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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.)

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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!

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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.

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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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More Young People Die in America than in Other Rich Countries (Two Pictures Explain Why)

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The average life expectancy of American men is almost four years less than men in Switzerland. In fact, among 17 high income countries, U.S. men ranked 17th in life expectancy. American women die young, too, with a life expectancy five years less than the average Japanese woman. Why is American life expectancy so poor?

In part, it is because too many Americans die at very young ages—30, 40, or 50 years old—compared to peers in other wealthy countries.

Sometimes healthcare pundits point to dismal American life expectancy to criticize the quality of care in the U.S. healthcare system. But it is not healthcare that explains much of the high mortality of young Americans. Consider American men. The number one reason they die at younger ages than men in other rich countries is homicide. The next two most important contributors are injuries, from either transportation (like car accidents) or non-transportation causes (falling off ladders and the like).

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

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Think Fast and You’ll Lose Money Quickly (A Behavioral Economics Explanation of Irrational Gambling)

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I have just given you $78. (I’m a generous guy.) Now I’m giving you a choice: you can enter a lottery where you have a 75% chance of losing that $78 and a 25% of keeping it, or you can hold on to $20 and avoid the lottery all together. Quick—tell me what you would choose!

Faced with such a gamble, there’s no right or wrong choice. If you want a sure $20, you’ll avoid the gamble. But if you want a shot at going home with $78, you’ll take the risk. Neither of these choices, on their own, is irrational.

But behavioral economists have identified a strange type of irrationality that influences people’s reactions to these kinds of gambles, and a recent study shows that the faster people think, the more susceptible they are to that irrationality.

I’m referring to the irrational way that people’s decisions are influenced by whether their choices are framed as losses or gains.

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

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The Most Potent Prescription Ever: Take Time for Yourself, As Directed by Your Doctor

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Dr. Norah Neylon was caring for a 50-year-old woman who was overwhelmed with care-giving responsibilities of her own. The woman’s mother was experiencing early signs of dementia. Five of her relatives had died in the past three years. She frequently had to fly back and forth from California to the Caribbean to take care of members of her extended family. Oh yes—and her blood pressure was dangerously elevated at 210/115.

So Neylon gave her a prescription. I’m not referring to the blood pressure pills she prescribed. Instead, I’m referring to another script, which read:

“Permission to put your needs first. Use at least once a day for thirty minutes, do not exceed the stated dose, this is potent medicine.”

Neylon’s patient laughed when she saw the script, and then began to cry. She hadn’t been putting herself first, and her health was suffering as a result.

Neylon relayed this story in a recent JAMA article “The Prescriptions I Write.” It’s a beautiful essay.

Many health problems are self-inflicted: Some of us bring illness upon ourselves by smoking or drinking too much, or sleeping and exercising too little. Other people become sick because they don’t take time to care for themselves.

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

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Obamacare Is Experimenting on Us (Does That Make Us Frankenstein or Fusilli?)

(Photo by Joe Raedle/Getty Images)

Obamacare is a large, unwieldy law. Despite its complexity, most people are familiar with its most important elements. They know it created a marketplace where people can shop for healthcare insurance; many are even aware that the cost of that insurance is subsidized for people with lower incomes. Others realize that Obamacare encouraged states to expand Medicaid. And of course, almost everyone has heard of the now defunct individual mandate which required people to purchase insurance or face a tax penalty.

But most Americans probably aren’t aware of what, in the long run, could turn out to be the most impactful part of the Affordable Care Act. The crafters of the ACA recognized that the science of healthcare delivery hadn’t advanced far enough to identify the best ways to improve healthcare quality while lowering healthcare costs. So, lawmakers set a slew of experiments in motion, designed to test ways of accomplishing these goals.

Results of those experiments have been coming out of the lab lately, raising the question of what kind of creatures Obamacare has been creating—are they like Frankenstein’s monster, terrifying but misunderstood? Are they like Edward Scissorhands, loved by suburban moms until they realize how dangerous he is? Or are they like a less renowned creature—Fusilli Jerry, the pasta stick figure that Kramer made for Jerry Seinfeld on that eponymous 1990s sitcom?

I side with the latter, because I view the Obamacare experiments as a type of pasta-flinging exercise. People at CMMI, the federal agency in charge of running these experiments, have been cooking up a bunch of ideas, throwing them into a pot, pulling them out one at a time, and then flinging them against a metaphorical wall to see which ones stick—which ones are ready for public consumption. Some relatively recent studies serve as a good introduction to what Obamacare has been cooking up for the American healthcare system.

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

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Frank Thomas – Baseball’s ‘Big Hurt’ – Hurts People by Promoting Harmful Supplements

(AP Photo/Kathy Willens)

Frank Thomas is a 6 foot 5 inch hulk of a man, the 7th player in MLB history to retire with a batting average greater than .300 and more than 500 home runs. He was also thought of as a clean player, despite playing in the steroid era, and even advocated for drug testing when the rest of the league was purposely, and lucratively, looking the other way.

So why is he now hawking testosterone supplements?

Frank Thomas, appearing in ads with fans praising him for looking fit enough to still be playing, credits testosterone supplement NUGENIX® (“GNC’s® #1 selling male vitality product”) for his current level of fitness.

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

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