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Tag: Quality

CONSUMERS/QUALITY: LASIK–not as user friendly as it’s supposed to be

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There’s been lots of BS about how the price reductions in those ads for LASIK "prove" that cash based consumer payment works in health care. I always thought they were like the teaser prices in travel  adverts in the Sunday papers–only good if you were leaving Tuesday at midnight, staying 4 months, taking no luggage, and having to fly the plane yourself while the pilot takes a nap.

And now HSC shows that it’s not as advertised.

HSC president Paul Ginsburg, Ph.D., points out that current efforts to increase price transparency for health care services often downplay “the complexity of decisions about medical care, patients’ dependence on physicians for guidance about appropriate services, and the need for information on quality.”
Ginsburg cautions that simply giving consumers a price list of “a la carte” services does little to help them make informed choices about which providers will cost less for an episode of care, let alone which providers offer the best value — or the optimal combination of the lowest cost and highest quality.
The article also points out that insured people have different needs for price information than uninsured people. Insured people need to know what their costs will be under their insurance and benefit structure. And policymakers should be careful not to overlook the role of health plans in negotiating better prices and translating complex price and quality data into usable consumer information that can potentially help steer patients to lower-cost, higher-quality providers, the article notes. Researchers chose the LASIK market for in-depth analysis largely because the vision correction surgery is widely regarded as the self-pay market with the most favorable conditions for consumer shopping. LASIK is an elective, nonurgent, simple procedure, giving consumers time and ability to shop; screening exams are not required to obtain initial price quotes, keeping the dollar and time costs of shopping reasonable; and easy entry of providers (ophthalmologists) into the market has stimulated competition and kept prices down.
However, LASIK patients still face significant hurdles when shopping from inconsistent bundling of what’s included in the procedure price to misleading advertising to quality concerns.
— Inconsistent Bundling. The package of services included in LASIK procedure fees varies across providers. For example, one critical factor is whether the cost of enhancement surgery is included in the fee. A price quote that appears to be the best deal but does not include follow-up operations if needed might end up being the highest-price option.
— Misleading Advertising. Misleading offers for free consultations or for LASIK for $299 and promises that LASIK would eliminate the need for glasses and contacts for life have all come under scrutiny by state and federal regulators, resulting in enforcement actions and settlements to halt the misleading practices.
— Quality Issues. Many industry observers expressed concern that LASIK is regarded as a commodity by some consumers, leading them to shop only on price, when provider quality may vary considerably. Even when consumers are interested in obtaining quality information, the study finds that it is not easy; those wishing to compare provider quality must gather information on success and complication rates from each LASIK surgeon’s practice.

Which of course means that if we’re going to get to real consumer purchasing, we need to figure out a rational way to price for rational bundles of service–and we have to make sure that providers are showing apples to apples comparisons.

PODCAST/TECH/QUALITY: MedEncentive–can a simply “elegant” solution really change health care delivery?

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Jeff Greene believes that his "elegant" solution can change health care delivery in one of the toughest places in America to do it–the wild medical mid-west. Jeff claims that the only two places on earth where life expectancy is falling are sub-Saharan Africa and Oklahoma City. (I assume Iraq is  soon joining that list!) His company MedEncentive offers a simple way of physicians to follow  guidelines, patients to get informed about their care, and apparently payers to save lots of money. Before you dismiss it, listen to this podcast.

(Technical note–For some bizarre reason Jeff’s channel was recorded a few seconds ahead of mine. So he’s answering my questions a little before I’ve finished asking them. Or alternatively, he’s psychic. At any rate it sounds a little odd. But I know you lot never listen to me on these podcasts anyway!)

QUALITY/INTERNATIONAL: More confusing international comparisons

I don’t know much about medical care, but I do remember that in Lynn Payer’s Medicine and Culture the most amusing factoid was that German doctors put people whose blood pressure was too low on medication to raise it. Does that mean that the study of blood pressure control reported on by the AP, which suggests that it’s lower here because of more aggressive prescribing than in 4 other countries, means anything in terms of reducing poor health outcomes? I doubt it. What about in increasing or reducing costs? I suspect you can guess my answer!  Here’s the abstract.

This stuff always reminds me of the Philip Morris study of the costs of smoking in the Czech Republic. Hint: smoking lowers societal costs cause the smokers pay more taxes than anyone else then die off quick before they cost the taxpayers much!

QUALITY/TECH: A nice conversation with Brent James

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This is possibly the most interesting podcast yet on THCB. And it’s certainly the longest. if you didn’t have the time to listen to the interview with Brent James, here’s the transcript. I really recommend this one–there are so many amazing nuggets that if you care about health care in the US at all you owe it to yourself to read!

Matthew Holt: This is Matthew Holt with The Health Care Blog, and I’m back with yet another podcast and this time it’s really very exciting for me that we have one of the pioneers of the entire medical safety and industrial process of medicine movement in the U.S., Dr. Brent James, with us this afternoon. Brent, good afternoon. How are you?

Dr. Brent James: Good afternoon. It’s a delight to be here.

Matthew: Great, great. Just by way of introduction for those who don’t know, and I’m sure most of my readers will know—I hope they do—given that it comes up enough in the blog. Brent, your official title is VP of Medical Research for Intermountain Healthcare? Is that correct?

Brent: That’s correct, and I’m the Executive Director of the Intermountain Institute for Healthcare Delivery Research.

Matthew: Great. And I would say that that sounds very well and good, but in fact that is really understating Brent’s impact. He’s both at the regional level in Utah with Intermountain been largely responsible with his team for some really dramatic change in the entire way  clinical care is being delivered on the in-patient side, and has had a lot of great information published and distributed out of that. On the national level, Brent, you’ve been involved in both the Institute of Medicine and the more recent Citizens Working Group in Healthcare, and there’s probably some other things you’ve been involved with. I don’t have them on the tip of my tongue, but certainly you’ve been a very visible player on the national level. In addition, and we’ll touch on this at some point in the conversation, you’re currently involved with the Institute for Healthcare Improvement’s — Don Berwick’s organization — new campaign which was announced last week for the Five Million Lives. Is there anything else big and important I’m missing from what you do? [laughs]

Continue reading…

CONSUMERS/QUALITY: A DIY Approach to the Diabetes Epidemic by Amy Tenderich

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#1 health care blogger, well actually #1 patient blogger, but probably the most important one in the whole medical blogosphere, Amy Tenderich has written a book called called Know Your Numbers, Outlive Your Diabetes about (obviously) how to manage diabetes. We don’t deal much with actual medical care over here at THCB, but for your holiday Monday I thought that an introduction to her book would be a great start. And of course who better to introduce it than Amy herself!

Forget any inkling you may have had that the media is sensationalizing the "diabetes epidemic"€ story. It’€™s real folks. In fact, the American Diabetes Association just launched a campaign called "Every 21 Seconds"€ as in that’€™s how often another American is diagnosed. Diabetes now affects the lives of 20.8 million children and adults in this country, and at the going rate, could rise to 50 million by the year 2025.
With the medications and tools available here in the US, the devastating effects of this disease are largely preventable.

Continue reading…

QUALITY: All is not well in the DM world

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Last year LifeMasters pulled out of one of the Medical Health Support DM pilots in rural Oklahoma because they found that adhering to the proper standards of care made the cost of care go up for those patients they enrolled, not down.

Now Healthways, the largest DM for-profit company, which has the greatest number of the Medicare Health Support pilots, appears to be seeing some big problems too.

MHS Pilots Based on the receipt of essentially complete first-year data which revealed smaller separation from the control group than reflected in previous reports, the Company’s net per share costs in the MHS pilots for the first fiscal quarter of 2007 totaled $0.10 per diluted share, $0.04 more than previously estimated. For the first 15 months of the pilots, per member per month (PMPM) beneficiary costs, including inflation, have been held flat, which the Company believes reflects meaningful impact resulting from program interventions. To date, however, the control group costs as reflected in the most recent report released by CMS’ third party actuarial firm are also unchanged, and do not reflect anticipated increases provided by CMS nor the results of historical national and regionally-specific trends identified by third-party actuarial analysis of the Standard Analytical File (better known as the Medicare 5% Sample). The Company has brought this issue to CMS’ attention and has received the Agency’s commitment to pursue understanding and resolution of this anomaly in a timely manner.

While the Company has no direct control over the timing of this review by CMS, it will communicate progress toward resolution. Based on the strength of the Company’s performance with the intervention group, particularly as compared to the Medicare 5% Sample data, as well as the questions raised by the unanticipated trend of control group costs, the Company is maintaining its fiscal 2007 guidance related to the MHS pilots until this issue can be resolved to the satisfaction of all parties.

In other words either Medicare has got the data wrong about its control group, or the control group is healthier than average, or (gulp) DM doesn’t save money for the sick Medicare recipients group. And so the DM companies, which have promised CMS that they’re going to pay them 5% savings for the sick group (and make their money on the reduction from there!), are going to be losing money.

Healthways stock is down around 15% over the last week as this news seems to have seeped out. But it’s PE ratio is in the 40s, and the stock price went up more than five fold 2003–6, suggesting that the market is expecting it to continue its quick growth. If MHS is deemed a failure, there may not be any growth. Watch this space.

(Thanks to Fred Goldstein for this tip).

QUALITY/POLICY: Gerald Ford–the poster child for what’s wrong with health care

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Gerald Ford died last night aged 93. By any standards he had a great life. He was a moderate Republican in the House for many years, and then a stop-gap President after Nixon, famous mostly for pardoning Nixon who hadn’t yet been charged with a crime. And then lived on for nearly another 30 years. The American dream of the College jock becoming President and achieving great wealth and happiness—and people liked him!

But it’s the manner of his death that I think is very important. Just two months ago in a “discussion” I had with David Gratzer of the Manhattan Institute, I raised the point that Ford had not one but two angioplasties at the Mayo Clinic—and that as he was likely to die soon anyway that money would have been better spent on pre-natal care for an uninsured woman who was featured on ABCNews that week.

David Cutler recently estimated that adding an extra year of life for the elderly cost $145,000.

So consider Ford’s last few months of life. He was admitted to hospital last January for pneumonia. Then spent much of July in hospital in Vail; then went to the Mayo Clinic for not one but two angioplasties in August. Then went back into hospital in California in October, and now has died in December. All that time he was obviously going to die within a year or so, and all that time he was at least 92 years old.

My guess is that over the last 12 months of his life well in excess of $100,000 was spent on his health care. And that money probably extended his life by three months at most. Now for all we know they may have been the most wonderful three months ever for him and his family, but I’m inclined to think that if he’d died in the summer, his family would have been equally fine with it, and the nation wouldn’t have felt any differently about him. But the cost of extending life an extra year in this type of case is probably around $400,000.

How can that possibly have been money worth spending? The answer is that it cannot have been. And that is where the money is in our system which could pay for all the pre-natal care for uninsured mums, immunizations for sick kids, and procedures for uninsured 50 year olds that we “can’t afford.”  And frankly it’s probably better and more humane care to provide palliative care at home than to put sick old people through yet more invasive and painful procedures.

So the sooner we start having that conversation the better. And if that conversation comes out of Gerald Ford’s death, then at least that spending on the last months of his life might have done some good.

PODCAST/QUALITY/TECH: An hour with Brent James

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This was a total pleasure. Yesterday I got to spend an hour talking with Dr. Brent James, one of the leaders in the patient safety movement, instituting process change in health care, and the man responsible in large part for InterMountain Healthcare’s status as the health care system known for delivering some of the best quality care in America (and the world). Brent of course was on the IOM Committee responsible for the "To Err is Human" report and is involved in the new IHI "5 Million Lives" campaign. Brent has much to say about all of that and a lot more, and it is fascinating stuff.

So for your year-end enjoyment here’s the podcast of our conversation. (A transcript will be up in a few days).

PHARMA/POLICY/QUALITY: Cost-effectiveness in drug approval

I’ve been hanging with the libertarian Canada-bashers from PRI! They and the California Health Institute (the Cal biotech and drug company industry group) invited me to a very, very nice dinner last night. I assume that they used the drug companies’ money rather than the Scaife’s so I can keep my lefty credentials! Then they had a meeting Friday morning, intended to scare the world about the prospect of an Australian-type cost-benefit analysis requirement for drugs coming here.

IMS put out a report saying that access to drugs in the US would be massively restricted if an Aussie style system was imported here; Randy Frankel from IMS gave the talk (although I sat next to him at dinner and he has a varied and interesting background including setting up disease management at Medco and he basically agreed that we were out of easy targets for drugs and had to decide what to do about biotech drugs that cost $100K for an extra year of life).

Ruth Lopert, adviser to the Australian system gave it a somewhat vigorous, but also defensive defence. She said a few things

  • Government doesn’t set prices…price is proposed by the drug co, but then accepted if it makes it under the cost-benefit analysis (i.e. better come into line!) so prices for me-too drugs are lower than for first movers
  • She says prices for innovative drugs are higher in Australia than they are here! (Gleevac, Embrel)
  • She says it’s not a mechanism for cost containment, Australia’s drug costs are going up 12% a year. (to which I should almost asked, but didn’t, why bother at all then!)
  • And if it’s not reimbursed by the state, you can pay out of pocket! And for most patients in Australia paying out of pocket costs less than the average payment me for drugs by a typical patient on Medicare Part D!

Marjorie Ginsburg, from Sacramento Healthcare Decisions, talked very entertainingly about their report in which they found that people where in general happy to say no to funding certain technologies (including Aricept for Alzheimer’s).  There is a subset of people who believe that if it saves one life (such as an implantable defibbilator) it’s worth it, but once you get past direct life saving technology, they don’t care. Only 12% said cost effectiveness should never be considered. 50% said it should always be. Other things they want — 67% wanted price controls, 56% wanted cost benefit analysis, 49% want more oversight. Her message is that this is acceptable—but don’t do it just by itself. It will have to be part of a whole package of how to deal with health- are. The way to get this done, she says, is to present as getting it best value, not cost savings.

Meryl Comer who’s been caring for her husband with Alzheimer’s for 12 years gave a harrowing talk about the impact that’s coming from that disease. She said that there’ll be 13.9m Americans with Alheimers by 2010. 650K are diagnosed while still under 65. Make it to 65 and there’s a 1 in 10 chance that you’ll get it; by 85 it’s 1 in 2. Still no cure, even though the disease was discovered in 1906. She wants to make sure that the access to successful cures is not prevented, because it’ll save so much.

Kwabena Adubofour, a diabetes care clinic director from Stockton gave a long talk about how EBM analysis for drugs is largely irrelevant while care is generally problematic, and that there’s massively unequal treatment based on ethnic origin, poverty, et al. His concern is that limiting pharmaceuticals via cost containment in this environment is a double hit on minority health care. He points out that there’s a huge gap in care for blacks compared to whites (much fewer rates of referral) women only got 60% of the referrals that men did, blacks only got 60% that whites did. He thinks formulary redesign is irrelevant—there’s lots more to do first. His long list of stuff included DM, pay for Improvement, reducing unnecessary care, etc, etc). He thinks that no one (as far as he can tell) is against rational thinking about how to tackle pharmaceutical costs (Can’t say that I agree with him about that!) But we should only be doing that in the context of this other stuff.

Peter Pitts, ex-PRI, ex-FDA, claims that the problem is that one size doesn’t fit all in health care (or anything else) because EBM is a regression to the mean. And the studies ignore the massive patient based variation. (and he’s right….) So his answer is no formualries. He says that restrictive formularies cause higher costs later. Genomics/personal medicine will fix all this. At least I think that’s what he’s saying. He’s saying we need innovation? (Are we opposed to that over on the EBM supporting side….I’d guess he’d say we are!)

BTW if you’re a former governor, you still have to show up at things like this. At least Pete Wilson is here. Another disincentive to run for public office!

The Q&A pretty much was a fight between Pitts and Lopert.

The audience was very amusing. 2 doctors asked random questions. One said “why is the government establishing these guidelines, shouldn’t a 100 flowers bloom”. Another decried cookbook medicine and said that “Evidence-based medicine is creating Alzheimers in doctors brains…” (i.e. it’s stopping doctors from thinking). Randy Frankel smacked them both down by explaining the variability in medical practice, and showed that it takes 17 years for a guideline to come into being.

Peter Pitts answered my long long rambling question/comment trying to figure out what the panel was about by (essentially) saying that he’s opposed to formularies, and that third party payers should pay for whatever the doctor wants to prescribe. Kwabena Adubofour says that in cost containment with pharmaceuticals, it’s always the cheapest drug that gets pushed—not the best “value” overall.

From the audience The medical director of Safeway (didn’t catch his name) and Anthony Barrueta VP of government relations at Kaiser Permanente both essentially said that EBM is about changing physician behavior and we need to do that. Because, for example, per capita we do 19 times the rate of back fusions than they do in Denmark. That’s some practice variation for you! That’s what happens when there are no guidelines…the Safeway med director says that when Australia is spending 9% of GDP and we’re spending 17% it’s crazy to think that we don’t have a problem.

An interesting session, but I don’t really know what it was about! We’re going to get some level of practice guidelines and EBM incentives via P4P, they’ll be fought tooth and nail, and cost-effectiveness analysis will be part of that process. But it ought to be done in the context of wider health care reform, because this is not the biggest problem in our health care system. And you know what is, with more evidence just last week…

QUALITY/POLICY/TECH: Quick notes from the road

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Apologies to those who’ve missed me. I’ve been lost in the mid-west taking part in some scenario planning about the big picture future of health care. I can’t give you any details (at least not yet) but it did involve me spending lots of time with a bunch of business association lobbyists who’s views on health care, shall we say, the average THCB reader wouldn’t expect me to share.

In the informal conversations, across the board there was, however, one huge topic of agreement amongst the boomers I met. They wanted themselves and their parents to die at home with palliative care; they felt that current end of life care verges not only on the irrational in terms of resource use, but also on the inhumane. And they think that within a decade, we will be having that conversation and forcing that set of opinions onto our medical providers. Who presumably will be rather more willing to hear us out, rather than insisting on engaging in those heroic measures that, the group felt, todays providers feel they must perform.

One other quick thing. Wednesday, Intel, BP and WalMart announced a PHR initiative, which I believe is being largely led by JD Klienke’s group in Oregon. On that topic I’m giving a talk to HIMSS N.California in San Ramon on Tuesday on the topic of PHRs. Also talking will be Kate Christensen from Kaiser Permanente, and Holly Miller from the Cleveland Clinic. I personally think this should be an interesting opportunity to hear a range of views and understand some developments in major PHR deployments from providers (and of course I’ll be witty and brilliant, just as soon as I’ve put my talk together). But apparently according to at least one other blogger, I’ve misunderstood it all, and really I’m just being a PR flack for the devil worshipers at KP central. I’ll report back as to whether the place still smells of sulphur.

 

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