shield will offer customers between $25 and $500 per medical procedure for more than 100 procedures. The amount of the rebate depends on the procedure’s complexity and the cost savings of the cheaper option.

A Blue Cross spokesman pointed out that picking a cheaper option is more valuable than just the cash rebate.

“There is also the big cost-saving potential where you can shop, find a high-quality provider, and really reduce your out-of-pocket costs,” said Blue Cross spokesman Austin Vevurka.

Insurers have for years sought to influence patient decisions through co-payments and high deductibles as a shared financial responsibility for medical costs. Blue Cross is taking the concept further by offering to share savings with the customer as a thank-you for reducing costs. In the past, this approach has been tried by financially rewarding doctors and hospitals for achieving cost savings.

Some health care experts are excited at the prospect of pulling back the veil on health care costs, saying that pricing transparency is long overdue. But others warn that using money to influence private medical decisions can be harmful, noting that not all doctors are equal.

“I would caution patients to be careful,” said Raleigh orthopedist Dr. Bradley Vaughn who operates at UNC Rex Hospital. “If someone saves $500 from a hip or knee replacement and suffers a serious complication, that $500 will be a drop in the bucket compared to all the misery they’ll experience.”

Blue Cross is offering the SmartShopper only to companies that pay for their employees health insurance and health care. In these instances, Blue Cross only administers the plan. There are nearly 400 such employers in North Carolina administered by Blue Cross and their plans cover nearly 1 million employees.

So far, 10 of those companies have opted to offer SmartShopper to their employees. Blue Cross, which covers 3.8 million people in the state, is not offering SmartShopper to patients on individual plans and other employer-sponsored policies at this time.

The State Health Plan, the largest Blue Cross customer in the state, has opted not to buy the SmartShopper service for the 727,000 state employees, teachers, retirees and dependents it insures. State Health Plan spokesman Frank Lester said the service “did not add any value.”

Nationwide, SmartShopper has generated more than $56 million in savings for employers and has paid out $6.7 million in cash incentives to employees in the United States in the past four years, according to Vitals, the New Jersey company that launched the technology in 2015. It’s used by 230 employers and more the 20 health plans with 2.5 million members around the country, company spokeswoman Rosie Mattio said.

Is it ethical?

Several medical ethicists praised SmartShopper as a technology that empowers the public on health care costs that have for far too long remained hidden in a black box.

“I like the idea of paying people to pay attention to what they’re doing because of the principle of responsibility — pay attention to the cost of your choices,” said Lance Stell, a retired philosophy professor at Davidson College who taught medical ethics to residents at Carolinas Medical Center. “We want patients to be empowered.”

And Dr. Peter Ubel, a physician and health sector management professor at Duke University’s Fuqua School of Business, made a different ethical point. “When a gastro-enterologist charges way more than another one down the street, nobody was raising ethical concerns about that, and yet you may be responsible for 20 percent of the cost.”

To read the rest of this article, please visit The News & Observer.

Posted in Uncategorized | Tagged , , ,

Emergency Room Prices: They Are Outrageous, But I Am Not Blaming ER Clinicians

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Recently I posted a piece, describing research out of Johns Hopkins, showing that when patients come to ERs – either with no insurance or insurance that is out-of-network – they often face charges that are four, six, or even ten-fold greater than what Medicare would pay for the same services.

After the post, I was inundated with angry tweets and emails, mainly from emergency medicine physicians outraged that I would blame them for these prices.

Below, I lay out some of these criticisms. I don’t expect I’ll satisfy all my critics, but I certainly want them to know that I’ve heard them, and that much of their concerns were ones I already shared.

Blaming Doctors:

Physicians told me that I was blaming them for high ER fees. I even received an irate email from an emergency medicine physician working in Europe, saying I had offended her, a strange response given that I was writing about the United States. But I think I know why she was upset. I presented data on physician fees. But when health policy wonks, like me, talk about “physician fees,” we aren’t referring just to what doctors charge for their services. Instead, we are talking about all healthcare charges that aren’t part of a hospital bill. Terrible terminology, I know. But it goes back a long ways, to the separate evolution of Blue Cross insurance plans (set up by hospitals to cover their fees) and Blue Shield plans (set up by doctors to cover other medical bills—hence “physician fees”). This terminology even got carried forward into Medicare when it was formed, with Part A paying hospital bills and Part B paying physician services—including things like outpatient xrays, lab tests, EKGs, and the like.

Here’s the misunderstanding: To Medicare, ER bills are considered physician services, not hospital bills. So when I rightly criticized the high cost of ER care, it sounded like I was blaming physicians.

(To read the rest of this article, please visit Forbes.)

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