Healthcare.gov 3.0–Improving the Design of the Obamacare Exchanges

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NEJMI joined two other, much smarter, colleagues in calling for the use of behavioral economics and decision psychology to improve the design of the websites people use to purchase health insurance in the U.S. That article came out today in the New England Journal of Medicine. Here is a taste:

In October 2013, the Affordable Care Act introduced a new insurance market — state and federal exchanges where people can purchase health insurance for themselves or their families. Although the rollout of the exchanges was disastrous, around-the-clock efforts fixed many of the biggest technical problems, and nearly 7 million people purchased insurance in the new market. The second round of enrollment exposed some new problems with the exchange websites — for example, Colorado’s website had difficulty determining whether people were eligible for tax credits — but these problems paled in comparison with those encountered when the exchanges were first rolled out. In short, we have a largely glitch-free system of health insurance exchanges that present millions of people with a robust set of health insurance choices.
Which means that it will soon be time to tackle the much more challenging job of designing exchange websites in ways that maximize the chances that consumers will choose plans best suited to their needs and preferences. If the first round of open enrollment was primarily about avoiding catastrophe and the second round was about ironing out wrinkles in the underlying programming code, then version 3.0, in our view, should focus on redesigning the way exchanges present their insurance choices, to avoid features known to bias people’s decisions.

When It Comes to Cancer Screening, Are We All Nuts?

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Washington-Post-LogoIn a recent Health Affairs article, David Asch and I wrote about how hard it can be to stop screening aggressively for things like breast and prostate cancer even when the evidence suggests we are doing more harm than good. Well, journalist Steven Petrow has a nice piece in the Washington Post looking at the good old testicular exam. Lots of nice insights, so I thought I’d share it:

Late last year, “Today” show anchors Willie Geist and Carson Daly took one for the men’s team when they underwent testicular cancer exams on live TV. Lots of predictable joking ensued, especially from co-anchor Savannah Guthrie, who ad-libbed: “When I heard what you guys were doing, I thought it was nuts!” The “attending” urologist, David Samadi of Lenox Hill Hospital in New York, also took to wordplay, asking: “Who’s going to play ball first?” Geist stepped up.
Within minutes both anchors received clean bills of health along with Samadi’s congratulations for getting the exams. Samadi also encouraged the rest of maledom to perform testicular self-exams monthly in the interest of early detection, which he said can save lives — but do they?
Nearly 9,000 cases of testicular cancer in the United States are diagnosed every year — especially among men ages 15 to 34, where it’s the most common cancer — so the “Today” segment seemed like a useful public service announcement.

But unfortunately there’s no evidence that self-exams detect testicular cancer at an earlier stage, according to Durado Brooks, director of colon and prostate cancer prevention programs for the American Cancer Society. Even if these exams did, says Kenny Lin, an assistant professor of family medicine at Georgetown University Medical Center, early detection has little, if any, bearing on outcomes for those who are diagnosed. Lin calls the “Today” segment “a stunt cloaked as a health message,” and he points out that even the august U.S. Preventive Services Task Force recommends against testicular cancer screening — a change from the past.

Other routine screening tests have also earned a thumbs down from the medical establishment in recent years, as more clinical evidence has been gathered showing them to be less beneficial than once thought. Among the tests no longer universally recommended: PSA screening for prostate cancer, breast cancer self-exams for women and mammograms for women younger than 50, and Pap smears for cervical cancer for women younger than 21. Not only do these exams have nearly no effect on outcomes, the task force said, they can sometimes do more harm than good.

Regarding testicular screening in particular, it “is unlikely to offer meaningful health benefits, given the very low incidence and high cure rate of even advanced testicular cancer” while “potential harms include false-positive results, anxiety and harms from diagnostic tests or procedures,” according to the task force.

So why do some doctors continue to recommend these screenings — and why do some patients still want them? (To read the rest of this article, please visit The Washington Post.)

The Power of Free

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The Atlantic recently reproduced a figure showing just how much people like things when they are free. Specifically, they looked at health interventions and show that people are more likely to take up these interventions, or products, when they don’t cost anything.
And certainly, free is better than expensive, but free is also a whole lot better than cheap. There is something special about going from any price to no price:
Power of Free

How Effective Are Mammograms?

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Mammograms have long been touted as a life-saving preventive test. But recently, people have been re-examining the relative harms and benefits of mammography. This re-examination became quite earnest when the United States Preventive Services Task Force recommended against beginning routine mammography before age 50. Even at later ages, experts are beginning to more thoroughly recognize that the benefits of mammography compete against some very serious harms. Consider the following picture, produced by the website 538, summarizing how mammography influences women at various ages:
MammogramsIn short – not a whole lot of lives saved, but a lot of non-cancers cured, even more non-cancers biopsied, and a whole slew of anxiety-inducing false alarms.

Found: Billions of Wasted Medicare Dollars

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Found Wasted Medicare MoneyIt is well known that Medicare expenditures threaten the financial solvency of the U.S. government. And it is pretty well agreed upon that some of our Medicare spending goes towards wasteful medical care.
But which medical care is wasteful and how much is such care costing us?  A study in JAMA Internal Medicine provides a sneak peek at answers to these important questions. The research, led by Aaron Schwartz , a graduate student at Harvard, focused on interventions that medical experts deem to provide little or no health benefit. For example, the Choosing Wisely campaign, promoted by medical societies, has concluded that testing people’s lung function prior to low and intermediate-risk surgeries does not improve surgical outcomes. Similarly, the United States Preventive Services Task Force has concluded that colon cancer screenings yield more harms than benefits for elderly patients.
The researchers explored how often Medicare beneficiaries received unnecessary services like this, a list of 26 tests or procedures that medical experts have deemed to be unnecessary. The researchers discovered that Medicare patients, on average, received one such intervention per year. The worse culprit, financially speaking, was stenting (propping open) coronary arteries for people with stable heart disease, which by one of their estimates leads to almost $3 billion per year of wasted Medicare spending. Close behind was another cardiology procedure, stress testing for patients with stable heart disease, which triggered over $2 billion of unnecessary spending. Toss in $200 million per year for unnecessary back imaging, another $200 million for unnecessary imaging tests to evaluate headaches, and the researchers uncovered over $8 billion of Medicare waste, for just these 26 interventions. (To read the rest of the article and leave comments, please visit Forbes.)

Genetic Testing Can’t Do Our Behavioral Dirty Work

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DNA PictureHere is the opening of a recent media story, reporting on a noble attempt researchers made to promote colon cancer screening by telling people when their genetic risk of such cancer was elevated:

People at average-risk for colorectal cancer (CRC) who underwent genetic and environmental risk assessment (GERA) to evaluate their risk for CRC were no more likely to undergo CRC screening than those people who did not receive this individualized assessment, results of a study showed.
Additionally, among those people who underwent GERA, those told that they were at elevated risk for CRC were no more likely to undergo screening than those told to be at average risk .

Along with Jennifer Blumenthal-Barby and Amy Lynn McGuire, I wrote an editorial accompanying the research report, which was published in the prestigious Annals of Internal Medicine. Check out the media story if you are interested.

If Costs Are Unknown, Can Doctors Still Talk About Them?

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don't talk about moneyI have been writing a bit lately on the need for healthcare providers to talk with their patients about healthcare costs, if for no other reason than to enable patients to determine whether they can afford to pay for the healthcare that their doctors are recommending them to receive.  I have been criticized for this position, on the grounds that I am rationing care from people with less money and connections than I have, a criticism that I have explained as being misguided.
But I have faced another more reasonable criticism too, one I want to write about today.  I have been reminded that doctors and other healthcare providers cannot easily discuss healthcare costs with patients because those costs are often unknown. Lisa Rosenbaum made this point in an excellent New Yorker essay:

“The first problem with financial disclosure from doctor to patient is a practical one. Doctors rarely know how much their patients actually pay. Patients are covered by a variety of insurers, all of whom offer several plans, for which any individual patient has a different copayment and deductible, which he may or may not have met.”

In this post, I will lay out a fuller version of this criticism and then explain why I still think doctors need to hold these conversations, and also why I think these conversations will become much more common in the near future… (Read more and view comments)

Unnecessary Mastectomies Following Breast Cancer Diagnoses?

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new york magazineI spoke the other day to Melissa Dahl, a writer for New York Magazine. She wrote a really nice piece on what medical professionals call “contralateral prophylactic mastectomy” – when a woman with breast cancer chooses not only to remove the affected breast, but also the unaffected breast in order to reduce the chance of a subsequent cancer. There’s no evidence that this practice reduces breast cancer related mortality. And yet the practice is growing. Here is the beginning of her wonderful essay:
It’s potentially the biggest health headline of the week: a new study shows that more women who have developed cancer in one breast are opting for a preventive double mastectomy—even if they’re not at a higher risk for getting the disease in the second breast, and even if that means going against their doctor’s advice. 
Much of the coverage of the study, published Wednesday in JAMA Surgery, took on a baffled tone, quoting medical professionals who couldn’t imagine a reason beyond anxiety to explain why patients would request an invasive procedure they didn’t technically need—and one that carries medical risks of its own. But even if this decision doesn’t make a lot of medical sense, decades of behavioral science research can offer clues as to why so many women are making it… (Read more at New York Magazine)
 

Want narcotics just ask for them?

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oxycontin-prescriptionA very disturbing new study was just published, in which physicians viewed a video of a patient with back pain asking for OxyContin. Twenty percent of docs said they would prescribe that med under that circumstance:

…Too often, doctors prescribe potentially dangerous medications to patients who shouldn’t be getting them, and what they prescribe is influenced by the pills patients ask for.
The study found that patient requests for certain medications — such as the powerful narcotic oxycodone — “substantially affected physician-prescribing decisions, despite the drawbacks of the requested medications.” The results suggested that even a gentle request from a patient could convince a doctor to prescribe potent, potentially dangerous narcotics — even when they’re not the best-practice treatment for the patient’s condition…(Read more about the study here)

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Are You Getting Too Much Medical Care?

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overtreatmentThis summer I had the pleasure of speaking with a very intelligent journalist, who was working on an article about overtreatment in medical care. That article has just come out, and I thought I would give you a sample of it here:
A few months ago, I went to my gynecologist looking for help with a
menstrual problem. She put me in stirrups, and the next thing I knew, I was getting a Pap smear. That wasn’t what I’d come in for, but it had been a year since my last test for cervical cancer, so I went along. After all, catching cancer early is always the goal, right? To
my surprise, I later learned that, according to the most recent science, it’s actually possible to catch a cancer too early. And being tested frequently—i.e., every year—was not my best game plan.
Most cervical cancers progress very slowly, and high-quality research has shown that some of the precursors to cancer that a Pap test can detect will go away without medical treatment. Right
now, however, there’s no “wait and see” in the system. When the Pap reveals certain abnormalities, the immediate next steps are additional doctor visits, plus invasive and painful testing, says Russell Harris, MD, a professor of medicine at the University of North
Carolina at Chapel Hill. This cascade of events saves some lives, but it also needlessly inconveniences and even harms many who were never in danger.
Experts have learned that we can have the best of both worlds: Because cervical cancer is so slow to spread, the Pap test can be done less frequently while still identifying the women who are at risk well within the window of when they can be successfully treated.
At the same time, doctors can spare those who are not truly at risk from unnecessary callbacks and biopsies… (Read more here)

PeterUbel