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TECHNOLOGY: PSA tests unnecessary, but it’s typical for Medicare?

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Medpundit points to a new study that questions the use of the PSA prostate test among the elderly.  As I learned via Family Medicine Notes, of positive PSA tests, some 7 in 10 are false positives (or at least don’t mean that the person concerned has cancer).  In the study, roughly 1/3 of 75 year olds got the PSA test, 88% because their doctor told them to get it. Meanwhile a substantial number of men die with but not from prostate cancer. In other words if you’re 75 and have no history of prostate cancer, what your PSA is doesn’t matter. Not only is the test a waste of money but chasing down the false positives causes more tests, costs and incoveniences down the road.

Medicare for ever has just paid  for procedures that are of dubious medical justification in its age group. Way back when there was a clinical trial of CABGs among men under 65, but very quickly and with no trial in the relevant age group, Medicare was paying for CABG’s in its population particularly in those over 75. The provision of kidney dialysis to the very old is another example of where age is not taken into account, although it is in the UK.  Whatever the moral rights and wrongs, the tradition of excessive care of the soon to-be-dead continues and there has been no debate about it. This is a classic case of where Medicare should change its payment mechanism to encourage the right behavior.  But it won’t.

INDUSTRY: Employer based health insurance–pay more, get less

Part of the reaction from employers to rising health care costs has been to push more co-payments, higher deductibles and larger out-of-pocket maximums onto employees. This has been viewed as an easier approach than increasing share of premium contribution, even though it has led to severe labor disputes in many cases. Ignore the fact that employment based insurance is a dumb idea–it just happens to be the way it’s done in real life. But what about people going through the process of paying more and getting less from their employer?

A new study from Sally Trude at the Center for Studying Health System Change called Patient Cost Sharing: How Much is Too Much? looks at the hypothetical actuarial impacts of a move towards higher deductibles, OOP maximums and co-pays. As you’d expect, it impacts most on sicker and poorer employees.  In fact for those very rare employees earning below 100% of Federal poverty but actually getting health insurance from their employer (and that must be virtually a null set), 44% of those with a deductible of over $1,000 will be spending more than 10% of their gross income on health care.

According to the Center’s survey research "most Americans, especially lower-income people, are willing to limit their choice of hospitals and physicians in return for lower out-of-pocket costs".  But given the shellacking managed care companies got when they tried that last time, don’t expect too many of those restrictive products to be rushing onto the market any time soon (although Blue Cross is trying to pull it off in California). Trude concludes:

    Employers continue to increase patient cost sharing to reduce annual premium increases and to encourage workers to economize when using health care services. As out-of-pocket costs increase, however, both the financial and medical consequences for seriously ill and low-income people increase. Nearly half of all personal bankruptcies are due in part to medical expenses. And research suggests that patients faced with higher cost sharing cut back on both needed and discretionary care.

The debate on user fees via the Rand experiment, Evans and Barer at UBC et al, basically concluded that point of service user fees have no impact on overall health care costs but do tend to stop the poor and sick going to the doctor (meaning that minor problems become major). So from a health policy perspective employers ought to be transferring their cost cutting to the front-end–and demanding more cost sharing in premiums.  However, that translates to all employees feeling the pain, rather than just those who are sick feeling it when they are sick.

By the way, I’m currently doing some other work looking into a number of these system problems, so if you have any suggestions about things to look into in the world of clinical or care inefficiencies please let me know.

POLICY: Health Care Costs 101

Occasionally you see a really dumb article.  Not wrong, just dumb.  This one in the NY Times last week asks Who Controls Health Care Costs?.  It wonders why Republicans would promote private plans as a solution to controlling Medicare costs when it’s been shown that both Medicare and private costs increase at roughly the same rate over time. Leaving aside the fact that the Republicans are doing this for ideological reasons, it’s worth taking a little walk down memory lane on health care costs.

The reason costs go up so fast in this country is because of what Alain Enthoven calls "cost-unconscious demand" and a general pattern of Fee-For-Service medicine. Do more, get more, and no one really worries about the cost. That’s more or less what we still have, although it’s become much more sophisticated.   Even after 40 years of health care cost inflation, the same basics apply. There are only three real approaches to change this;

    1) Make individuals conscious of the entire cost of the system care–don’t disintermediate it via employers and insurance companies–including either having them pay all their insurance premiums or all cash out of pocket.
    2) Make consumers directly responsible for health care via a directly proportional tax (this is how it works in Belgium and is what Vic Fuchs proposed recently).
    3) Give responsibility for the cost of the whole ball of wax to someone else who has to manage the bottom line (almost always the government, as in the UK and Canada)

We are nowhere near any of those solutions in the US, so costs will keep going up (as will uninsurance and underinsurance, as there is a what economists call a price effect).

Meanwhile, the leading advocate for my third solution, otherwise known as single payer, Steffie Woolhandler, also got her own interview in the Times.

And for those interested in performance-based reimbursement, a group of health policy wonks who favor a market-based solution, including Enthoven, believe that Medicare could and should change the market by rewarding providers with pay for performance. Not a bad idea, but not realistic in the present climate.

PHARMA: The AMA goes out on a limb on DTC ads

While some doctors have been complaining about DTC ads for a while, surveys show that they don’t really mind too much, and that when patients ask for a drug the doctors often prescribe it.  Finally the AMA has come up with a revolutionary proposal: the ads should say what the drug is used for! Presumably doctors are fed up with answering that question to confused patients who’ve seen Levitra ads.

In fact DTC advertising has indubitally pushed up drug use and drug costs.  But it’s also increased understanding of various diseases among patients. So calling DTC advertising a major cause of increased health care costs when drugs represent less than 10% of all costs is a little over the top.  Of course the media companies do appreciate the $3bn a year that is dropped their way by the drug companies. Some of this was discussed by Art Caplan and Sherry Glied in Teri Gross’ Fresh Air show on NPR  this morning on the increase in health costs.

On a totally random aside, they can’t show DTC advertising in the UK.  Otherwise Glaxo might have slipped up in the way that GM screwed up by calling the Chevy Nova (Don’t Go) in South America (although apparently it’s an urban legend). After all the ad here says take Levitra if you’re having trouble staying "in the game"; they might have talked about trouble going "on the game", which is British slang for being a prostitute!

INDUSTRY: Tom Scully’s had enough

The New York Times is shocked, "shocked!" to find that a senior administration official is going to retreat to a bigger salary in the private sector. Even more amazingly the official concerned is Tom Scully the head of CMS. Frankly I think the NYTimes is stretching it to put this on the front page. Scully was the Washington guy for the for-profit hospital chains before running HCFA/CMS and was in the Bush pere White House before that. He’s not exactly the first official or Congressman to jump over to the "dark side" and, let’s face it, there’s barely a door to revolve through these days–it’s more like a transparent shower curtain. Anyway did the Times really expect him to sit around at CMS and implement the mess the Congress just left him?

QUALITY: Helmet doesn’t save young skier

A 13 girl died this weekend after skiing into a tree at Alpine Meadows near Lake Tahoe. I’m a very keen skier and snowboarder and, although I wasn’t close to dying, I tore 3 ligaments in my knee after snowbaording into a tree last year. So I have a deep personal interest in the subject and have been evaluating knee guards as I get back onto the slopes.  What surprised me is that the girl was wearing a helmet. You’ll find that many skiers are wearing them these days, but apparently they don’t help in every case.

QUALITY: Kaiser cheaper and better than the NHS, says NHS

A study in the BMJ said, apparently with the approval of the UK health minister John Reid, that Kaiser Permanete provided better care than the UK’s NHS at better overall value and similar cost! This follows an academic report that suggested that UK care standards should become more like American ones. No, they’re not thinking of importing our insurance industry, but this is suggesting that length of stay in the UK is too long and should be brought in line with best American practices.  That’s not too far wrong in my view.  LOS over here is too short, forced that way by per admission DRGs, but not grossly so. Whereas LOS in most other countries is 2-3 times as long and lowering it would mean that care could be better delivered in the community at lower cost–rather than in a SNF at higher cost as is often the case in too-early discharges here. (In Uwe Reinhardt’s argument this leads to higher than necessary average inpatient costs as the first day in a SNF actually costs more than the last day in a hospital). I  know something about international comparisons (as well as something about Kaiser and the UK), and there is a nugget in here which I’ll bring out more in the future. 

Meanwhile, think about this on the macro level;, the Brits are looking for ways to cut cost in their system and they’re spending less than half what we do! And consider one more thing–costs in Florida are twice what they are in Minnesota, so we could do the same thing if we wanted (and could be bothered to read Wennberg’s stuff).

Hat tip to the wonderful MedPundit for this story, although why is a good free-marketeer like Sydney trolling the news outputs of a nationalized monopoly business like The BBC? Maybe there’s something to that socialism thing after all??

PHARMA: Statins good but no better than aspirin?

Today’s NY times gets very excited about the ability of statins to lower cholesterol and therefore reduce the risk of heart disease. In particular they cite the improvement you get from getting LDL below the consensus "normal" levels. Of course as the article called Just how low can you go? points out, this is great news for the statin makers.  Only around 10% of those who seem to be indicated for statins are actually taking them.  On the other hand scaremongers (i.e. this blog and others) keep pointing out that there can be side-effects from statins, which include severe muscle pain and some say long-term amnesia.  While it’s OK for the NY Times to act as Pfizer’s PR company on occasion (and this may actually be one of them), and to correctly point out that the incidence of side-effects is very, very low, they might have noted another study out yesterday.  That study, in the British Medical Journal suggested that a new blockbuster drug you may have heard of called aspirin was found equally efficacious and far more cost-effective in preventing heart disease than statins. And not just a little more, but by a factor of 20.

The full paper admits that aspirin use does have side-effects (usually stomach bleeding), but obviously, as in the case of the Cox-2 inhibitors, the patients could be started on that regimen and switched to statins if they can’t handle the aspirin.  Overall this study should give pause to the statin manufacturers.  In the UK where the government already concedes that its paying too much for statins and is trying to move them OTC, this could be the start of a movement to replace them with a rather more mature and much cheaper product! In the US where cost-effectiveness is not a recognized concept, don’t expect too much attention to be paid. But as we eventually (i.e in ten years time) move into an era where the government and public starts to expect value for money from drug companies as well as miracle cures, this type of analysis will become more common and more important.