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Category: Health Policy

New Technologies Drive Cost Growth Over Time

By KEN TERRY

(This is the eighth and final installment in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)

Medical technologies include drugs, devices, tests, and procedures. Considered as a whole, these technologies are the key driver of growth in health costs, according to Georgetown University professor Gregg Bloche and his associates.

Bloche, et al., view insurance coverage as the chief enabler of these technological innovations. In a 2017 Health Affairs Blog post, they said,Drug and device developers, clinical researchers, and their financial backers anticipate coverage for new tests and treatments with little concern for whether they add substantial therapeutic value, and they make research and development decisions accordingly.”

In an interview, Bloche further explained, “If you’re a technology developer, you can reasonably anticipate that if your product achieves a low but significant health gain, insurers are going to be under pressure to pay for it.”

Insurers do cover most new drugs, although they may make it difficult for patients to access the ones that they deem to be low-value, notes Peter Neumann, director of the Center for the Evaluation of Value and Risk in Health at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center in Boston.

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Obstacles to Value-Based Care Can Be Overcome

By KEN TERRY

(This is the seventh in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)

Even in a healthcare system dedicated to value-based care, there would be a few major barriers to the kinds of waste reduction described in this book. First, there’s the ethical challenge: Physicians might be tempted to skimp on care when they have financial incentives to cut costs. Second, there’s a practical obstacle: Clinical guidelines are not infallible, and large parts of medicine have never been subjected to rigorous trials. Third, because of the many gaps in clinical knowledge, it can be difficult for physicians to distinguish between beneficial and non-beneficial care before they provide it.

Regarding the ethical dimension, insurance companies often are criticized when they deny coverage for what doctors and patients view as financial reasons. Physicians encounter this every day when they request prior authorization for a test, a drug, or a procedure that they believe could benefit their patient. But in groups that take financial risk, physicians themselves have incentives to limit the amount and types of care to what they think is necessary. In other words, they must balance their duty to the patient against their role as stewards of scarce healthcare resources.

On the other hand, fee-for-service payment motivates physicians to do more for patients, regardless of whether it’s necessary or not. In some cases, doctors may order tests or do procedures of questionable value to protect themselves against malpractice suits; but studies of defensive medicine have shown that it actually raises health costs by a fairly small percentage. More often, physicians overtreat patients because of individual practice patterns or because they practice in areas where that’s the standard of care. As long as doctors believe there’s a chance that the patient will benefit from low-value care, they can justify their decision to provide that care.

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Talking Politics in the Exam Room: A Physician’s Obligation to Discuss the Political Ramifications of Science with Patients

By HAYWARD ZWERLING

I walked into my exam room to see a patient I first met two decades ago. On presentation, his co-morbidities included poorly controlled DM-1, hypertension, hyperlipidemia, and a substance abuse disorder. Over the years our healthcare system has served him well as he has remained free of diabetic complications and now leads a productive life. Watching this transformation has been both professionally rewarding, personally enjoyable, and I look forward to our periodic interactions.

At this visit, he was sporting a MAGA hat. I was confused. How can my patient, who has so clearly benefited from America’s healthcare system, support a politician who has tried to abolish the Affordable Care Act, used the bully pulpit to undermine America’s public health experts, refused to implement healthcare policies which would mitigate COVID-19’s morbidity and mortality, and who minimizes the severity of the coronavirus pandemic every day. Why does he support a politician whose healthcare policies are an immediate threat to his health and longevity?

My brain says, “You are the physician this patient trusts to take care of his medical problems. You must teach him that COVID-19 is a serious risk to his health and explain how the President’s public health policies threatens his health. You must engage in a political conversation.”

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Biden’s Nov 9th speech: “Don’t you force me to pass Medicare 4 All”

By MATTHEW HOLT

The new Supreme Court, in all likelihood including just nominated Justice Amy Coney Barrett, will be hearing the California v Texas suit against the ACA on November 10th, seven days after the election. The lower courts have already ruled the ACA unconstitutional. Some hopeful moderates among my Democratic friends seem to believe that the justices will show cool heads, and not throw out the ACA. But it’s worth remembering that in the NFIB vs. Sebelius decision which confirmed the legitimacy of most of the ACA back in 2011 all the conservative justices with the exception of John Roberts voted to overturn the whole thing. With Ginsburg being replaced by Barrett there’s no reason to suppose that she won’t join Thomas, Alito, Kavanagh & Gorsuch and that Robert’s vote won’t be enough to stop them this time. The betting odds must be that the whole of the ACA will be overturned.

There is nothing the Democrats can realistically do to prevent Barrett filling RBG’s seat on the court, but assuming Biden wins and the Democrats take back the Senate, the incoming Administration can give the Supremes something to think about regarding the ACA. I would not suggest this level of confrontation before the election but, if Biden wins, the gloves must come off.

Assuming he wins and that the Dems win the Senate, this is the speech Biden should give on November 9th. (The TL:DR spoiler is, “Keep the ACA or I’ll extend Medicare to all ages”)

“I’m directing this speech to an extremely select number of people, just the Supreme Court Justices appointed by Republican Presidents. It is obviously no secret that we have political differences on many issues and we find ourselves in the strange situation in which I am the incoming President with an incoming Democratic Senate majority and yet you are considering overturning the signature bill of the administration in which I was Vice-President. You may recall that at the time of its signing I told President Obama that it was a “big f****** deal”  and, although many of my colleagues in the more progressive wing of the Democratic Party have criticized the ACA since its passage, it turns out that I was right. 

I am not referring here to the apoplexy that the ACA created amongst the Republican Party including not only the current and outgoing President but also almost all Republican members of Congress between 2010 and 2018. Instead I’m referring to the ACA’s impact on the nation and its health care system. 

Since 2010 there have been many changes to the way our nation’s health care system operates; almost all of them have their roots in the ACA. 

First, the ACA gave access to health insurance coverage to many people who had great trouble getting it before. That includes young people moving between their parent’s home, college and getting into the workforce; small business owners; freelance workers; the unemployed; people with low incomes; and people with underlying “pre-existing” health conditions. I remind you that due both to the pandemic and changes in our economy, there are many, many more of these people now than there were in 2009. 

Before the ACA these people were either not well served by the private health insurance industry or literally were unable to buy coverage at all. This not only caused extreme personal and financial suffering and in some cases death to the people affected, but also impacted the economy. It restrained innovation and entrepreneurship, and it meant that the participants in the health care system–including very many well meaning clinicians and provider organizations–had to play very inefficient games in order to try to provide those people with much-needed care, which drove up the cost of care to everyone else. Warren Buffet calls that the tapeworm in the US economy.

The ACA changed this in two main ways.

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Measuring the Effectiveness of Cost-of-Care Conversations

By NELLY GANESAN, JOSH SEIDMAN, MORENIKE AYOVAUGHAN, and RINA BARDIN

With support from the Robert Wood Johnson Foundation, Avalere assesses opportunities to normalize cost-of-care conversations through measurement.

Cost continues to pose a barrier to accessing healthcare for millions of Americans. Research has shown that conversations addressing costs among patients, caregivers, and the clinical team can help build a more trusted relationship between patients and clinicians.

Avalere has partnered with Robert Wood Johnson Foundation (RWJF) since 2015 to work toward normalizing cost-of-care (CoC) conversations in clinical settings, including identifying barriers and facilitators to engaging in conversations about cost. CoC conversations can be defined as discussions that address any costs patients and families might face, from out-of-pocket (OOP) to non-medical costs (e.g., transportation, childcare, lost wages). To that end, Avalere collaborated with the National Patient Advocate Foundation to explore the feasibility of patient-centered measure concepts to support quality improvement, increase satisfaction, and improve outcomes. This issue brief highlights the challenges associated with measurement in this space alongside alternative solutions to encourage CoC conversations in practice.

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Congress Is Getting the Transition to Alternative Payment Models Wrong

By TAYLOR CHRISTENSEN

Alternative payment models (APMs) are a hot topic these days, and everyone seems to agree that we need to transition toward them and away from fee for service (FFS). But how should we do it?

First, let’s think about this task as government policy makers would think about it.

They would probably start by saying, “We need to find a way to give incentives to providers and payers to try out these different APMs.” This would be fairly easy to do through Medicare, so they would create some Medicare APM programs and structure them in a way that makes the benefits of joining large enough that lots of providers will want to participate.

And for the sake of uniform provider incentives, they would also want to encourage private insurer-provider diads to start using APMs, preferably ones as similar to the Medicare APM programs as possible. And so they would probably have to offer private insurers and/or providers money to do so.

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Now Is Not the Time to Forget About the AIDS Epidemic

By SOMA SEN

I keep hearing the voices of colleagues and friends that have been part of the AIDS epidemic compare it to the current COVID-19 pandemic. In fact Dr. Kathy Creticos, Director of Infectious Disease at Howard Brown Health spoke about the politicization of both the pandemics. 

“Here we are in 2020 with this disease that kills people, that we don’t have any treatments for, that we really don’t understand the full manifestation and presentation biology of the virus,” Creticos said In the final segment of an interview with Contagion during International AIDS Society (IAS) AIDS 2020 Virtual Sessions. “We’re really dealing in the same situation as in the HIV epidemic.” 

Her words make me reflect on the levity with which the Raegan administration treated the AIDS epidemic and it’s parallel to the Trump administration’s treatment of the current pandemic. However, she makes an important distinction between the two when she says, “I think a lot of it has to do with the fact that COVID affects everybody, but HIV was certainly perceived as not affecting everybody.”

As an Asian American researcher with more than 15 years of experience in this area, whenever, I bring up the issue of the scourge of HIV/AIDS in our community, the common response both from inside and outside the community is “It’s not a problem in this community.” 

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If I Can Be Safe Working as An ER Doctor Caring for COVID Patients, We Can Make Schools Safe for Children, Teachers, and Families

By AMY CHO

We need to stop arguing about whether schools should reopen and instead do the work to reopen schools safely. Community prevalence of COVID-19 infection helps to quantify risk, but reopening decisions should not be predicated on this alone. Instead of deciding reopening has failed when an infected student or teacher comes to school, we should judge efforts by our success in breaking transmission chains between those who come to school infected and those who don’t. We should judge our success by when we prevent another outbreak. We should pursue risk and harm reduction by layering interventions to make overall risk of transmission in schools negligible. This CAN be done, as healthcare workers all over the United States have shown us. Unlike politics, we should avoid thinking this is a binary choice between two polarized options. At the heart of these decisions about tradeoffs should be the assumption that the education of our children is an essential, public good.

I advocated for school closures in March. We had little understanding of the risks and transmission of COVID-19 and faced massive shortages of personal protective equipment (PPE). The closures were a blunt force instrument but bought precious time to learn and prepare. Pandemic control, by flattening the curve and buying time for discovery of more effective therapeutics, care and a vaccine, remains a critical tool to save lives. But COVID-19 will not be eradicated. We must come to terms with the reality that COVID-19 will circulate among us, likely indefinitely. Shutdowns slow spread but at a great cost, disproportionately paid by vulnerable groups including children, women, minorities, and those with the least financial resources. Getting children safely back to in-person school should be among our highest priorities.

Hospitals never considered closing. As healthcare workers, we cannot physically distance from patients. We watched in horror as hot spots like Bergamo suffered high nosocomial and staff infection rates as they were quickly overwhelmed. In response, we worked tirelessly and collaboratively to protect one another while continuing to provide care.

The good news is that we seem to have learned how to prevent in-hospital transmission of COVID-19. A recent study showed that at a large US academic medical center, after implementation of a comprehensive infection control policy, 697 of 9,149 admitted patients were diagnosed with COVID-19. But only TWO hospital-acquired patient infections were detected. COVID-19 is not “just the flu,” but it isn’t Ebola either. I no longer worry that I will become infected with COVID while working in my emergency department. It is not easy, comfortable nor cheap, but a bundle of universal masking and eye protection, appropriate PPE use, sanitation, improved room ventilation, and protective policies have proven effective at preventing in-hospital outbreaks. 

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Doctors Urge Caution in Interpretation of Research in Times of COVID-19

September 9, 2020

To:      

American College of Cardiology

American College of Chest Physicians

American College of Physicians

American College of Radiology

American Heart Association

American Society of Echocardiography

American Thoracic Society

European Association of Cardiovascular Imaging

European Society of Cardiology

European Society of Radiology

Heart Rhythm Society

Infectious Disease Society of America

North American Society of Cardiovascular Imaging

Radiologic Society of North America

Society of Cardiovascular Magnetic Resonance

Society of Critical Care Medicine

Society of General Internal Medicine

Society of Hospital Medicine


Dear Society Leadership:

We are a group of clinicians, researchers and imaging specialists writing in response to recent publications and media coverage about myocarditis after COVID-19. We work in different areas such as public health, internal medicine, cardiology, and radiology, across the globe, but are similarly concerned about the presentation, interpretation and media coverage of the role of cardiac magnetic resonance imaging in the management of asymptomatic patients recovered from COVID-19.

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Hospitals Must Give Up Power to Save Healthcare

By KEN TERRY

(This is the sixth in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)

As hospital systems become larger and employ more physicians, healthcare prices will continue to rise and independent doctors will find it harder to remain independent. Hospitals will never fully embrace value-based care as long as it threatens their primary business model, which is to fill beds and generate outpatient revenues. To create a viable, sustainable healthcare system, the market power of hospitals must be eliminated.

Federal antitrust policy is not adequate to handle this task. Even if the Federal Trade Commission had more latitude to deal with mergers among not-for-profit entities, the industry is already so consolidated that the FTC would have to break up health systems involving thousands of hospitals. Such a gargantuan effort would be practically and legally unfeasible.

All-payer Systems

 The government could curtail health systems’ market power without breaking them up. For example, either states or the federal government could adopt “all-payer” models similar to those in Maryland and West Virginia. Under the Maryland model introduced 40 years ago, every insurer, including Medicare, Medicaid, and private health plans, pays uniform hospital rates negotiated between the state and the hospitals.

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