Archive for August, 2013
Insurance companies are starting to see the light. According to the Wall Street Journal insurance companies are eliminating payment for proton beam therapy for prostate cancer because less expensive and effective treatment already exists. This is a good example of the reasonable application of cost-effectiveness evaluation. Finally.
Standard radiation therapy passes through the body damaging all tissue in its path. The point is to damage the prostate with cancer in that same beam path. Injury to tissue in front and in back of the prostate is reduced by rotating the beam around but still keeping focus on the prostate.
Proton beam radiation damages tissue to a specific depth — the beam does not damage tissue beyond that depth. In essence, lessening the damage along the exit track compared to standard radiation.
The concept of proton beam therapy is great, except for building a giant machine to make the beam, except for the huge expense of the machine and not much gain in the death rate from prostate cancer compared to standard therapy. How can this be, high tech is supposed to be better?
The problem is: proton beam therapy is just a little better than standard therapy but it is hugely more expensive. Proton beam therapy costs $32,000 versus $19,000 for standard therapy.
Researches often calculate how much a therapy costs to extend quality life by one year (one QALY or quality adjusted life year). This type of analysis was done by researchers in Philadelphia. They found the cost per QALY for a 70 year old man for proton therapy is $63,511 and for standard therapy is $38,808.
As stated in previous posts most health care experts believe the cost per QALY should not exceed $50,000. Basically, the limitation is based on how much money can be spent without bankrupting society. Another way to look at the cost is that the treatment is not ready yet — research must find ways to make it workable at a lower cost.
The bottom line is insurance companies are making decisions on these really high priced treatments like other countries do, by considering costs and benefits. Unfortunately, this decision process is not widespread. Unless this type of analysis happens on a larger scale there is little hope for US health care solvency.
Insurance companies are usually not big enough to withstand the complaints and suits from that one person demanding the higher priced care. Eventually, the US government must insist on this type of cost control.
Recently published guidelines for lung cancer screening (USPSTF) lack sufficient consideration of side effects and give no consideration to cost. Insurance companies, so far, don’t pay for it and the American Lung Association has many questions about the basis for the recommendations.
Is CT screening really helpful to people at risk for lung cancer? Is screening driven by profit motives for hospitals and radiologists? The latter question may seem harsh but the well documented price gouging by radiology on other CT tests forces the question.
The data are clear: chest CT scans can detect early lung cancer soon enough to allow successful surgical removal. But, the devil is in the details.
Can the US healthcare system afford this screening — what health services should be eliminated to pay for this very expensive endeavor (like childhood immunizations)? Can patients who eventually are found not to have lung cancer (the vast majority of those screened) afford the test and the side effects of the invasive tests screening causes?
The recommendation seems premature. The formation of national guidelines without adequate considerations of cost is hard to believe given our national problem with excessive health care cost.
Many other countries consider the cost of a test or treatment needed to give a person a “quality year of life”. How much is that year worth? a billion dollars, a million dollars, a thousand dollars, all your money, all the money you wanted your kids to inherit? Tough questions, especially if you are not a billionaire. Well, experts on national health care say that dollar figure should not exceed $50,000.
Whether you believe the $50,000 number or not, at least we need to know exactly what such screening will cost. We purchase healthcare — we don’t get it by magic.
So, what are patients and health care provider to do? At this point: follow the recommendations and hope less costly and less invasive means are discovered. Here is what the American Lung Association advises:
The best way to prevent lung cancer is to never smoke or stop smoking now.
- Q: Who is a good candidate for lung cancer screening?
- A: The National Lung Screening Trial (NLST) criteria are:
- a current or former smoker (former smokers having quit within the past 15 years)
- and in the age group from 55 to 74 years
- and with a smoking history of at least 30 pack-years (1 pack/day for 30 years, 2 packs per day for 15 years, etc.)
- and no history of lung cancer
- There is no evidence at this time that other high-risk groups should be screened. Patients with lung disease, particularly COPD should be evaluated by a pulmonologist regarding the advisability of CT screening in the context of the severity of their disease.
- At this time, only Low Dose CT scans are recommended for screening. Chest X-rays are not recommended for screening.
Beyond the question of cost is the question of who pays. Should smokers as a group pay for the screening or perhaps cigarette makers? Given the lackadaisical attitude of congress about the risks of smoking, ostensibly representing US citizens, perhaps we should all gladly pay for the screening through insurance.
Here are two simple things hospitals could do to reduce readmissions: 1) Make a primary care appointment for hospital follow-up at the time of discharge 2) Dispense enough of the patient’s medications to last until the primary care appointment or to last 2 weeks, whichever is longer.
Patients are often readmitted because they did not take the medications prescribed at discharge. The beauty of the suggestions: hospitals save money since the cost of medications is low by comparison to readmission, patients will likely take the medications they are given, primary care providers will be engaged, and there is a financial incentive to make the appointment within 2 weeks.
How much extra are you willing to pay to continue to see your current primary care provider? $100 per visit? $20 per visit, or $2 per visit? That’s an individual decision. But, insurance industry studies show an average person in a health plan would change primary care providers if they had to pay more than $2 extra.
This is one of those dichotomies where people rate choice of providers very highly but in practice are not willing to pay more than about $2 to pick one provider over another. Doctors uniformly place a much higher value on the doctor-patient relationship than patients themselves.
However, to paint the picture with a large brush leaves out details. Patients who have primary care providers that manage chronic illness like diabetes, asthma or migraine headaches are much more willing to pay higher co-pays to maintain that relationship. Sometimes the relationship with a specialist is worth more to patients, but not always, because of a prevailing notion specialists are more alike than primary care providers.
The $2 statistic also includes the huge number of people who do not see a health care provider regularly — they just go to a clinic when a problem arises. In fact, they just want to be seen quickly, the name of the provider is not important.
Over the past 10 years employers have changed insurance carriers on average every 3 years. A change in insurance often forces people to change providers in order to stay “in-panel” and avoid high out of pocket costs. Anna Wilde Mathews’ article “Health Plans Limit Choice of Doctors” appeared in the Wall Street Journal today (8/15/13). She suggests the Affordable Care Act causes patients to change health care providers, an assertion that has no relevance, since that’s how our current system works! Not to say this is good — in fact, forcing patients with chronic illnesses to change providers borders on unethical business behavior.
Conclusion: rather than whine about the Affordable Care Act we need reasonable legislation to improve US healthcare, NOT legislation to return to something worse. Businesses should not have to change health plans so frequently. We need more large high functioning health plans (like Kaiser Permanente and a few others) so businesses don’t feel the need to change insurance carriers so patients can keep the health care providers they like.
The cause of hospital readmissions is not a secret. Patients are readmitted to the hospital because the patient, physician or both are too optimistic about the patient’s situation: too optimistic about the patient’s social problems, too optimistic about the strength of primary care, or too optimistic about the possibility of surgical complications.
It feels better to be Optimistic than the alternative. It feels better to the patient to be going home. It feels better to the doctor to believe all is well. But, the data about readmissions suggest the feelings are not always accurate. Perhaps we should be optimistic there are ways to find and correct the reasons for readmission. Providers need to focus on solving more problems before discharge, not just the problem of sending the patient out the door. Providers need to follow a discharge check list, just like a pilot getting ready for takeoff – not just be optimistic the plane will do just fine.
Rehospitalization is often attributed to fragmentation of health care. So, what constitutes a non-fragmented (smooth) transition from hospital to home? The following is the basis of that preflight checklist:
- The hospitalization is long enough to make sure the patient is stable.
- Providers anticipate the day of discharge:
- the likely date of discharge is discussed at least twice
- on the day of admission
- when the patient is feeling better, at least 48 hours before actual discharge
- patient questions are answered
- minimize medication complexity
- absolute minimum number of meds
- simplify dose schedule (don’t mix intervals)
- educate about new medications
- explain and write down
- the reason the patient was hospitalized
- the final diagnoses
- the name of surgery performed
- the complete list of medications including
- home meds discontinued
- home meds continued at same or different doses
- new meds (make sure they are generic or on the insurance formulary)
- why each medication is needed
- financial problems addressed (can medications be purchased?)
- home social situation reviewed
- obtain home monitoring equipment (glucose meters, scales, blood pressure checkers)
- send needed prescriptions to the patient’s pharmacy electronically
- the likely date of discharge is discussed at least twice
- family engaged, discharge plans discussed with family
- visiting nurses called if needed
- primary care providers called and discharge summary faxed same day
- discharge instructions reviewed verbally and in writing with patient
- follow up appointments made
- specialty care as needed
- primary care within one week
- transportation arranged
- phone follow-up next day by discharging provider
What indicates high risk for rehospitalization?
- Intensive care stay
- Living alone
- Previous readmissions
- Lack of insurance
- No primary care provider
- Smoking or other substance abuse
- Congestive heart failure
- COPD or asthma
- Insulin dependent diabetes
- Surgical wound drainage
- Weakness or falling
- Over 15 lb wt loss
- No phone at home
- No transportation (except ambulance)
Rehospitalization may be foreshadowed during a hospitalization. Health care providers sometimes fail to notice wound drainage, night time confusion, low grade fever, shortness of breath, leg swelling, anxiety, or comments about the cost of medications. The errors of omission can be reduced by minimizing provider changes and hand-offs — so patients do not “fall through the cracks”. Providers should take a second look at labs, vital signs and nursing notes before giving the green light for discharge.
Sarah Needleman of the Wall Street Journal was the author of “Rx to Avoid Health-Law Fines” which appeared August 8, 2013. She reported on new companies that help hospitals reduce hospital readmissions by printing sensible discharge instructions and also by predicting the chance of readmission to help focus resources on high risk patients.
Discharge software is expensive and probably not more effective than a good checklist of risks. Most importantly, hospitals must have action plans for each high readmission risk factor (like no transportation or no phone).
The Robert Wood Johnson Foundation published “The Revolving Door: A Report on U.S. Hospital Readmissions” in February 2013. The report puts a strong focus on fragmentation of care, being a root cause of rehospitalization. The fragmentation can be significantly reduced by strong primary care, doing close follow-up after discharge, engaging additional social services if needed, extensively using the phone to communicate with patients who have chronic illness.
A good idea: phone follow up. Many primary care providers complain that post hospital phone calls are an unreimbursed expenses (so they don’t make the calls) — hospitals should consider paying a fee to primary care for phone calls during the month after discharge.
Another good idea: the hospitalist outpatient check. Some hospitalist groups actually have a discharge follow-up clinic for patients who had a long hospitalization or who have rehospitalization risks. The visit is usually a couple of days after discharge and is focused on solving problems before they become big problems and also to make the transition to a new or existing primary care provider.
Elisabeth Rosenthal of the New York Times is the author of the lead story on 8/4/13 “For Medical Tourists, Simple Math” about the high cost of hip surgery in the US with an astounding comparison to the low cost in Belgium. She quotes US orthopedic surgeon Rory Wright saying that joint makers keep prices high “because they can”, not because of research and development or liability costs. Once again, the Times presents strong evidence of price gouging in the US health care system.
Below is the cost information presented in the article in US dollars in 2012 — the fees presented reflect the repudiated “chargemaster” fees for uninsured individuals Belgium has national health insurance with some basis in reality for payments (and some national price and profit restrictions)
Below is a table from the Commonwealth Fund on fees paid to doctors by public payers (like Medicare) and private payers (like private insurance)
The US makers of knee and hip implants (Zimmer and OrthoWax) pay their CEO’s in excess of $8 million dollars per year each. In 2007 device makers had to pay $311 million to settle a claim of kickbacks to surgeons. Artificial hips cost about $350 each to manufacture but hospitals and insurance companies usually pay between $4,500 and $7,500 each.
- People in the US without insurance are at a tremendous disadvantage.
- Hip and knee implant manufacturers make huge profits in the US. Other countries solve the problem with price controls and limits on profits placed on the very US companies that freely gouge US customers and damage the US economy. Does congress care?
- If you live in the US, need surgery, don’t have insurance, and do have enough money for an airplane ticket then: go to another country for your surgery (Belgium has a lower infection rate than in the US as another advantage).
- Lack of insurance should be a vanishing problem in the US with ObamaCare but the high cost paid by insurance (ultimately paid by everybody) is far too high.
- The work of surgeons is undeniably valuable. Somehow many other products and services associated with surgery seem to get paid high fees for no reason. An operating room is not surgery, a metal implant is not surgery, and a hospital room is not surgery. Those associated services are hugely overpriced and need price controls and profit limitations.
- Surgeons get paid much more than primary care providers, which makes sense based on the years of training and experience. If surgery is really needed then health systems and patients gladly pay for the talent.