It Should Scare Us That Tuition Is A Tiny Amount Of Medical School Revenue

Medical school is expensive. Tuition for private medical schools average more than $60,000 per year. That’s tuition, folks; not tuition, room, and board. At the University of South Carolina, out-of-state tuition is more than $90,000 a year.

But don’t assume your local medical school depends on tuition dollars for its financial well-being. The contribution of tuition towards medical school revenue is a tiny fraction of what it once was.

To read the full article, please visit Forbes.

Science Isn’t Meant To Be Followed

President Trump has taken a pointedly anti-scientific approach to the Covid-19 pandemic. When he is not hiding data, gagging public health experts, or touting unproven cures, he is downplaying the toll the virus is taking on people’s lives.

In the face of such indifference to facts, it is understandable that many people, including both Republican and Democratic governors, contend that politics should stand aside while science leads us out of this mess. For instance, a pact among Eastern states promises to coordinate their pandemic response in a manner “driven by data and experts, not opinion and politics.” A pact of western states put it even more tersely, vowing that “health outcomes and science – not politics – will guide these decisions.”

Unfortunately, that belief reveals a deep misunderstanding of the proper role of science in guiding public policy-making. Science cannot lead us out of the pandemic. Whatever paths we take to navigate COVID-19 need to be chosen through political processes. The true role of science is to illuminate these pathways, guiding our policy choices by showing us what’s at stake.

As an analogy, consider the role of science in helping a person newly diagnosed with advanced cancer. As a physician who studies medical decision-making, I would never recommend this patient choose a treatment without help from medical science. But science alone doesn’t always point to an obvious choice. Perhaps one chemotherapy has a small chance of curing the cancer but a risk of serious side effects, while another, gentler chemotherapy will slow down, but not cure, the cancer. This patient faces a difficult trade-off between chance of cure and likelihood of experiencing miserable side effects. In this situation, the best choice isn’t a matter of science, but instead hinges on a value judgment: on how an individual patient weighs the pros and cons of the alternatives.

Like a patient stricken with illness, the United States needs to decide how to treat the COVID-19 pandemic, with every pathway forward confronting us with tragic trade-offs. What can science do to help us navigate these trade-offs?

To read the full article, please visit Forbes.

When Farmer Joe Gets Sick, Here's Who He Sees

In this March 22, 2010 photo, Amanda Cockrell, 32, left, a nurse practitioner at Rush Lifetime Medical Associates examines Shanequa Reeves, 18, in Chicago. With a looming shortage of primary care doctors, 28 states are considering expanding the authority of nurse practitioners. These nurses with advanced degrees want the right to practice without a doctor’s watchful eye and to prescribe narcotics. And if they hold a doctorate, they want to be called “Doctor.” (AP/John Smierciak) photocredit: ASSOCIATED PRESS

The U.S. isn’t exactly overflowing with primary care physicians. The job pays poorly compared to most medical specialties, while often requiring mastery of a fraud range of material. In fact, with expansion of insurance coverage through the Affordable Care Act, many experts worried that it would become increasingly difficult for people to gain access to primary care physicians, especially in rural parts of the country, which have long-standing shortages of such professionals.
So when Farmer Joe gets sick, who does he see? With increasing likelihood, he’s being cared for by a nurse practitioner (NP).
(To read the rest of the article, please visit Forbes.)

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.

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.

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.)

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.)

Bait and Switch: The Sneaky Way Your Employer Just Passed Healthcare Costs onto You

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If you get health insurance through your job, beware: you might be picking up more of the cost of your medical care than you realize. With increasing frequency, employers are directing their workers to the kind of high deductible, high out-of-pocket insurance plans that leave workers financially responsible for a surprising portion of their healthcare expenses.

Not long ago, having insurance coverage meant your costs were largely covered. Americans could count on their employers to offer health insurance plans that covered the vast majority of their healthcare expenses. What’s more, employers even chipped in generously to cover a good chunk of people’s monthly premiums. As a result, Americans with good jobs could live their lives unafraid that they would be financially devastated by an unexpected acute illness.

But this generosity came at an increasingly unaffordable cost for American companies, with the price of health insurance threatening their bottom line. In response, companies have looked for ways to get their workers to pick up more of the tab.

Enter high out-of-pocket health plans.
On the surface, these plans look like bargains, because they cost less each month than other plans. When signing up for insurance, many people are attracted to these plans, knowing they will have less of their take home pay diverted to an insurance company. But then they discover that even a minor illness can turn that bargain to a burden.
(To read the rest of this article, please visit Forbes.)

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

(Photo By BSIP/UIG Via Getty Images)

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.)

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.)

PeterUbel