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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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You Know Who Else Fails ‘The Jimmy Kimmel Test?’ Hospital Emergency Rooms

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When Jimmy Kimmel’s child was diagnosed with a serious heart condition, Kimmel realized that people without his wealth (or his generous insurance coverage) would not be able to pay for the life-saving care that his child received, if their children were to be similarly ill. So he gave a moving monologue one evening, explaining why he now believes that healthcare policies should be judged by whether they keep finances from being a barrier to receiving lifesaving care, a view that some now call “The Jimmy Kimmel Test.”

Kimmel’s monologues on this topic have gone viral, but it doesn’t look like hospital ERs have gotten the message. Too often, they charge patients outrageous prices for their services, especially when people don’t have insurance.

Do you think these hospital ER prices are irrelevant for you, because you have insurance? Think again.

Suppose you are on vacation when your diabetes spins out of control. Or you are shopping at a local mall when you have a fainting spell. You are rushed to the nearest hospital by an ambulance crew to an emergency room, where you get an IV, an EKG, and other state-of-the-art care. All is good, until you receive the bill.

According to a recent study, if you happen to receive care in a for-profit hospital emergency department that’s out of your insurance network, you can expect a bill that’s almost six times higher than what Medicare would have paid for those same services. Did you get an EKG? Medicare would have paid $16 for that test. Your bill could be more than $300, a bill that you will have to pay, not your insurance company.

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

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Healthcare Spending and Life Expectancy: in One Stunning Picture

Let me be clear: how long people live in any country of the world is determined by lots of things, not just by the quality of their healthcare system. Nevertheless, one of the things medical care is supposed to do is help us live longer and healthier lives. So you would think that a country which dramatically increases its health spending would gain more in life expectancy than similarly wealthy countries that do not increase such spending.

Your thinking would be wrong.

Here is a picture from The Financial Times, showing that in 1970 the US already lagged behind the UK and Japan in life expectancy by about one year, despite spending a little bit more per capita on healthcare. By 2014, the US spent more than twice as much as those other countries on medical care, with residents of the United States now living five years less than people in those other two countries:

Again, this difference in life expectancy doesn’t arise simply from the quality of medical care in these three countries, but has lots more to do with eating habits, drinking habits, traffic safety, and the like. That said, it points out a real major problem – despite the great wealth of this country, we haven’t figured out how to help Americans live long and healthy lives.

 

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The Life-Expectancy Gap in One Depressing Picture

Here, from the Financial Times, is a picture showing that the lower your income, the less increase you’ve gotten in life-expectancy the last four decades:

Income inequality is one of the largest human problems of this century.

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Your Doctor May Spend More Time with a Computer than with You

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Medical appointments are getting shorter by the year. Sometimes it feels like doctors have no time to spend with their patients.

What’s to blame for these brief clinical interactions? It could be the electronic health record, or EHR. Because of changes in how insurance companies and the government pay for medical care, doctors increasingly need to document their care on the computer, causing many physicians to spend more time with their desktops than with their patients.

Two recent studies give us quantitative estimates of the stupendous amount of time physicians spend on computers, rather than in direct contact with their patients. In one study, researchers directly observed physicians in outpatient clinics, asking these doctors to document the time they spend on the EHR after hours. The study assessed physicians from four specialties: family medicine, internal medicine, cardiology, and orthopedics. The study found, on average, that doctors spend half their working time on the EHR.

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

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Party First, Ideology Later

We think of political parties as being ideological homes. If you embrace conservative ideas, you gravitate to the Republican party, and so on.

But probably just as often, people have party homes (“My dad was a Dem, and so am I”), in which whatever the party embraces magically fits their ideology. Consider the following picture of people’s attitudes towards free trade. Long a conservative (thus Republican) favorite, now that Trump dislikes free trade, so do many Republicans:

Too often people believe first and think later!

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Burdened by High Medication Costs? Your Boss May Be Able to Help

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Pharmaceutical companies have been charging way too much for way too many of their products. Both Donald Trump and Hillary Clinton complained about drug prices during the election campaign, but neither political party has taken action since November to tackle the problem. Insurance companies aren’t doing much about this problem either, despite having a huge incentive to tackle high prices.

But there is someone who appears to be up to the challenge – employers. According to a recent study in the New England Journal, a consortium of 55 Catholic organizations decided to redesign their employee healthcare benefits in 2013. Before that time, these organizations provided their employees with tiered co-pays for their medications. Under formulary tiers, a patient might pay $10 a month for generic drugs, $25 a month for brand-name drugs, and $100 or more per month for expensive specialty drugs and biologics. Tiered formularies are designed to motivate patients to use less expensive medications, because they carry lower co-pays. But such formularies are usually blunt motivational instruments. They might convince a patient to choose a generic medication rather than a brand-name cholesterol pill, but the patient will have no further incentive to choose the least expensive generic medication. Similarly, a patient with rheumatoid arthritis will face a significant co-pay for a biological therapy, but that co-pay won’t change from one biologic drug to another, even if those drugs have very different price tags.

That’s where reference pricing comes in, a topic I have written about before. The Catholic organizations got together and looked at different categories of medication, and decided how much they would pay for drugs within each category, with the understanding that patients would pick up the rest of the tab. For example, medications for stomach reflux range in price from $26 a month to almost $300 a month. The employers promised to cover $26 of the cost of whichever reflux medications patients chose to take. Similarly, patients who wanted to take $400 nasal inhalers for their allergies could go ahead and do that, but the insurer would only cover $34 of that price, given that an equally effective inhaler was available at that price.

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

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