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anish_koka

Cardiologist, Private Practice

On the Morality of Insurance Premiums

As CVS-Aetna merger talks fill the air this Christmas season and experts weigh in on the impact this will have on the economy and consumers alike, I’m sitting at a little desk in a little office contemplating health insurance.

I run a little shop that’s about as far from CVS-Aetna as you can get in the health care space : a solo practice doctor with four full time employees and revenues a little south of $65 billion dollars.  I shouldn’t feel too alone.  Small businesses account for 99% of US firms and employ almost half of all private sector employees.  But knowing my problem is one shared by many provides only partial solace.

Prior to arrival of the ACA, I provided health insurance to everyone through the company.  At the time I had 3 full time employees and the insurance broker I worked with got me a quote for $1300 / month.  Now, I really didn’t want to be in the providing healthcare business, so when the ACA arrived with its individual market I was happy to facilitate buying health insurance from the exchanges.  So initially, I chose to pay for my employees plans on the individual market.  I was quickly told by my accountant that paying for my employees insurance in this manner was running afoul of a three letter entity of the federal government called the IRS.

Apparently the individual ACA market premiums were allergic to being deducted in this pre-tax manner.   Fine.  So I went ahead and paid each employee $6000 per year extra with the understanding that they would use that money to buy health insurance on the individual market.

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Orbiting ORBITA

I’m sitting amidst a number of cardiologists to go over the most recent trials presented at the interventional cardiology conference in Denver.  The cardiology fellow presenting goes quickly through the hors de oeuvres until finally getting to the main course – ORBITA.

ORBITA sought to test the very foundations interventional cardiology was built on – the simple idea that opening a stenosed coronary artery was good for patients.  The trial was a double blind randomized control trial of patients with tightly stenosed arteries who either had a stent placed or had a sham procedure.  Before the results are presented, the lay media headlines from cardiobrief, the New York Times, and the Atlantic are presented to guffaws from the audience.  The indignant smirks are audible as the accompanying editorial remarks from Rita Redberg and David Brown are displayed :

”The results of ORBITA show unequivocally that there are no benefits for PCI compared with medical therapy for stable angina, even when angina is refractory to medical therapy.”

The trial results follow – no statistically significant difference in the primary outcome of exercise time increment between sham and stent, and no difference in angina between the two groups.  The meat of the presentation involves the limitations of the trial that make the trial inapplicable – 200 patients total, 6 week follow up, the underlying heterogeneity of the patient angiograms that were randomized, and the wide confidence intervals of the primary outcome that swallowed the actual effect size.  Two different angiograms were shown to the audience from the ORBITA appendix.

The images demonstrate two ‘blockages’.  To the eye, at least, one appears tighter than the other.  The audience was polled on each image – everyone voted to stent the tighter blockage and medically manage the lesser of the blockages.  It could be all perception but I could feel the relief in the room as ORBITA was being made irrelevant.  The implication clearly was that some angiograms used to show the lack of benefit from stents would not have needed stenting in the first place.

There was no real challenge to the presenter save for one:

“One of the authors – Rita Redberg – is very sharp – why do you think she wrote that editorial?”

There was no good answer – the presenter shrugged and muttered something about an anti-interventional cardiology bias.

It was at that moment that I realized why cardiologists were having such trouble with  ORBITA – we were arguing like puritans.   Everyone in the room already ‘knew’ stents worked.  This was an exercise in bias confirmation when what was needed was an examination of the source of bias.  Faced with the ultimate epistemological challenge we were resorting to authority to dismiss findings we didn’t like.  Now I think cardiologists have authority with good reason, and certainly ORBITA may have limitations inherent in any small randomized control trial that’s performed, but we can do a better job answering the fundamental question raised here that relates to the primary evidence opening a narrowed artery actually can relieve angina.

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Valuing Value-Based Payment

The idea that payment should be linked to the value lies at the heart of most of the transactions we participate in on a daily basis. Yet, value based payment in healthcare has seemingly run into very rocky waters as of late.  It is at this precarious time that stakeholders representing large employers and other purchasers of health care’ took to the Harvard Business Review to write in defense of value based payment reform.  The authors pepper their article with cherry picked ‘successes’ of the value movement and urge the country to forge ahead on the current path.  The picture that comes to my mind hearing this is of the Titanic, forging ahead in dark waters, never mind the warning signs that abound.

One of the authors of the paper – Leah Binder – is President and CEO of the Leapfrog Group – a nonprofit organization founded in 2000 dedicated to triggering ” giant leaps forward in the safety, quality and affordability of U.S. health care by using transparency to support informed health care decisions and promote high-value care”.  This is a laudable goal, but it is very much predicated on the ability to measure value.  A perusal of the Leapfrog group’s  homepage notes a 1000 people will die today of a preventable hospital error.

The warning is explicit – choosing the hospital you go to could be the difference between life or death.  I have spent some time in the past about the remarkably weak data that lead to an estimate of 400,000 patients dying per year in hospitals due to medical errors, but suffice it to say the leapfrog group subscribes to the theory that of the ~700,000 deaths that happen in hospitals per year, half are iatrogenic.  With no exaggeration, I can say firmly that those who believe this are in the same company as those who believe the earth is flat.  If the home page of the Leapfrog group, examination of their claims in their HBR article merits additional concern.

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The High Cost of Public Reporting

In an age where big data is king and doctors are urged to treat populations, the journey of one man still has much to tell us. This is a tale of a man named Joe.

Joseph Carrigan was a bear of a man – though his wife would say he was more teddy than bear.  He loved guitar playing,  and camp horror movies.  Those who knew him well said he had a kind heart, a quick wit and loved cats.

I knew none of these things when I met Joe in the Emergency Department on a Sunday afternoon.  I had been called because of an abnormal electrocardiogram – the ER team was worried he could be having a heart attack.  Not able to make sense of the story on the phone, I was in to try to sort it out.  Joe was gruff, short with his answers – but clearly something just wasn’t right.   He was only 54 but had more problems than the average 50 year old.   Progressive calcification of his aortic valve  some years ago  had caused intolerable shortness of breath resulting in  replacement with an artificial valve. Longstanding diabetes had resulted in kidney failure and dialysis,  and most recently abnormal liver tests had  revealed the presence of the early stages of cirrhosis from hepatitis C.  Yet Joe continued to live an active life – with only a tight circle of family and friends aware of the illnesses beneath the surface.Continue reading…

How Much Is That CAT Scan in the Window?

Who knew healthcare could be so complex? The GOP proposal for health care reform rests on health savings accounts and high deductible health plans.   The basic premise is that price opacity, and deep pocketed third party payers drive up the cost of health care.   Giving patients dollars in health savings accounts they control should make them price sensitive, and thus help reduce the cost of healthcare.  A recent analysis by Drs. Chandra and others provides an interesting perspective on the matter.

The researchers took a large self insured firm that required all of its employees to switch from an insurance plan that provided free healthcare to a nonlinear, high deductible plan.  The switch worked.  Health care spending was significantly reduced, but the concern was the mechanism by which spending was reduced.  One would like to believe spending reductions related to price shopping, so patients were getting the same services just for cheaper.  Unfortunately, it appeared that consumers reduced all spending regardless of whether it was worthwhile or not.  Deciding what is worthwhile in healthcare is a complicated business that I will leave for another day but I agree with the general contention of the paper – giving a patient control over health care dollars does not make for a smart price shopper.

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Giving Cancer Hell

There are 80,000 new cases of primary brain tumors diagnosed every year in the United States.  About 26,000 of these cases are of the malignant variety – and John McCain unfortunately joined their ranks last week.  In cancer, fate is defined by cell type, and the adage is of particular relevance here.

Cancer is akin to a mutiny arising within the body, formed of regular every day cells that have forgotten the purpose they were born with. In the case of brain tumors, the mutinous cell frequently happens to not be the brain cell, but rather the lowly astrocyte that normally forms a matrix of support for brain cells.  Tumors made up of astrocytes are called astrocytomas.  Classification schemes for brain tumors in the era of molecular subtypes has grown enormously complex, but a helpful framework is provided by the appearance of these tumors under a microscope.  Grade 1 tumors are indolent, with little invasive capacity, while Grade 4 tumors are highly invasive, marked under the microscope as dense, sheets of cells that can even be seen to grow their own blood supply.  Senator McCain has a grade 4 astrocytoma, otherwise known a a glioblastoma (GBM) – the worst kind.   Social media from all sides of the political spectrum lit up with well wishes – with most casting the disease as something to be defeated.

Others within the medical community took a different take.

Mehreen is right.  GBM is a deadly disease,  the 5-year survival rate for patients with GBMs is <3%.  The majority of GBM patients live less than a year.  Yet, the medical community of neurosurgeons and oncologists that treat these tumors go to battle with these tumors.  Why?

I asked a very busy neurosurgeon this same question.   I asked him what he told patients. He told me that he never mentions the word cure.  There is no cure.  The goal is to manage the disease and buy more time.

Median survival for GBM is measured in weeks, not years.  Do nothing, and expect 14 weeks; combining surgery, radiation therapy, and chemotherapy may give you 45 weeks.

chart

What we describe is median survival, of course, and as Stephen J Gould eloquently put in his diatribe against statistics in cancer – the median is hardly the message.   The oncologist you want is the one who doesn’t tell you about median survival when breaking the news to you of your cancer – she implicitly understands each GBM has a different path.  Here are three such paths.

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The BCRA Is An Improvement Over Obamacare. Here’s Why..

Dr. Jha writes on these pages in typically stirring fashion about his views on the recent health care kerfuffle and rightly so fingers what the real focus of our efforts should be: Cost.  He ends by slaying both sides because of their refusal to confront the hospital chargemonster – the fee schedule hospitals make that remarkably only really applies to the uninsured.

Unfortunately, the solution proposed ensures hospital fee schedules for the uninsured are no greater than Medicare reimbursements, which is far from perfect.  Consider that the Medicare reimbursement for a stent placed to an ischemic limb is in the range of $15,000.  While this makes for a less daunting bill for the uninsured, in reality for the vast majority of folks that are uninsured $15,000 is about as far away as $150,000.

But my major disagreement with the good Dr. Jha relates not to his attempt to slay the chargemaster, but his underappreciation for the attempts made in the GOP bill to control health care spending.  A conservative mantra about the why of health care costs focuses on the existence of deep pocketed third party payers that make costs opaque to patients.  Attempting to have patients understand what they’re being charged has been conservative dogma, and there are a number of studies that suggest patients with health saving accounts are more cost conscious when they interact with the health care system.  Dr. Jha glosses over this important point – This is the Republican attempt to bend the cost curve!  And at least to this physician who’s lived through the last eight years, a plan that has a considerably greater chance of success than any number of failed acronyms designed so far by enlightened theorists from the Acela corridor.

HSA chart

The policy experts are hard to convince about HSAs, and point to the above chart as evidence of the uselessness of HSAs.

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