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.)

What Confusion about Health Insurance Looks Like in the Doctor's Office

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Mark Letterman’s rheumatoid arthritis had been progressing unrelentingly despite popping dozens of pills each week – eight methotrexate pills on Mondays alone. Letterman felt like he was 63 going on 93.
If rheumatoid arthritis progresses unchecked, it is as debilitating of a disease as can be imagined. Don’t think garden variety arthritis that only interferes with activities like, um, gardening. Think: finger and wrist joints so inflamed it feels like your hands have suffered a heat stroke from the inside out. Imagine: the joints of your toes so damaged you have to purchase shoes at a medical supply store, even though you will still be lucky to walk on a good day. Rheumatoid arthritis is a severe, inflammatory disorder that simultaneously deforms and disables.
Letterman – a pseudonym – and his doctor gave permission for Verilogue Inc., a marketing company, to audio-record their interaction. The clinic appointment was one of many that my colleagues and I analyzed to see what happens when doctors and patients discuss healthcare costs. That appointment revealed a disturbingly common problem – sometimes doctors and patients get so confused about insurance coverage, they can’t figure out how best to treat patients’ illnesses.
(To read the rest of this article, please visit Forbes.)

If We Cut Surgical Pay, Will Surgeons Cut into More People?

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Knee replacements are booming. Between 2005 and 2015, the number of knee replacement procedures in the U.S. doubled, to more than one million. Experts think the figure might rise 6-fold more in the next couple decades, because of our aging population. Since many people receiving knee replacements are elderly, Medicare picks up most of the cost of such procedures. It shouldn’t be surprising, then, that the program is experimenting with ways to reduce the cost of each procedure.
The problem is – if healthcare providers make less money on each knee replacement they perform, they might start replacing more people’s knees than they should.
Does that sound crazy? Well consider what happened when Medicare began experimenting with a new way of paying for knee replacements – something called bundled payment. Under such reimbursement, Medicare pays one lump-sum for the total cost of a knee replacement – not just the cost of the operation but also the cost of post-operative x-rays, physical therapy, even time in nursing homes or rehab hospitals. Before bundled payment, providers received separate payments for each of these services. As a result, inefficient providers would take more x-rays than necessary, or keep patients in rehab hospitals longer than needed, and they would be rewarded for such inefficiency. Under bundled payment, providers cannot send separate bills to Medicare for hospital charges, physician fees, outpatient x-rays, and the like. Instead, they get a lump sum payment to cover all these expenses. Moreover, Medicare tracks all the knee-replacement costs for a given patient, over a 90 day period. If a patient incurs lower expenditures than expected, Medicare gives the providers part of these savings back as a reward. (Warning – this is a WAY oversimplified description of bundling.)
Early evidence suggests that bundled payments reduce the cost of knee replacements by an average of almost $1200 per patient. Save that much money on a couple million such procedures in a year, and we are looking at billions of dollars of savings. Moreover, research to date suggests that these savings don’t come at the expense of quality, at least as far as we can tell. (Quality measurement in healthcare is notoriously difficult.) For example, when knee replacements were paid for through bundled payments, there was no subsequent increase in readmission to the hospital or emergency room visits among patients whose procedures were reimbursed according to bundled payments. Same quality at a lower price – who could be against that?!
Well, caution is in order. Healthcare systems that enrolled in the bundled payment system might have saved money on each procedure, but they more than made up for that by increasing the number of procedures they performed – about three procedures more per hospital compared to hospitals not receiving bundled payments. This finding, indeed ALL these findings, are tremendously preliminary. Bundled payments are still in their infancy. Quality measurement still doesn’t capture everything we’d like it to.
(To read the rest of this article, please visit Forbes.)

Medicare Is Reducing the Cost of Knee Replacements (Here's How That Could Backfire)



Knee replacements are booming. Between 2005 and 2015, the number of knee replacement procedures in the United States doubled, to more than one million. Experts think the figure might rise sixfold more in the next couple decades, because of our aging population. Since many people receiving knee replacements are elderly, Medicare picks up most of the cost of such procedures. In response to this huge rise in expenditures, Medicare is experimenting with ways to reduce the cost of procedures. But that raises a disturbing possibility. If orthopedic surgeons make less money on each knee replacement they perform, they might start performing unnecessary procedures.
Consider Medicare’s recent experiments with reimbursing knee replacements according to “bundled payments.” Under such reimbursement, Medicare gives healthcare organizations a lump sum to cover the cost of a knee replacement–not just the cost of the operation but also the cost of post-operative x-rays, physical therapy, even time in nursing homes or rehab hospitals. Before bundled payment, providers would receive separate payments for each of these services, meaning inefficient providers might take more x-rays than necessary, or keep patients in rehab hospitals longer than they needed such comprehensive care, and be rewarded for this inefficiency by receiving additional payments. Under bundled payment, Medicare tracks all the knee-replacement costs for a given patient, over a 90-day period. If a patient incurs fewer expenses than expected, Medicare gives the providers part of these savings back as a reward. (Warning–this is a very oversimplified description of bundling.)
Early evidence suggests that bundled payments reduce the cost of knee replacements by an average of almost $1,200 per procedure. With a million such procedures performed in a year, that reduction could save over $1 billion. Moreover, these savings don’t seem to come at the expense of quality, at least as far as we can tell. (Quality measurement in healthcare is notoriously difficult.) For example, when knee replacements were paid for through bundled payments, there was no subsequent increase in readmission to the hospital or emergency room visits among patients whose procedures were reimbursed according to bundled payments. Same quality at a lower price–who could be against that?!
To read the rest of this article, please visit Forbes.

Watch Out Hospitals: Medicare’s Planning to Punish You if You Misbehave



It used to be that hospitals billed Medicare for the services they provided, and Medicare – I know this is crazy! – simply paid the bills.
Those days are rapidly receding into history. Soon, a significant chunk of hospital revenue will be at risk, under a series of Medicare pay-for-performance programs. The idea behind P4P (as the cool kids call it) is simple. Third party payers, like insurance companies or the Medicare program, will monitor the quality of care offered by health care providers like hospitals. High quality providers will receive more money than low quality ones, thereby giving providers an incentive to improve the quality of care they provide.
Medicare has created several P4P programs which, unless they are halted by the Trump administration, are slowly coming into effect. By 2017, as I will show in a bit, these programs could put a sixth of Medicare payment at risk.
What are these programs?
One is the Hospital Value-Based Purchasing Program or (and you have to give Medicare folks kudos for their marketing prowess) VBP. Under VBP, Medicare monitors a bunch of quality measures, like the rate of hospital acquired infections, the number of patients falling while in the hospital, and even the risk adjusted mortality of hospitalized patients. Medicare scores each hospital based on how well it performs compared to other hospitals, and compared to its previous performance. This score determines part of a reward or punishment at the end of the year. By 2017, 2% of Medicare hospital payments will be redistributed according to VBP results, with money transferred from low to high performing hospitals.
Medicare has created another acronymically-challenged program, HRRP, which stands for Hospital Readmissions Reduction Program. The program measures how often patients with diagnoses like heart attacks, congestive heart failure, and pneumonia are readmitted to hospitals after an initial stay. The program will financially penalize hospitals that have excessive readmission rates.
Finally, under its HAC program (not named after the sound made by someone with bronchitis), Medicare is tracking how well hospitals reduce the rate of Hospital Acquired Conditions, like catheter-related bacterial infections. Some of these measures overlap with the VBP measures, amounting to a double counting. That’s a problem I’ll talk about in a minute.
(To read the rest of this article, please visit Forbes.)
 

Why The Government Tried To Fix Primary Care And Failed



Americans spend more per-capita on medical care than just about any other country and, yet, they often have little to show for it. Americans have worse access to care than people in other countries, and are often less likely to receive primary care services, like preventive therapies and screening tests. Determined to address these problems, Medicare leaders have been testing out new models of primary care, hoping to find win-win situations – reimbursement schemes that improve quality while maintaining or lowering the cost of care.
So far, many of those efforts have failed.
Near the end of 2012, Medicare began giving extra money to almost 500 primary care practices across the US, money the practices used to try to improve the care they offered to their patients. The goal of this Comprehensive Primary Care Initiative was to prod primary care practices to make it easier for patients to: contact providers quickly; coordinate care with other specialists; provide care management to patients with complex chronic illnesses; and better engage with patients and their care givers. The extra Medicare payments were decent sized, almost $60,000 per physician per year. The practices could use this money to hire extra nurse practitioners, or to reimburse those who were working odd hours to give patients more access to care, or other efforts.
Medicare not only gave practices these upfront payments, but also offered to give practices extra money if they reduced overall spending for their Medicare population, an incentive known as shared savings.I am a primary care physician and for around 20 years I worked in VA medical centers, a system that, during my time there, did a great job of coordinating care between primary care physicians and sub-specialists, and of offering care management for patients with complex illnesses.
When I practiced in the VA, I often worked closely with pharmacists and nurse practitioners, for example, to address the need of patients with uncontrolled diabetes. So I am very excited that Medicare is trying to invest in and test ways of improving primary care.
Medicare administrators hoped that better primary care would lead to lower costs. Coordinating care with specialists, for example, should reduce unnecessary testing. Better care management should reduce the need for hospital care.
(To read the rest of the article, please visit Forbes.)

Your Physician Can't See You Yet – She's Busy Filling Out Paperwork!



Left to our own devices, most of us physicians try our best to provide high quality care to our patients. But almost none of us provide perfect care to all of our patients all of the time. In fact, many of us get so caught up in our busy clinic schedules we occasionally forget to, say, order mammograms for women overdue for such tests, or we don’t get around to weaning our aging patients from unnecessary and potentially harmful medications.
Because the quality of American medical care is often uneven, third-party payers – insurance companies and government programs like Medicare – increasingly measure clinician performance and reward or punish physicians who provide particularly high or low quality of care.
The result of all this quality measurement: gazillions of hours of clinic time spent documenting care rather than providing it.
According to one study, in fact, clinic staff spend more than 15 hours per week dealing with quality measures for every physician in the practice. In other words, a six-physician clinic group can expect 90 hours of staff time spent documenting quality performance. And it’s not just the staff that are left to do such documentation. Physicians spend precious time in such activities, too. The same study estimates that physicians spend almost 3 hours per week documenting the quality of their care. Here’s a picture of that finding:

Your Physician Can't See You Yet -- She's Busy Filling Out Paperwork 1
Is it any wonder why so many American physicians report being burned out by their jobs?
To read the rest of this article, please visit Forbes.

The Healthcare Efficiency Myth – What Really Happens When Doctors And Hospitals Join Forces

For much of the history of U.S. medical care, hospitals and physicians have existed as separate financial entities. Physicians in the U.S. have typically been self-employed, as solo or group practitioners and not as hospital employees. An internist like me might have admitting privileges to several local hospitals. When we admit patients to one of those hospitals, we bill insurance for our services. The hospitals send insurers separate bills for hospital related expenses. Physicians and hospitals have depended on each other to conduct their business, but they have done so while largely maintaining their financial independence.

The U.S. government is trying to change that. The Medicare program is encouraging healthcare providers to consolidate forces into entities like accountable care organizations, in hopes that such integration will increase healthcare efficiency. These hopes exist because some of the most respected healthcare institutions in the country – places like the Kaiser Permanente system and the Mayo Clinic – have long integrated their physicians with hospitals. Indeed, some contend that this integration creates more efficient care.

Such integration could end up costing lots of us lots of money. When hospital and physician practices join forces, healthcare prices often rise.

That’s certainly the conclusion of a study published in JAMA Internal Medicine, led by Hannah Neprash out of Harvard Medical School. Neprash and colleagues explored what happened to healthcare spending when physicians and hospitals integrated. They discovered that outpatient spending rises as physicians gain market power through their hospital alliance. The spending increases are due almost entirely to price increases. Here is a picture of their findings. The main thing to note is that the taller bar, in each pair of bars, is the increase in healthcare prices while the shorter bar is the increase in utilization, following consolidation of physician practices and hospitals:

The Healthcare Efficiency Myth 1

The tall bar on the left reflects a large increase in outpatient spending after hospitals and physicians integrate. The shorter bar right next to it reflects a modest, and statistically insignificant, increase in outpatient utilization at the same time. Spending rises while utilization stays flat – that can only happen because the price of services has gone up.

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

An Easy (But Politically Complicated) Way To Save Billions Of Dollars On Medical Care


Photo credit: KAREN BLEIER/AFP/Getty Images
Photo credit: KAREN BLEIER/AFP/Getty Images

I sometimes worry that my wife Paula won’t be able to see me grow old. Not that I expect to outlive her. She is four years my junior and has the blood pressure of a 17-year-old track star. It’s her eyesight I’m worried about, because she is at risk for a form of blindness called macular degeneration. Paula is the youngest in a long line of redheads, several of whom have been diagnosed with this illness. Her fair-haired grandmother developed macular degeneration and was eventually unable to see her bridge hand and had to give up her golf game, just when she was threatening to score below her age. Fortunately, Paula should be able to avoid her grandmother’s fate, because we now have outstanding treatments for this disease.
Too bad these treatments are costing us billions more than they should. The price of some macular degeneration treatments is staggeringly high, and both doctors and the pharmaceutical company making the treatments are motivated to keep it that way. If we as a country want to forestall blindness in people like my wife, without going bankrupt in the process, we need to pressure our government to do some hardball negotiating.
By way of background, my grandmother-in-law suffered from what ophthalmologists call “wet” macular degeneration. Frail little blood vessels began proliferating in the back of her retina. It’s not unusual to have lots of blood vessels back in the retina. It’s that red blood, after all, that causes so many of us to look possessed in family photos, with red eyes staring demonically into the lens. But in wet macular degeneration, there’s even more blood vessels than normal in the back of the eye, and they are more inclined to leak than typical blood vessels. This leaking fluid damages the nerve cells we depend upon to see light and darkness. For years, there was little doctors could do to slow these leaks.
Then along came Avastin.
Some of you may recognize Avastin as being a cancer drug. That’s true. Avastin works by disrupting a chemical our body makes to promote blood vessel growth. Tumors that depend on new blood vessels to grow are thereby thwarted by the drug. So, too, is macular degeneration. No new frail blood vessels means no blood vessel leakage!
Many ophthalmologists treat wet macular degeneration by injecting Avastin directly into the back of patient’s eyeballs. (Under local anesthesia, of course!) And the drug isn’t even terribly expensive. By one estimate, Medicare pays about $50 a pop for monthly Avastin injections. There is a problem with this effective and affordable treatment, however. Avastin has never been approved by the FDA to treat macular degeneration. Physicians are allowed to use it as an off-label treatment, but because it is off label, it needs to be reformulated by pharmacies into an injectable form, and before standards for such reformulation were bolstered, some patients experienced eye infections from contaminated vials.
Fortunately, there is a second drug to treat macular degeneration, one very similar in its chemical composition, another blood vessel-blocking drug called Lucentis. Unlike Avastin, Lucentis is FDA-approved to treat the disease. That means it is made by the manufacturer in a ready-to-inject formulation, and there is no need for pharmacies to do any additional prepping. Lucentis is just as good as slowing the progression of macular degeneration as Avastin. There’s just one little problem with Lucentis, however. Instead of costing Medicare $50 per pop, it costs up to $2,000.
To read the rest of this article, please visit Forbes.
 

Can’t Afford Medical Care? Welcome to America!

David Blumenthal and colleagues recently wrote a wonderful piece in the New England Journal on the future of Medicare. In it, they present a powerful picture comparing how often people in 11 countries have difficulty accessing medical care because of costs.
The good news? The USA came in first place. The bad news? First is worse!
Can't Afford Medical Care Welcome to America
 
 

PeterUbel