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What Is the Cause of Excess Costs in US Health Care? Take Two

Mar 7, 2012• 59

By Mark Hoofnagle, MD

We’ve discussed it before. Why are costs so much higher in US healthcare compared to other countries? The Washington Post has a pointless article which seems to answer with the tautology costs are high because healthcare in America costs more. How much more? Well, we spend nearly twice as much per capita as the next nearest country while failing to provide universal coverage.

In the WaPo article they make a big deal of the costs of individual procedures like MRI being over a thousand in the US compared to $280 in France, but this is a simplistic analysis, and I think it misses the point as most authors do when discussing this issue. The reason things costs more is because in order to subsidize the hidden costs of medical care, providers charge more for imaging and procedures. For instance, Atul Gawande, in his New Yorker piece “The Cost Conundrum” wonders why it is that costs are higher to treat the same conditions in rural areas and in a major academic centers like UCLA than at a highly specialized private hospitals like the Mayo Clinic? I think the reason is it’s not nearly as expensive to administer and provide care for a select group of insured midwesterners at the Mayo than it is to provide care to the underserved in the poor areas of inner-cities and in poor rural locations.

Stop Lying to Your Doctor

Mar 7, 2012• 2

By James Salwitz, MD

George Washington never met an Oncologist. I know this because of the Cherry Tree story. If our first President had spoken to a cancer doc, then that honesty fable would have been different. Anyone can tell the truth about cutting down a tree. It takes real guts to say to an oncologist, “I cannot tell a lie, I have a problem.”

Doctors frighten all of us. No matter how warm and congenial they are, there is always the threat of what they may say. A few words from a physician can change your entire life. An oncologist may be the scariest of all. For this reason it can be very hard for any of us to tell our doctor the complete absolute truth.

It is easier to diminish or deny pain, then describe in detail and submit to tests. Emphasizing the balance in a diet has less risk than noting it is only 600 calories. Increasing fatigue can be blamed on stress, not progressive weakness. Everyone seems to have quit smoking, despite yellow stained nails. “Social” drinking sounds better than a daily six-pack. We carefully parcel out the information we tell our doctor. It is gut level denial and it does us no good.

Physicians understand the desire of patients to limit and control the conversation. They learn to recognize incomplete and evasive answers. They try to ask questions which produce accurate information. A compassionate doctor knows that his response to a patient’s words is as important as the question asked.

Even though it can be hard, it is in our best interests to supply good information to our caregivers. Doctors cannot make correct diagnoses or order proper treatment using erroneous data. Unneeded X-rays are frequently ordered to fill gaps in information, which the patient could have supplied. Understanding it can be tough to disclose personal medical facts, here are several ideas that might make communication easier and more complete:

Research Shows … the Obvious

Mar 6, 2012

By Merrill Goozner

A couple of studies out today from Health Affairs belabor the obvious.

First, the one less covered: Hospital Compare, the government website that for the last seven years has provided the public with detailed information about hospital performance, had no discernible impact on improving outcomes. It had no impact on how well the studied hospitals treated heart attacks and pneumonia, and only a modest improvement in outcomes for patients with heart failure. “The jury’s still out on Medicare’s effort to improve hospital quality of care by posting death rates and other metrics on a public website,” says lead author Andrew M. Ryan, an assistant professor of public health at the Weill Cornell Medical College in New York City.

Comment: Since when has disclosure ever affected behavior? Has it stopped physicians from taking money from the drug industry? Has detailed nutrition labels ended the obesity epidemic? Look at how well it is working in campaign finance reform. We have more information than ever about how our elections are being bought and sold. Disclosure is the reform that avoids reform. The real issue for hospitals is how well they do in improving their performance on checklists of quality indicators, and whether that improves outcomes (the QUEST demonstration project at CMS suggests it does). Disclosure of poor performance may be a goad to action (or not, as this current study suggests). But it is not a substitute for action.

The second, more widely reported study showed that doctors with electronic access to patients’ prior imaging studies wound up ordering more imaging tests than doctors without access to such electronic records. Absent other incentives, why would anyone expect otherwise? Imaging is one of the great generators of “false positives” in the medical system. See something on a scan, better get a biopsy or do an angioplasty. Or at least another scan. Double the number of eyes seeing that scan and you double the number of false positives. The depressing fact is that under the current fee-for-service payment system, everyone gets paid that second time around.

Wrong Rx for the FDA

Mar 6, 2012• 3

By Henry Miller

The congressional legislators who oversee the Food and Drug Administration and control the nation’s coffers have shown again that they neither understand drug development nor the regulatory problems that plague it.

In February, Sen. Barbara A. Mikulski(D-Md.) unveiled a bipartisan bill intended to spur innovation in research and drug development for chronic, costly health conditions such as Alzheimer’s disease, cancer, diabetes and heart disease.

According to the press release, the bill will invest “in public-private partnerships to ensure scientists and researchers are able to develop new safe and effective drugs,” shrink product development timelines, increase the number of drugs in the development pipeline and expedite the FDA review process.

However, there is currently plenty in the development pipeline. The federal government is boosting funding for research and development on Alzheimer’s disease; the Department of Health and Human Services alone will allot more than $500 million to it in fiscal year 2013. Moreover, drug companies spend more than $65 billion annually on R&D.

For example, there are now nearly 100 drugs in development for Alzheimer’s disease, dementias and other cognitive disorders, and almost 900 medicines being tested for cancer.

Autofill Gone Wild

Mar 5, 2012

By Dinosaur, MD

I appreciate getting notes from specialists. Really. It’s great to be kept in the loop with patients’ care, especially when other doctors are using EMRs that directly fax me notes the same day as the visit. Sometimes, though, things can get a little out of control.

I’ve ranted before about offices that use templated EMRs to generate documentation of things they never actually did. Today I received the following letter:

Reason for the appointment:
1. Abdominal pain
2. Post colonoscopy with biopsy

History of present illness:
1. Abdominal pain: he failed to show up for this appointment

Current medications:
[med]
[med]
[med]

Past medical history:
[problem]
[problem]
[problem]
EGD 2008 negative, EGD 2011 negative, colonoscopy 2005 normal
2010 Chest CT with 3 mm lung nodule, low risk

The Bottom Line

Mar 5, 2012• 10

By Kelly Wright, MD

It’s cool. So cool, that President Obama used one. So cool, it’s been on the cover of Newsweek. It’s been in multiple television commercials, radio advertisements, highway billboards, and was even coined one of the top 14 medical breakthroughs of 2011 by Boston Magazine, a city teeming with medical innovation. Yet surgeons and health economists are unable to explain the fascinating rise of robotic-assisted surgery.

Currently, a single company manufactures and distributes the robot, a line of surgical equipment used to conduct robotic-assisted surgery. The robotic system consists of a surgeon’s console with 3-dimensional high definition vision and a patient-side cart featuring robotic arms with proprietary wristed instruments. The system translates the surgeon’s natural hand movements on instrument controls into corresponding movements of instruments inside the patient, giving the surgeon control, range of motion, and depth of vision similar to open surgery.

The sole manufacturer hopes to establish the robot as the standard for surgical procedures by encouraging surgeons and hospitals to adapt the technique while marketing aggressively to patients about the benefits of robotic surgery. As of June 2011, the manufacturer had installed 1,933 robotic systems. They estimate that 278,000 robotic-assisted surgical procedures were performed in 2010, up 35% from 2009, and aims to achieve one million annual procedures in the United States over the next few years (Invester Report 2011). To achieve this goal, the manufacturer strategically markets to smaller hospitals and surgeons who may not be skilled at conventional laparoscopy to give them an edge for attracting patients.

If You Feel OK, Maybe You Are OK

Mar 2, 2012• 6

By H. Gilbert Welch

Early diagnosis has become one of the most fundamental precepts of modern medicine. It goes something like this: The best way to keep people healthy is to find out if they have (pick one) heart disease, autism, glaucoma, diabetes, vascular problems, osteoporosis or, of course, cancer — early. And the way to find these conditions early is through screening.

It is a precept that resonates with the intuition of the general public: obviously it’s better to catch and deal with problems as soon as possible. A study published with much fanfare in The New England Journal of Medicine last week contained what researchers called the best evidence yet that colonoscopies reduce deaths from colon cancer.

Recently, however, there have been rumblings within the medical profession that suggest that the enthusiasm for early diagnosis may be waning. Most prominent are recommendations against prostate cancer screening for healthy men and for reducing the frequency of breast and cervical cancer screening. Some experts even cautioned against the recent colonoscopy results, pointing out that the study participants were probably much healthier than the general population, which would make them less likely to die of colon cancer. In addition there is a concern about too much detection and treatment of early diabetes, a growing appreciation that autism has been too broadly defined and skepticism toward new guidelines for universal cholesterol screening of children.

The basic strategy behind early diagnosis is to encourage the well to get examined — to determine if they are not, in fact, sick. But is looking hard for things to be wrong a good way to promote health? The truth is, the fastest way to get heart disease, autism, glaucoma, diabetes, vascular problems, osteoporosis or cancer … is to be screened for it. In other words, the problem is overdiagnosis and overtreatment.

What I Learned At Haas Business School’s Health Care Conference

Mar 1, 2012• 1

By John Graham

There’s a lot of entrepreneurial energy in the Bay Area, but I’m always surprised at how much of it is directed towards health care. As Apothecary readers surely recognize, if we were to rank sectors where the government lies ready to crush the entrepreneurial spirit, health care and education must lead the list.

So, I was excited to have wrangled an invitation to the UC Berkeley’s Haas School of Business‘ annual Business of Health Care Conference, a day-long event held last week. This year’s conference, the sixth, titled Entrepreneurial Solutions to Health Care Challenges, assembled a high-profile group of entrepreneurs, scholars, and investors.

The most informative panel that I attended addressed “Venture Capital – Positioning Health Care Startups for Success,” moderated by Rebecca Lynn of Morgenthaler Ventures. The panel comprised Missy Krasner, also of Morgenthaler Ventures and the former Google executive who launched the now defunct Google Health; Lisa Suennen, a co-founder of the Psilos Group (perhaps the longest-standing pure-play healthcare VC); and Jeff Tangney, former president of Epocrates and founder of Doximity.

Key take-aways from the panel discussion were:

Digital health is where the opportunity lies, but both healthcare investors and IT investors bring unhelpful biases to this new sector.
Although the Bay Area crowd is loathe to hear it, some of the best new health IT businesses are in places we’d shun – like Michigan or Nashville.
Some digital-health entprenreneurs think they have a business, but they only really have a product. Nothing wrong with that, but you’ve got to sell it, not fund it.

Not Such a Bitter Pill

Mar 1, 2012• 35

By Kevin J. Rogers

Whenever I think about health care reform, I am reminded of the song from the film Marry Poppins that goes “Just a spoonful of sugar helps the medicine go down.” You would think from the way Conservatives are always blathering on about the moral fiber of America breaking down because no one takes responsibility for their actions anymore, they could use a spoon full of fiber rather than sugar. They warn about the dangers of the “nanny state,” and “socialist ideas,” and deride progressives for “being enemies of success.” At the end of the day, so the conservatives say, it’s a matter of personal responsibility and personal choice.

You know what? I couldn’t agree more. It really comes down to the choice between a thick glass of Metamucil or a smooth glass of sweet tea. Which would you prefer?

Having everyone take responsibility for their own health care started as a Republican idea. And by and large, Americans agree. But a new poll out this week showed many Americans still have a long way to go in understanding what the new healthcare actually does, particularly on the “individual mandate” portion and in the face of continued right-wing attacks on health reform.

Simply stated, the new health care law makes sure everyone takes charge of their own care and gets affordable insurance, because when people without it get sick, the costs get passed down to the rest of us. For health insurance to work, it’s necessary to include people who are healthy to help pay for those are sick. Under the ACA, you can keep the coverage you have. Or, if you don’t like your plan, or don’t have one, you can pick an affordable insurance option to take personal responsibility for yourself and your family.

XEROX HIMSS12 Post-Game Show

Mar 1, 2012

Plan on joining us for a TweetJam today moderated by Matthew Holt.

Never participated in a TweetJam before? It’s simply a time to gather on twitter around a particular topic and learn from each other. Anyone can ask, or answer, a question. All you have to do is log in to Twitter, follow us at the Twitter handles @THCBStaff and @ServicesatXerox and use the hashtag #HealthITJam to participate in the discussion.

See you there at 2:30 EST.