Archive for March, 2013

Occupational Health — what a job is worth

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Today’s lead story in the New York Times  (3/31/13) is about the sad result of a dangerous chemical used by workers to make cushions for furniture.   The chemical is n-propyl bromide (n-PB), a spray adhesive to stick urethane cushions together.   Click this link to see an n-Propyl Bromide materials safety data sheet (MSDS).  The workers were exposed to the chemical and suffered long-term neurotoxicity manifest by difficulty walking and using the hands.   The workers were clearly hurt and there is a lot of finger-pointing at the management and the US  Occupational Health and Safety Administration.

A true story with a better outcome follows:

A man started his own home insulation business and learned how to spray foam insulation.  He was young and very fast so he decided he could apply the foam and get out of a room so quickly protective gear was not needed.   He hired several other workers for his small company.  Time went by and he developed cough, wheezing and shortness of breath always worse after a day on the job.  His wife insisted on a visit to a lung specialist who told him he had occupational asthma from the spray and must NEVER use the substance again.  He stopped using the spray and immediately purchased safety equipment for his workers.  The company owner commented: “wow, that’s bad stuff”.

The difference between the two stories illustrates important points:

  • If the owner of a company develops a health problem from occupational exposure the doctor is not questioned and immediate corrective action is taken.  The scenario is called the “pilot’s incentive”.  Pilots are very willing to fix airplane safety problems since a crash might kill them.  But, business owners divorced from the health risk and concerned about how much the corrective action would cost do not act quickly.
  • Workers often seek help from local physicians.  The physicians are afraid of getting drawn into a suit.  And, as in this case, if the MSDS does not explicitly list the health problem no action is taken.  Doctors avoid chemical related workman’s compensation because of the paperwork and legal obstacles involved.  MSDS sheets must be updated every 3 years.  However, there is no mandate to perform research to actually add to the basic information — and it seems foreign safety data is not well accepted.
  • Knowledge of occupational-exposure risk often does not deter workers.  For example, in the late 19th century miners knew the risk of death from using the steam driven hammer called the “widow maker”.  The miners died in their 20’s from breathing rock dust, a disease later named silicosis.  But, they took the jobs anyway because the pay was good.  The pay at the furniture factory was $10/hour,  perhaps that was the best pay available.  Workers were aware of co-workers getting sick but they worked on and on despite difficulty breathing and difficulty walking.
  • Workman’s compensation insurance is required in every US State.  If an injury is caused by something at the workplace the worker usually gets monetary compensation.  And, the compensation is tax free.

Here are some simple suggestions:

  • If you have a health problem make sure to tell your doctor about your work environment and any exposure to fumes, dust, chemicals and radiation.  Bring copies of the MSDS sheets appropriate to your job (employers are required to have a file of this information).
  • If other people at the job site are having similar health issues the job may be the cause — no matter what the MSDS says.
  • If a workplace health problem is suspected see an occupational medicine specialist.  Your local health care provider may be knowledgeable but may be easily overwhelmed by the amount of uncompensated time it takes to resolve the issue.
  • There are other jobs, other cities, and other states — disability and death can never be fully compensated so don’t risk your health for a job.

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Financial Considerations — great graphs

Graph Graphic

Dan Munro of Forbes Magazine assembled several interesting health care economics graphs for 2012.  See his article for details and for the source of the data.  Here are some of the graphs:

The first shows the rise in costs for working Americans.  Currently the premium is 50% paid by employer and 50% by the employee.


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The second shows how the US compares to other countries — basicaly the US spends more but does not get a benefit in life expectancy.

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The third shows the US spends a lot more than other countries in the Medicare age group.

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So what is the problem?  One would be tempted to conclude Medicare is the cause of the high costs in the older age group.  But Medicare is more efficient than private insurance based on loss ratios.  And, Medicare has spearheaded reduced payments to hospitals with DRGs.  If Medicare replaced private insurance many estimate a small reduction in total health care cost.   However, the inability of Medicare to set or negotiate prices for drugs, imaging  and devices is sadly lacking compared to the other 40 countries in the world with health systems.   Efforts to cap Medicare cost without giving Medicare the economic tools other health systems have will just result in low quality, high cost and poor access to care.

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International Comparison — sky high cost

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The Washington Post has a couple of great articles about the cost of health care in which the US is compared to other countries.

The table below is from the first article listed above.

Click on the graph for an interactive version. (SOURCE: International Federation of Health Plans. GRAPHIC: Wilson Andrews - The Washington Post. Published March 2, 2012.)

Both articles are written by Ezra Klein.  The data itself comes from the International Federation of Health Plans.   Mr. Klein points out the US as a country does not have the financial controls common in other advanced countries.  He concludes the rate of growth in prices as well as the current prices of health care simply must be reduced.  Other countries should serve as a model.

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Lack of Consistency — medical care variability

Combined target graph

An Interim Report from the Institute of Medicine (IOM) about geographic variations in care was just released.   This is a very scholarly report with massive statistical analysis.   The basic idea was to review what Medicare paid for various types of medical care, devices and drugs across the US to see if some pattern could be identified.  The hope was to find some way to alter the payment scheme to improve the value of health care.  Alas, they could not find a pattern, only wild variation.  An individual doctor might be cost-effective for one disease and a money-waster in another, doctors within a group would range from  judicious to wildly profit-motivated and the variations between hospital referral areas show the same scatter.

The graph.

The holes in the target above are an example of wide variation.  The archers did not hit the bulls-eye  very often — there is a lot of variation.  A particularly interesting graph from the report is redrawn above on the right.  This is about how often gastroenterologists in an unnamed state perform a stomach scope (EGD) with the billing diagnosis of heartburn  (i.e. gastroesophageal re-flux) .

The vertical axis is the number of EGD procedures per 100 diagnoses of heartburn (the procedure rate).  The horizontal axis is the ordered list of 403 gastroenterologists in the state.  The list is in order of the lowest to highest rate of performing EGD.  The ovals placed on the s-shaped curve represent 17 different doctors all in the same group.  The remainder of the 403 gastroenterologists are plotted as dots on the curve.  If all the gastroenterologists approached heartburn in a consistent and reliable manner the graph would just be a horizontal line somewhere in the lower part of the graph.  Instead we see some gastroenterologists performing a scope on 100% of people they see who have heartburn — to be clear, this is the picture of unnecessary procedures or “padding” the bill.

What does it mean? 

Gastroenterologists are poor marksmen.  No, no, no.  It means they are shooting at different targets.  Some aim to maximize revenue,  some aim to follow evidence based (lower cost) guidelines and some aim in-between.   Keep in mind that a gastroenterologist is paid about $200/hour for clinic visits and about $1000/hour when doing procedures.   The doctors on the right side of the graph clearly have targeted the high paying procedures “scope first and ask questions later!”

The IOM claims no insight into the mysterious variation.  It is not necessary to study this more!  Look at other countries, they don’t have this problem because other countries don’t pay doctors by the number of procedures performed.   Simply pay the gastorenterologist the same hourly wage for seeing patients in the clinic as doing a procedure.  In the big picture, the variation can be markedly reduced by having doctors employed by an accountable care organization (ACO).  The ACO sets the salary, pays the malpractice insurance and provides the office to practice — a doctor in an ACO just has to focus on doing what is right for the patient, not what is most profitable for the gastroenterologist.

What should be done?

Although the graph puts gastroenterologists in the spot light the data show the same scatter across the spectrum of doctors.  US health care is sliding more and more into the swamp of poor quality and high cost.  The US needs doctors to aim for the right target and to aim for reliability, which means to consistently hit the bulls-eye.   Hopefully the IOM will have the strength to recommend strong action to change the whole system of  payment for US doctors, hospitals, drug companies and equipment manufacturers.  Instead of trying to make a perfect system we need a good system that can be adjusted as needed to achieve both high quality AND low cost care.

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Second Opinion — really?

marcus welby 2nd opinion

Dr. Kiley asks Dr. Welby for a second opinion (circa 1970).  What was the story?  A crusty patient does not believe Dr. Kiley’s diagnosis and demands a second opinion from Dr. Welby.  Oh, the drama, the crushed feelings of Dr. Kiley, the wisdom of Dr. Welby, and the horror that neither knows how to use a microscope!

Holly Finn wrote an article today in the Wall Street Journal “First of All, Get a Second Opinion” (WSJ March 23, 2013).  She is strongly in favor of second opinions for two basic reasons:  there are now more successful companies that specialize in second opinions and 60% of people who seek a second opinion obtain recommendations which are less invasive and less costly.  But, she is taking the statistics out of context.  99% of people do not get a second opinion but the 1% who find a problem with the first opinion are often correct another solution is better.  The take-home lesson, like many things in life,  if something does not sound right,  it’s probably not.

Contrary to popular belief most physicians are very happy to help a patient get a second opinion.  Why?  Because a patient who feels uneasy with a situation will not follow directions, will not take prescribed medications, and will be hyper-critical if the outcome of treatment or surgery does not meet their expectations.  So, all a patient has to do to get a second opinion is to ask the provider (“do you think a second opinion would help us?”).

It is important to keep the primary care provider “in the loop”.  The best consultations or second opinions happen when there is a good exchange of information — what has been done, what tests show and what medications have been tried.

When should a person ask for a second opinion?

  • When a provider is unable or unwilling to discuss your questions or the information you have found in books or the Internet.  An unending barrage of questions is counterproductive — be prepared by doing your homework and ask a few good questions.
  • When you simply do not understand the diagnosis.
  • Give your provider an opportunity to adjust medications if side effects happen or if medications are not working as expected.  A second opinion is a good idea if the treatments and modifications are not working.
  • When the provider is unable to make a diagnosis of a problem.
  • When you have been diagnosed with a life threatening condition — you may not get a second chance for a second opinion so don’t wait.  Sometimes a bad situation can not be cured — at least you will have some comfort that what can be done is being done.
  • When your doctor is not giving you more than one option for treatment — there is always an option (perhaps not a good one, but there is always a choice)
  • When you are uneasy about the need for any surgery.  A CNN report  lists 5 surgeries that should trigger a second opinion:
    • Heart bypass surgery (get a second cardiologist opinion)
    • Hysterectomy (often not needed)
    • Pregnancy termination for fetal abnormality (because the diagnosis can be difficult)
    • Surgery for varicose veins (often not needed)
    • Treatments for brain tumors (a really big step)
  •  Sometimes insurance companies require a second opinion for certain problems.  Listen carefully to that second opinion even if you were happy with the first opinion.  There is indeed a lot of unnecessary testing and surgery which can be  dangerous for you and expensive for the insurance company.

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Good Advice from Clinical Research

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The ABIM foundation asked all the major medical and surgical specialty societies  in the US to each submit “Five Things Physicians and Patients Should Question“.   The specialty societies picked five tests or procedures they thought were being overused or wasteful.  Each one of the “things” is an important well researched piece of advice the societies believe health care  providers and patients should know.  Who is doing the questioning is not clear — but it seems if providers are not following the advice then other doctors, quality assurance departments and patients themselves should ask questions.

The assortment of ABIM documents is mainly intended for physicians so they do contain technical terms.  Fortunately, the ABIM partnered with Consumer Reports to write FREE consumer friendly versions of the ABIM recommendations.  The site has a nice navigation bar so you can quickly find helpful information.  Here is a link to the site:  Consumer Health Choices.

The author of this blog created an abridged version  for a quick scan of everything to date.  Take your choice, either the original, the Consumer Reports version or the abridged (no beating around the bush) version.   A few societies have not yet submitted information so check back with the ABIM Foundation site later if interested.

There seem to be some common threads in the advice:

  1. Don’t do tests if there is no plan to act on the tests (or to find a disease that has no treatment)
  2. Don’t do screening tests if testing errors cause unnecessary or harmful surgery or other tests.
  3. The time interval for screening tests is very important (especially for cost reasons)
  4.  Imaging (nuclear scans, CT, MRI, PET, ultrasound etc.) has been massively overused — always question whether imaging is needed.
  5. In general, don’t fix things that don’t eventually cause symptoms

The advice is both favorable for patients and favorable to reduce the cost of health care.  The US needs more of these evidence-based guidelines.

 

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