The Health Care Blog – Page 480 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Tending to the Health Care Workers of America

May 27, 2014• 12

By Timothy Hoff

Given the attention now paid to implementing national health reform, the bulk of which is now upon us as 7 million new individuals now have health insurance, one important issue remains largely ignored by policy makers and industry leaders–health care workers are very unhappy.

A 2012 national survey of 24,000 physicians across all specialties found that if given the choice, just over half of these doctors — only 54 percent — would choose medicine as a career again. Fifty-nine percent of physicians in a 2013 survey could not recommend their profession to a younger person, and forty-two percent were dissatisfied in their jobs. Forty percent of physicians in another 2013 national survey self-identified as burned out.

Nursing has gained the moniker of one of the least happy jobs in America, with nurses traditionally experiencing high rates of job dissatisfaction, burnout, and turnover. Some of the reason for this malaise among our highest status health professionals has to do with the stressful, uncertain nature of health care work.

But it also is an outcome of the everyday worlds in which all health care workers now find themselves: a world drenched in paperwork, packed patient schedules, and decreased control. In short, the new world of health reform.

We are in the midst of a technological and business revolution in health care delivery. We are also on expanding patient demand in ways not seen in generations. But we are not meeting the needs of health care workers, who are expected to produce at a higher level than ever before.

If We Want Lower Health Care Spending, We Are Going to Have to Pay for It

May 26, 2014• 13

By David Dranove & Craig Garthwaite

Ultimately, spending less on health care is a relatively easy task: We either need to consume fewer services, or spend less on the services that we consume. But much like we teach our Kellogg students about maximizing profits, the devil is in the details.

It’s certainly tempting to ask the government to swoop in on a white stallion and solve the all our problems by fiat. For example, we could have the government simply exploit its monopsony power and set prices, but an artificially low price will lead to an inefficiently low quantity of services and future innovation (stay tuned, we will have more to say about this next week).

Similarly, we could explicitly ration quantities (as opposed to implicitly doing it through a large uninsured population). But how could we hope to determine the right level of care? Ultimately, if we ask the government to unilaterally fix this problem, instead of a white stallion we could behold a pale horse and all that it entails.

The good part, perhaps the best part, about the Affordable Care Act is that it attempts to address this problem using market forces. The question is whether we are ready for what these market forces will entail.

We will focus today on the role of market forces in the insurance market to control prices in the newly established ACA exchanges.

This month the Obama administration announced that it would allow insurers to use “reference pricing” for insurance programs in the exchanges. Under a reference pricing system, insurers set the maximum price they will pay for a specific set of services and if patients go to a facility that costs more than that amount they are required to pay the difference.

If Marketing Is so Dangerous, Should Medical Schools Be Doing so Much of It?

May 25, 2014• 5

By Richard Gunderman, MD

Beginning about 5 years ago, many US medical schools introduced severe restrictions on marketing activities by pharmaceutical companies and medical device manufacturers.

These measures often prohibited representatives of such firms from entering patient care areas and even medical school facilities, with the exception of tightly controlled training activities, and then by appointment only. In some cases, medical schools have issued outright bans against industry support of educational activities.

What is the rationale behind such actions? It boils down to a concern that industry funding may inappropriately influence both medical education and patient care. For example, a physician visited by an industry representative might be more likely to prescribe one of the firm’s drugs. In announcing a ban on such activities, one school likened the industry to Don Juan, worrying that physicians might prescribe drugs because they were “seduced by industry,” and not because “it’s best for the patient.”

There is evidence that even physicians who believe their decision making is not biased by marketing are in fact affected by it. Moreover, a good deal of such marketing is not exactly purely scientific. A perusal of medical journals reveals a plethora of full-page ads featuring slogans such as:

“Simplicity is clear information at your fingertips,” and highlighting images such as a physician walking down a hallway with a tiger, describing the featured drug as a “powerful partner.”

Such marketing is not inexpensive. Placing a full-page ad in a medical journal typically costs around $4,000. On the other hand, as an air traveler I have come across a number of slick full-page airline magazines ads touting medical schools and their affiliated hospitals.

These cost on average $24,000.

The Case For Traveling to the Center of Our Social Networks

May 23, 2014• 2

By JAMES FOWLER

Much has been made of David Lazer’s finding that Google’s Flu Trends tracker seriously missed the mark in its measurement of flu activity for 2012-2013—and in previous years, too.

For those who don’t know, Flu Trends monitors Google search behaviors to identify regions where searches related to flu-like symptoms are spiking.In spite of Flu Trend’s notable misstep, Lazer still believes in the power of marrying health and social data.

In discussing the results of his study, he has maintained Google Flu is “a terrific” idea—one that just needs some refining. I agree.And, earlier this month, Nicholas Christakis, several other colleagues, and I—with funding from the Robert Wood Johnson Foundation—published a new method offering one such refinement.

Our paper shows that, in a given social network (in this study’s case, Twitter), a sample of its most connected, central individuals can hold significant predictive power.

We call this potentially powerful group of individuals a “sensor group.”

By finding and monitoring the tweets of a sensor group, we can catch—and sometimes even predict—the outbreak of contagious information early on. That detection edge could improve how we track the outbreak of disease epidemics, the rise of certain terms or phrases, or shifts in political sentiment.

Whereas Flu Trends relies on a relatively static, proprietary “dictionary” of flu-related search terms based on average Google search habits, the sensor method taps into what is really happening in social networks in real time.

By drawing on language being used by a sensor group—such as mentions of an emergent symptom or a popular newly coined name for a disease—Google could gain insight into what their dictionary might be missing.Sampling both the average Googler’s behavior and that of the exceptionally connected social network user can paint a much fuller picture of whatever landscape we are interested in tracking. We can more accurately see how it looks now—and how it could look in the near future.

Why the Phrase “Noncompliant Patient” Bothers Me, And Should Probably Bother You Too ..

May 23, 2014• 19

By Elaine Khoong

“Patient noncompliance.” I wasn’t very familiar with this term until I started my clinical rotations. But after just the first week, I started noticing that health care providers throw this phrase around all time.

We particularly like using it as an excuse. Why did this diabetic patient require a foot amputation? Why does this patient come in monthly with congestive heart failure exacerbation? Why did this patient suffer a stroke? It’s often simply attributed to patient noncompliance.

What bothers me the most about this phrase, though, is how it’s often stated with such disdain. We act as if it’s incomprehensible that someone would ignore our evidence-based recommendations. If the patient would only bother to listen, he or she would get better. If we were patients, we would be compliant.

But that’s simply not true. We are no different from our patients. We practice our own form of noncompliance. It’s called guideline non-adherence.

Despite the fact that many guidelines are created after systematic reviews and meta-analyses – processes we would never have time to go through ourselves – we, like our own patients, are often noncompliant.

Research on guideline adherence has been around since guidelines started becoming prominent in the early 1990s. Despite the many studies and interventions to improve guideline adherence, the rates of guideline adherence still remain dismally low.

I find this particularly disconcerting. Despite my own interest in research, it makes me question the value of research. Why do we spend millions of dollars to find a better intervention that does not change how most providers deliver health care?

The NFL’s Conflicted Relationship With Doctors

May 22, 2014• 6

By Arthur Caplan

Too often doctors, trainers and other health care professionals who work for professional sports teams are accountable only to their teams and, especially, team owners. To keep their jobs they have to keep coaches, general managers, fans and billionaire investors happy.

This situation has created an intolerable ethical mess in which athletes’ health is too often their lowest priority. It is time to fix that.

Concussions are giving professional football, hockey and other sports a huge headache these days. The implication is that the NFL, NHL and their doctors long knew that “getting your bell rung” was bad for an athlete’s brain but said nothing.

Now a group of former NFL players are suing the league claiming that they were given powerful painkillers and anti-inflammatory drugs to keep them on the field. They say no one ever warned them about the long-term dangers of addiction, horrible side-effects or playing injured while drugged to withstand pain.

The eight plaintiffs, led by 1985 Superbowl champions Richard Dent, Jim McMahon and Keith Van Horne, say the league “recklessly and negligently created and maintained a culture of drug misuse, substituting players’ health for profit.”

Team doctors and trainers “were handing out drugs like it was Halloween candy,” says the group’s attorney Steve Silverman. Among the drugs said to be given freely were Toradol, Percocet, Vicodin, Ambien, Prednisone and Lidocaine. The eight players estimate they were given “hundreds, if not thousands” of pills through the course of their careers.

None of this comes as a surprise to sports fans, especially those of a certain age, who remember the NFL, NHL, MLB, NASCAR, FIFA, pro cycling and NBA of the ’70s, ’80s and ’90s when doctors and trainers kept athletes going at any cost with any pill, salve, injection, bandage, device or inhaler they could get their hands on.

“Just win, baby” was the guiding ethical principle of the era and doctors and trainers put aside their oaths and codes to make sure stars played, their team won, the fans were happy and the owners renewed their contracts for another season.

A New Era in Value-Driven Pharmaceuticals

May 22, 2014• 3

By Leonard Kish & Cyndy Nayer

At the end of March the Amercian College of Cardiology (ACC) and the American Heart Association (AHA) issued a joint statement saying they “will begin to include value assessments when developing guidelines and performance measures (for pharmaceuticals), in recognition of accelerating health care costs and the need for care to be of value to patients.”

You may have heard of value-based medicine, but are we entering a new era of value-based medications or value-driven pharma?

Price transparency is great, but it has be combined with efficacy to get to value (price for the amount of benefit). Medical groups are catching on to how important value assessments are, because if patients can’t afford their medication, they won’t take their medication, and that obviously can turn into poor outcomes.

Twenty-seven percent of American patients didn’t fill a prescription last year according to a Kaiser Family Foundation Survey. This trend seems likely to continue as we move toward higher-deductible plans, where those with insurance can have great difficulty affording medications.

Included in the ACC/AMA statement was a quote from Paul Heidenreich, MD, FACC, writing committee co-chair and vice-chair for Quality, Clinical Affairs and Analytics in the Department of Medicine at Stanford University School of Medicine.

“There is growing recognition that a more explicit, transparent, and consistent evaluation of health care value is needed…These value assessments will provide a more complete examination of cardiovascular care, helping to generate the best possible outcomes within the context of finite resources.”

Spreading risk and payment to different members of the health care value chain is beginning to make it apparent to more people and organizations that resources are finite. Patients and their physicians are starting to ask which treatments are worth the cost and have best likelihood of adherence.

An outgrowth of the move toward digital health and accountable care is that we’re entering every patient into a potential personal clinical trial with their data followed as a longitudinal study, and we can look much more closely at efficacy and adherence and reasons why it happens and why it doesn’t.

It won’t be long before we start to see comparative effectiveness across a variety of treatments and across a variety of populations. When we can connect outcomes data, interventions and costs all in the same picture we begin to see where the value (price against results) is and where it isn’t.

A Closer Look at Public Trust in Healthcare

May 22, 2014• 2

By PAUL KECKLEY

Public trust matters. It’s hard to build and easy to lose.

Of late, subpar performance has drawn public attention to a wide variety of industry notables:

General Motors agreed to a fine for malfunctions resulting in 24 recalls in recent years including 2.6M most recently with faulty ignition switches.
Security breaches in customer information at Target, Michaels and other retailers hurt sales and cost at least one CEO his job.
The Department of Veterans’ Affairs has been exposed to questions about its safety record, notably delays in treating veterans in its hospitals in 9 states.

Entire industries have seen their public trust erode as a result of misdeeds or self-inflicted wounds—the investment banking industry’s mortgage loan debacle, venerable news organizations from lack of objectivity, industrial food manufacturers from unhealthy supply chain management and so on. And industries like higher education and others face tough questions about their value proposition, as if decades of good will no longer matter.

In most cases, leaders of the most prominent organizations in these industries accept responsibility, appoint task forces to investigate and address their issues with the media and investors head-on. Their trade groups, likewise, announce new initiatives to restore public confidence. They hire professionals to bolster their influence. and in some cases, rebuild their reputation.

Public trust in industries matters as much as confidence in the individual companies and organizations themselves. An industry’s reputation and good will is always buoyed by the reputation of the companies that are its marque market leaders, and always at risk as a result of the misdeeds of any member, known or unknown.

By and large, excepting occasional drug manufacturing scares or recent well-publicized safety issues in a few of the 3000U.S. compounding pharmacies, our industry has remained virtually unscathed from the ever-more-skeptical public’s thirst for muckraking. The U.S. health system enjoys the confidence of the majority, especially older adults for whom it is always top of mind.

But the reality is this: the US health industry is susceptible to erosion of its public trust, not as a result of the Affordable Care Act nor political in fighting in Congress.

The VA Scandal: Implications for Health Reform and a Call for Clinical Research into the Reported Death Rate

May 22, 2014• 38

By JAAN SIDOROV, MD

As your correspondent understands it, dozens of veterans died while waiting for outpatient appointments at the Phoenix Veterans Administration (VA) Hospital. Approximately 1500 vets were assigned to an “off-the-books” waiting list that made the clinics’ official waiting times appear shorter than they really were.

Because waiting times are an important feature of health care quality, the VA was probably holding its local administrators responsible for routinely measuring and reporting them up the chain of command. If reports are true, instead of using their increased budgetary resources to provide more care, the Phoenix bureaucrats allegedly responded by gaming the system.

And the scandal is flourishing. Investigations suggest other VA hospitals may have also adopted the same wait-list legerdemain. A senior D.C. official resigned fast-tracked his already scheduled retirement. The VA Inspector General’sinvestigation prejudgment is that none of the deaths can be attributed to delays in care. You can’t make this stuff up.

“Good grief!” says your correspondent. Numerous articles like this, this and this had convinced lay writers, impressive policy wonks and countless physicians that this version of government run health care was not only the greatest thing since the invention of Medicare, but a model for U.S. health care reform.

Not any more.

Because Cancer.

May 21, 2014

By “Knot Telling”

Do not tell me how to feel!

For those who may not read through to the end, here is the take home: you do not get to tell me how to feel or what my attitude should be, no matter who you are.

Sure, it’s more comfortable for me and the people around me when I’m have a positive attitude, but that does not mean that I have to live “all bliss all the time” like some insane American cable television station. Being positive does not mean pretending that nothing is wrong because… cancer, people!

A young woman who, I think, just turned twenty-two posted this on her Facebook page: “That’s the thing about pain. It demands to be felt.” She knows what she is talking about, by the way.

It does no good to pretend that emotional pain does not exist. It does no good to pretend that it’s not there. The only way I’ve ever found to get through pain is to recognize it, sit with it, walk through it to the other side. Sometimes that process leaks out into the environment and then I don’t smile prettily at everyone around me. Sometimes I’m snotty and bitchy and generally not one of Jesus’ little sunbeams. Sorry about that, but… cancer, people!

Here’s another news flash. A positive, determined attitude will not cure cancer, no matter what the popular media tell you. The following quotations are from the American Cancer Society:

In 2010, the largest and best-designed scientific study to date was published. It looked at nearly 60,000 people, who were followed over time for a minimum of 30 years. This careful study controlled for smoking, alcohol use, and other known cancer risk factors. The study showed no link between personality and overall cancer risk. There was also no link between personality traits and cancer survival.

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