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


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.)

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


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.)

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

(Randy Holmes/ABC via Getty Images)

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.)

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


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.)

Why Investing in Better Primary Care Failed to Save Money


We have a huge healthcare problem in the U.S., spending way more than other wealthy countries, expenses that not only burden state and federal governments, but that also take money out of American pockets.
Some people hope that better primary care will reduce U.S. healthcare spending. They point out that a small number of chronically ill patients—super-utilizers—account for half of healthcare spending. The hope is that taking better care of these super-utilizers, with more robust and improved care coordination, will improve their health and reduce healthcare spending.
Or perhaps not. When the Palo Alto VA tested an intensive primary care program for its super-utilizers, healthcare spending and utilization didn’t budge. One iota. Except for primary care utilization which, unsurprisingly, rose significantly among people receiving intensive primary care.
The Palo Alto study was well-designed. The researchers targeted patients who were in the top 5% of healthcare utilization. These patients were typically elderly, and on average had 10 chronic health conditions. Two-thirds carried mental health diagnoses, and a quarter had a history of homelessness. The population included people I am very familiar with from my almost 20 years in the VA: older men with PTSD and anxiety; hypertension, diabetes, coronary artery disease, congestive heart failure, emphysema, and a touch of renal failure; recent hospitalizations for pneumonia, leg wound infections, or maybe a mild stroke.
(To read the rest of this article, please visit Forbes.)

Is Peer Pressure to Increase Physician Performance Overrated?


It has become trendy in health policy circles to believe that behavioral economic interventions are the key to health system improvement. After all, traditional economic interventions like pay per performance have generated underwhelming results, with little or no change in physician behavior. Why not try a non-financial, psychological intervention—like performance feedback!
Well, a study conducted in the last couple years in Switzerland raises questions about the effectiveness of such feedback. In the study, researchers randomized physicians to either receive feedback every three months (on how many antibiotics they prescribed compared to their peers), or receive no feedback. They hoped that such feedback would shame over-prescribers into prescribing more parsimoniously. The physicians in the intervention group received a one-page letter every three months, with a nice picture showing them their relative rate of antibiotic prescribing.
(To read the rest of this article, please visit Forbes.)

The Primary Care Doctor Is Not In

In a clever study, secret shoppers called primary care offices in an attempt to make a new patient appointment. People with Obamacare insurance, or “marketplace plans” in the below figure, had a hard time finding appointments. But so did people with traditional insurance.

But there’s a bigger takeaway, one slightly obscured by the misleading y-axis, that doesn’t go all the way up to 100%. So here’s my over-simplified version of the study results:

That’s right – only 30% of people were able to make a doctor’s appointment.

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


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?


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.)