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Is Federal Policy Really to Blame for the High Cost of Cancer Care?

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U.S. healthcare costs have been high for decades, outpacing other developed countries since at least the 1980s. But costs continue to rise, and that is causing many experts to ask why. Some people blame federal policies. As an example, they point to reimbursement policies that create incentives for healthcare providers to consolidate. When hospitals merge with each other, or when hospitals buy out physician practices, healthcare providers gain negotiating leverage over insurers, which enables them to negotiate higher prices.

But what evidence do we have that federal policies are to blame for such consolidation?

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

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Want to Prevent Heart Attacks? Perhaps Don’t Try This Behavioral Economics Intervention

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If you experience a heart attack, you are probably going to need to take pills to prevent another such attack. People who take beta blockers, aspirin, or cholesterol pills after heart attacks are less likely to experience a second such attack. (Note: Don’t take any of these pills until you have spoken to your doctor. These medications aren’t for everybody.)

There’s a problem, though. Lots of people don’t take these pills, even after their doctors have prescribed them. Life gets in the way. They forget to take them, or they run out of pills, or they don’t get to the pharmacy for refills.

To increase the chance people will take these important pills, a team out of the University of Pennsylvania created a behavioral economic incentive. The intervention was multipronged. It included enrolling patients in lotteries, which gave them a chance to win money every day they took their pills. It encouraged patients to enlist a friend to help them stay on track taking their pills, a friend who would get notified every time they skipped their medications for a few days in a row.

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

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A Prick a Day Won’t Keep Your Blood Sugar Away

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When it comes to wreaking havoc on people’s bodies, diabetes isn’t picky, wreaking havoc upon people’s hearts, brains, eyes, kidneys, and peripheral nerves. To forestall such damage, many people with diabetes withstand another kind of bodily harm—they prick blood from their fingers each day to test their blood sugar. For many people with Type 2 diabetes, also called adult onset diabetes, those daily prickings are probably unnecessary. If you have Type 2 diabetes, it’s a good time to ask your doctor whether you can forgo those painful prickings.

In diabetes, people’s bodies lose the ability to tightly control the level of glucose circulating in their bloodstream. (Glucose is sometimes called “blood sugar,” although it is only a cousin of table sugar, sucrose.) When glucose levels rise in the bloodstream, the body normally sends out a cascade of chemicals, like insulin, to corral the molecule: to pull it out of the bloodstream and force it into other tissues. People with Type 1 diabetes, often called juvenile onset diabetes, suffer damage to the cells in their pancreas that secrete insulin. As a result, their glucose levels rise dramatically in response to a meal. Without treatment, many of these patients will suffer severe illnesses or even die from high blood glucose. People with Type 1 diabetes usually need to take insulin, and while closely monitoring their blood sugar adjust their insulin dosages.

People with Type 2 diabetes, on the other hand, usually have functioning pancreases, and without treatment, don’t usually experience life-threateningly high glucose levels after dinner. Instead, their ability to control blood glucose levels has deteriorated, usually because of chronic overweight or obesity, causing their glucose levels to rise more than normal after meals, and stay high for an abnormally long amount of time.

In order to help patients with Type 2 diabetes, physicians have long urged them to check their blood sugar at least once a day, to monitor their glucose levels. When I was trained, I was taught to have people check multiple times a day, so I could show them how to adjust their medications to more tightly control their blood sugar. If a patient had lots of high readings in the afternoon, for example, I might suggest that they increase their morning insulin.

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

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Where You Live in America Determines When You Die

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Debates over income inequality divide liberals and conservatives. In the last few decades, income inequality has soared in the U.S. In the 1950s, the top 1% of Americans brought home about a tenth of the country’s income. By 2012, those 1%’ers accounted for almost a quarter.

Only a minority of Republicans are troubled by these statistics, versus three-quarters of Democrats. We are a nation divided—in wealth and in politics. But perhaps another kind of American inequality can bridge this partisan divide—a life expectancy gap.

Consider the facts. The average life expectancy in the U.S. is almost 80 years. But that average obscures enormous differences based on where people live. In some U.S. counties, life expectancy is close to 90. But in others, people are lucky to live to 65.

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

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How to Tell Grandpa He Is Too Old for Another Colonoscopy

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Cancer screening can save lives: Mammographies reduce the chance women will die of breast cancer; and colonoscopies reduce the chance people will die of colon cancer.

But should my 93-year-old father receive a screening colonoscopy? The test is uncomfortable, carries risks, and costs money. Even more importantly, my dad probably won’t live long enough to benefit from the test. That’s why most medical experts think people like my dad—people unlikely to live another decade—should not receive cancer screening tests like colonoscopies. But how in the heck is my dad’s doctor supposed to deliver this news to him?

My father’s primary care doctor could tell him: “I have good news for you. You don’t need a colonoscopy—you’ll probably die of something else before colon cancer gets you!” But according to recent research, that message isn’t likely to go over well with its audience. The study, out of Johns Hopkins, convened senior citizens and asked them what they thought about conducting screening tests in patients of advanced age. The people told researchers that they understood the concept of stopping testing when people get too old to benefit. But they did not like the thought of doctors telling them that their impending mortality is the reason they will no longer receive such testing. “You’re too old to benefit” is a harsh message.

So what should physicians do?

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

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Healthcare for the Uninsured Is Wasteful (For a Surprising Reason)

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American physicians dole out lots of unnecessary medical care to their patients. They prescribe things like antibiotics for people with viral infections, order expensive CT scans for patients with transitory back pain, and obtain screening EKGs for people with no signs or symptoms of heart disease. Some critics even accuse physicians of ordering such services to bolster their revenue.

So what happens when uninsured patients make it to the doctor’s office with coughs, low back pain, or other problems? Do physicians stop ordering all these unnecessary tests and services, out of recognition that most of these patients won’t be able to pay?

study out of Harvard by Michael Barnett and colleagues provides a rigorous answer to this question. The researchers evaluated how often patients received any of a slew of unnecessary services. They compared patients with private insurance to those with Medicaid (which generally reimburses physicians much less generously than private insurance), and also to those with no insurance.

They found that almost 20% of privately insured patients receive unnecessary services, a staggeringly disturbing number. But even more disturbingly, the same percent of Medicaid enrollees and uninsured patients also receive unnecessary services.

In short, there’s way too much wasteful care, regardless of what kind of insurance people have (or don’t have).

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

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The Good and, Too Often, the Bad of Primary Care in the U.S.

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Death by a thousand bureaucratic demands. That’s how many American physicians currently describe their jobs, with work days that often don’t end until long after their kids go to sleep, when they finally finish documenting their clinical interactions. You see, government regulators and insurance company bureaucrats have been imposing a growing number of quality measurements on doctors, who consequently have to spend hours each day tracking what they’ve done to and for their patients.

But physicians need to understand that the need for late-night documentations is partly their fault. Government payers and insurance companies are monitoring American physicians for a simple reason—too often, the medical care physicians provide is of substandard quality.

Consider findings from a study by David Levine and his colleagues at Harvard. They reported on how the quality of primary care evolved between 2002 and 2013. They found that primary care physicians do a great job in some tasks—90% success at offering cervical cancer screening, for example, all the way back to 2002; more than 90% success in avoiding unnecessary sleeping pills in elderly patients for most of the past decade. In addition, primary care physicians have improved their performance in some notable ways since 2002: the percent of people with heart failure receiving life-saving beta blockers has increased from less than half to almost two thirds in that time period; the number of people with coronary artery disease receiving cholesterol pills has also increased from half to almost two-thirds.

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

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How Physicians Respond to the Price of Lab Tests before Ordering Them

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Healthcare prices in the U.S. are often hidden. Some people think this price opacity contributes to our nation’s high healthcare spending. If people don’t know how expensive healthcare is, they won’t have much reason to restrain healthcare utilization.

recent study tested what would happen if physicians were immediately informed of the price of lab tests that they were planning to order for their patients. The study took place in three Philadelphia hospitals. The researchers randomized whether or not the electronic health record gave physicians price data on specific lab tests. For some lab tests, the computer never gave doctors price information; for other tests, they always got price information (after a baseline, so the researchers could establish how often doctors normally ordered the tests).

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

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Why Living in a Rich Country Can Give You Cancer

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As a primary care physician, I have counseled thousands of patients to get cancer screening—blood tests to look for prostate cancer, mammograms to detect impalpable breast cancers, and colonoscopies to find precancerous colon lesions. I’ve even tried to find cancers on physical exam, palpating people’s necks for thyroid growths, for example. The goal of all these screening tests was clear to me—find cancers early and we can get rid of them before they become life-threatening.

All the while, I knew there was a downside to much of my efforts. I was potentially finding “lesions” that, if untouched, would have never harmed my patients. I wasn’t just diagnosing cancer and its predecessors; I was overdiagnosing it. Two studies from Dartmouth physician Gil Welch brings new evidence of the surprising frequency of such overdiagnoses, including surprising data on the epidemic of overdiagnoses in rich countries like the U.S.A.

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

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How a Leading Medical Journal Helped a Pharmaceutical Company Exaggerate Medication Benefits

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How excited would you be about a medication that lowered your risk of cardiovascular death, heart attack, or stroke by 1.5%? Excited enough to spend a few thousand dollars a year on the drug? I expect not.

What if, instead, the drug reduced those same terrible outcomes by 20%? That’s probably enough benefit to interest some in the drug.

Well, those statistics come from the same clinical trial, evaluating the same drug. In fact, they present the exact same results, but they simply do it in different ways. The 1.5% number refers to the absolute reduction in the risk of those outcomes—the drug reduced the two-year risk of cardiovascular death, heart attack, and stroke from 7.4% to 5.9%. That’s an important reduction by any account. That’s on par with many medications that have become critical in combating cardiovascular diseases. But that 1.5% reduction sounds much less impressive than the “20% reduction” that the authors describe in the discussion section of their New England Journal article, and was repeated, practically verbatim, by the physician who wrote an accompanying editorial in the same journal.

How can these experts claim a 20% reduction in risk when the study showed only a 1.5% reduction? Because 1.5% is approximately 20% of 7.4%. When summarizing the impact of this drug, the researchers and the editorialist chose to emphasize the relative risk reduction of the treatment rather than the absolute risk reduction.

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

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